Investor Update

May 20, 2019

Slides

Ladies and gentlemen, thank you for standing by. I'm Stuart, your Chorus Call operator. Welcome and thank you for joining the Fresenius Medical Care Meet the Management Series twenty nineteen Path to Home. 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. I would now like to turn the conference over to Dominik, Head of Investor Relations. Please go ahead, sir. Thank you, Stuart. We would like to welcome all of you to the Fresen MegaCare Meet the Management Series twenty nineteen with the Path to Home. We appreciate you joining today. As always, I'm happy to start out the event by mentioning our cautionary language that is in our safe harbor statement on Slide two of the test to home presentation. For further details concerning risks and uncertainties, please refer to this document as well as to our SEC filings. Following the NxStage acquisition and our investment in increasing the number of treatments in a home setting in The U. S, we had many basic questions on therapies and strategic background. Therefore, we decided to set up this call to explain in more detail the high level approach and the different therapy options. Please be aware that this call is not planned to and will not cover the financial background or any costs or revenue questions in this relation. I'm pleased to have Ruiz Powell, our CEO and Chairman of the Management Board and Doctor. Frank Maddox, our Global Chief Medical Officer, here to present. Ruiz will explain why we promote home dialysis and how we will increase the home penetration. Frank will give you an insight into the medical perspective of the treatment options of our patients and especially home dialysis. Please make use of the rare opportunity in the Q and A session to have a global medical director available. Please note that the webcast will also include a short video of Ries talking to one of our home dialysis patients, Vanessa Evans. If you follow this event over the phone, please be aware that we will broadcast the audio here as well. I will now hand over to Ries. The floor is yours. Thank you, Dominic. Also a warm welcome from my side to everyone. Thank you for your interest, and we hope this will be a learning experience for you. Let me start with reasons for home on Slide 4 with a global treatment overview. Globally, approximately three point four million patients need dialysis treatments to survive. By far, the majority of patients are treated in freestanding clinics or hospitals. About eleven percent treat themselves at home with either peritoneal dialysis, and we refer to that as PD. And today, only one percent use home hemodialysis, and we refer to that as HHD. But for the time that we're together today, I will talk in full language for you and not drop a bunch of acronyms on you. If you do get confused by the phrases PD, which is peritoneal dialysis, hemodialysis and home hemodialysis, don't worry, Frank can do a much better job explaining the treatment options than I can. But we do want you to leave here with a good feeling and understanding about the message we're trying to convey. On the right hand side of the slide, we show you the growth rates for modalities, and we've grouped them in different periods of time to give you a sense of how we are progressing and I would say the recent future, not way, way back in time. As you can see, we expect overall dialysis growth to be around 6% annually from 2018 until 2023. Home hemodialysis will show an annual growth rate of 11% over this time frame. So extremely good significant growth. Turning to Slide five. On the previous slide, you saw that about nineteen thousand patients treat themselves with home hemodialysis. Here, you can see more than half of them are based in The United States, which is by far the largest home hemodialysis population on the globe. Looking at peritoneal dialysis, the picture is in China, followed by Mexico, and then The United States is only number three, probably different than you expected, but good for everyone to know. Two lessons we can learn from just looking at these numbers. There is a tremendous amount of potential for home hemodialysis outside The United States. Turning to Slide six. Why do we want to increase the home home hemodialysis population in particular? First of all, because it's exactly what we need to do and we are destined to do, creating a future worth living for patients worldwide every day. Frank is going to elaborate why and how our patients show better clinical outcomes from being treated in the home. But I think it's pretty obvious, even without the medical perspective, why our patients benefit from being able to choose how they want to be treated. With peritoneal dialysis or home hemodialysis, patients spend less traveling to clinics back and forth. They can maintain a relatively normal lifestyle like being able to continue with their hobbies or go to work, which is incredibly important for many of our home patients to be active and working. And whenever their condition makes it necessary for them to come to a clinic, we will be there to help them in that venue as well. But also, for us as a company, it makes absolute sense from an economical point of view. By increasing the home population, we are able to decrease the headwinds we face due to the shortage of labor and wage inflation that we experience every year S. As well in other developed markets, and the emerging markets will get there at some point in time as well. We believe this is inevitable. Mid term, we will even be able to decrease our capital expenditures, produce maintenance and some investments that we currently spend today and ramping up new clinics on a global basis. Looking at Slide seven. So if home dialysis is so much better, why haven't we pushed for more home in the past? First, we have. We have been growing our PD business continually in the last years. But for hemodialysis, we were lacking the technology that convinced patients and doctors it was as safe and easy and effective to use. As we have seen in the past, if you're going to move a market, you need to be able to move this market through technology. Our history at FMC has been when we brought the first volumetric machines into the dialysis market, people really began to gravitate to Fresenius equipment. And it only happened because we had the leading technology. Going back to the early 2000s in The United States, when we made the decision to convert all of the FMC patients to single use dialyzers, we moved market. And we can only do that because of the hundreds of millions of dollars we'd invested in Ogden, Utah, where we were producing single use dialyzers. Technology is the edge. Technology makes the difference when you combine it with great patient care patients and the ability to look at the outcomes, which Frank will speak to, and understand that their lifestyle is better. Payers are being treated more fairly because we're as economically treating these patients as we possibly can. And now what we have with NxStage and their machine and their equipment is a pipeline of products that will help us continue to make this technological leap for patients that want to be at home, particularly in home hemodialysis. But please keep in mind, it is not us who makes the decision if a patient is to be treated at home or in center. That decision is made by the patient and the physician. And here, we currently see a mind shift among our physicians beginning to realize and champion how beneficial home therapy is for their patients. And again, as we've said many, many times and we'll say it again today, eighty two percent of our patient base when surveyed in The United States says, I want to be treated at home, whether they really can be or not, which they decide that with the physician, but they want to be at home. And fortunately for us, the U. S. Government is promoting a stronger focus on home now. Not a lot of detail, but we're doing everything we can to help them figure out what that detail should be. I'd like to stop talking now and give you an opportunity to listen to one of our patients who is on home hemodialysis. Hopefully, her journey will give you a sense of the message we're trying to convey to you today. Let's talk about your journey. Well, my name is Vanessa. I've been a home dialysis patient for fourteen years, but I've actually been a dialysis patient for twenty one years, so long time. And I did in center dialysis for about eight years. In center dialysis was, it was good, but it was difficult. I wasn't feeling well. Even though I was a very compliant patient, I watched what I ate, I watched what I drank, but even so I was on blood pressure pills. I felt exhausted after my treatment. I felt like I had run a marathon, but I literally hadn't done anything. So that was hard. I'm sure, but you persevered. I did, I persevered. I did do eight years of in center and I started to literally go online and research about different kinds of dialysis. And I came across home hemodialysis. And so my next steps were to find out where I could do it. Even though I found the clinic, it still took me a year to the transition to be able to do home dialysis. I did have help from my in center staff. I had a wonderful tech who started to do self care with me in center. So that when I actually went home and did the training, it really only took me two weeks because I had a couple of those weeks of self care in center to get prepared and train and go home. Incredible story. And look at where you are Falls under that category, if I knew then, But what I know congratulations. And when I see the journey, very different than many people to have transplant and gone in center and then come out and go home. What we want to do at Fresenius Medical Care, particularly with now having next stage as part of the family, make that journey as flexible and as tailored to the patient as we can. Because we know some patients may never go home. Right. But we have to provide them the best that we can. And then for those that are at home and perhaps they want to be in center for a time or two to get a break, we need to make that life journey. Right. We are the company that will give you that best journey in whichever way you want to go forward. But we couldn't do it without people as yourselves that have walked that path that can help us understand where we could do better. You can let us know that as well. I just am so excited for patients that they're going to be educated to understand what their modality options are. As you stated, the point is to feel supported and for patients to know their options and know that we have a care team that's working to with get us to the right spaces of where we need to be. I actually was able to get off all my blood pressure pills within the first three days of doing home dialysis. I felt really an abundance of energy. That's when I looked to start my own business. And actually, that's when I started doing some advocacy work for We make dialysis part of our lives. I just got back from Florida. I took the machine with me. I haven't let it slow me down, and I dialyze in my hotel room and then go enjoy the day. So I don't have to make my schedule around the clinic. Can make my schedule around what I need to do. But I'm always connected with my nurse and my clinic. So that if there was something I know that I could call them and they can help me get into a clinic that is nearby. I'm amazed at how you pulled all that together. And in your case, we're always happy to say that we're able to give a patient their life back. But the real story has got to be that it never got taken in the first place. Yeah. And so if we do this better on the front end, we don't have to come around on the back end, shall we say. The real goal is for stories such as yours, if you will allow me, they become obsolete. Right. Because we've been able to do this and nobody ever had to get their life back. They had it from day one. Yeah. As they took that journey. That's what I want patients to know. And more importantly, have that education to know that those modalities are there. And knowing that home is an option, supporting them is priceless. That'd be a great thing for me. You so much. Yes. Thank you. Thank you for listening. I hope that was helpful and that it gives you some perspective on this lady's journey. Now I'd like to hand this over to Doctor. Frank Mattox, the newly appointed Global Chief Medical Officer for Fresenius Medical Care. Thank you very much, Faris. Our patients will experience multiple modalities of therapy while they live their lives with kidney failure. And my hope today is to review with you some perspectives on each of these particular therapies and our focus on how we feel we need to support and recognize that the patient's journey will be incorporating many of these areas. The five areas include transplant, peritoneal dialysis, home hemodialysis, in center hemodialysis and supportive care. If we go to Slide 11, there are four primary factors that we think are acting on the field of advanced renal disease care. And one is the recognition that a health epidemic exists today with kidney disease occurring with other common disorders, especially obesity, hypertension, diabetes mellitus. And the advancement of these diseases also advances a population of patients who will struggle with kidney disease. Globally, there continues to be a substantial burden complexity in managing these patients with lots of medications, multiple comorbidities and many needs to try to support their both their medical therapy and support their social needs while they're living with this disease. Our patients are interested in empowerment and choice. They wish to live their lives and fit within their lives the therapies that they require and the choices that they will make with their physicians, with their family and in trying to live a meaningful life is one of the key goals that we see as part of our responsibility. And then finally, we see that governments today are beginning to recognize that home dialysis is a cost effective system of care. It is one that has been certainly recognized and mentioned by both Health and Human Services Secretary, Alex Azar, in his public speeches as well as the Director of the Centers for Medicare and Medicaid Innovation, Adam Bohler. And we've supported the advocacy that's required to try to build a system of care for home dialysis. So we move on to Slide 12. Let's think a little bit about the lifetime journey that patients will see. Each patient will have a unique journey. It is one that in fact the order of modes of therapy will depend on their particular goals and needs and will in fact be a decision that they make with their physicians as well as they make with their family and those that are trying to support their disease. I'd like to discuss these particular therapies in some more detail at this point. If we could go on to Slide 13. Kidney transplantation is the obtaining of an organ, a kidney from a living or deceased donor that's transplanted into a patient and is the closest to native kidney function of any therapy that replaces a person's own kidney function. It's highly effective when it's successful. And in fact, the rates of kidney transplant, the kidney surviving in a patient after the first year is well over a decade at this point. And that's quite good for patients when they can, in fact, find that it's the right therapy for them. It is not the right therapy for every single patient. And at this point, there is imbalance in the availability of organs for transplantation and the number of patients waiting for a transplant. In 2018, there were just over twenty one thousand kidney transplants and kidneys represented sixty percent of all organ transplants, at least in The United States. Today, the demand is substantially higher higher with just over 100,000 patients waiting for a kidney. There are approximately six hundred and fifty thousand patients with end stage kidney disease in The United States and more globally. And we feel strongly that we need to have an open dialogue with the transplant community to understand what our role may be in helping with waitlist management, with desensitization protocols and helping make sure patients stay as healthy as possible if kidney transplant is one of the modalities that they are interested in. Moving on to Slide 14. Peritoneal dialysis is a procedure that utilizes the lining of the abdominal cavity as a membrane, which is highly filled with many blood vessels and, in fact, can actually remove both fluid and toxic materials into this fluid. So fresh dialysate fluid is infused into the abdominal cavity. It's retained there and interacts with the membrane to absorb both fluid volume as well as toxic materials. And then it's exchanged out for fresh fluid. And as these exchanges occur three to five times daily, the patient actually is relieved of some of their burden of excess fluid volume that their own kidneys cannot get rid of as well as the opportunity to remove some of the important toxic materials that build up from daily living. It is a very empowering procedure and that patients control their own therapy and are frequently directly involved in that procedure. And it is a very gentle process on the cardiovascular system comparatively while also preserving any residual renal function that a new patient to dialysis might still have in a small area. Moving on to Slide 15. At home hemodialysis is a therapy that's at the core of what our interest in NxStage were in some of the therapies that they have developed. In this case, blood is removed from the body and pumped through an artificial kidney that's dialyzer, and return to the body, but it's done in a setting in which the patient is directly involved in that care, in many cases with a caregiver, in many cases on a schedule that fits their lifestyle and recognizes that a typical treatment is three to five episodes per week. And some patients choose to do this overnight. So they do it, what's called nocturnal home hemodialysis. There's a professional scientific debate going on right now on the degree to which more frequent dialysis has cardioprotective effects, and we are actively involved in those discussions. But recognize that your own kidneys are working twenty four hours a day, seven days a week. Offers an opportunity to try to understand what is a more physiologic treatment that again reduces the stress on the cardiovascular system. We think these are important components of home hemodialysis and the opportunity for the machinery of home hemodialysis as we have found in the NxStage System one series machines to be much more friendly and easy for patients to use to understand and to be able coordinate with our caregiving training centers. Moving on to Slide 16. The fourth modality is the one that is most predominant and is the one that today is used in center hemodialysis. Hemodialysis. It's typically a three time per week schedule. This three times per week is not designed on a physiologic basis, but it is the basis by which the system of care was developed. And that system of care has provided broad access to care for patients just about anywhere that where they live today, they have access to the opportunity for a treatment to be done. Treatments typically are done though by dialysis nurses and technicians and the care team and it's done in one location. So it is somewhat less empowering of patients, although we have seen some number of self care units where patients participate particular care. We think there is some advantage to the social connection that occurs when patients get together. They do benefit from that at some stage. But in fact, in center hemodialysis frequently is the therapy in which patients are more passively given their particular treatment. Moving on to Slide 17. The fifth area and modality of care is one that I think is important because each patient has their own goals for therapy. And in many patients, as they are getting closer to their end of life or their other illnesses that made them quite sick and ill, they may have a set of goals for their therapy that are very different than being fully rehabilitated. And they mostly want to be maintained comfortably. They want to avoid pain and breathe comfortably. And these critical health conditions recognize that supportive care is a very, very important modality of care for people the goal for their therapy is to relieve their discomfort. So if we move on to Slide 18, let's talk a little bit about home dialysis and some of the benefits here. And I think it's important to recognize that if you actually look at clinical caregivers, both nephrologists and nursing staff, you see this very high proportion of people who would choose to do their dialysis treatment on their own terms at home and recognize that home is not really about the geography in which the therapy is given. It's about the philosophy that patients are actively empowered and part of the provision of that care. We think that, again, these home therapies offer a lifestyle that may be more attractive to many patients that have many activities. And you heard this story from Vanessa Evans. And I think there are many, many patients that would recognize that they may want to travel. They may be very involved in their family or community life. They may be working. They may be, in fact, still going to school. And these therapies give them a higher degree of power and choice. We also think that cardiovascular protection is an opportunity to be enhanced by the home dialysis therapies, and I'll talk about that a little bit more in a moment. If we go on to Slide nineteen, one of the central themes of our clinical agenda this year and for coming years is this concept of karyoprotection. We think that cardiovascular disease is one of the most high drivers of morbidity and mortality in the population of patients that we treat. And we think both peritoneal dialysis and home hemodialysis at various times during the journey of a patient through late stage CKD, advanced kidney disease and renal replacement therapy can be enhanced by trying to protect their residual kidney function and to manage those components of their therapy that try to reduce the persistent volume overload that can occur that results in high blood pressure, that results in ventricular hypertrophy and a swelling of the muscle of the heart as well as heart failure disturbances in the heart. We think to improve these outcomes, one of the things that needs to be addressed is this opportunity to try to avoid the subtle volume overloading that can occur and have this persistent cardiovascular impact and effect. Let's move on to Slide 20 and talk about some of the outstanding questions that exist around home dialysis. Primarily, the greatest difference in home dialysis and home hemodialysis from in center is the fact that the patient is more in control of the timing and the provision of their therapy. They with their caregiver or in some cases themselves alone in solo environment, they are empowered to, in fact, understand their care very well, to recognize what the subtle changes are day by day that affect the needs of that care and to make sure that they're getting a full and adequate treatment each time. How often do home patients see their doctor? Well, this is one of the areas where technology has really helped change this quite a bit. As we know, rounding patterns for attending physicians vary in the in center environment from every treatment week to sometimes once a month. Typically, home patients are seen monthly. But with the telehealth provisions, the opportunity for patients to interact and be connected with their care team continues to be substantially higher in this generation than it was in prior generations. Patients go to their home center. It can be monthly. It can be quarterly. It can be annually. Typically, it's monthly. Interact with not only their physician but the interdisciplinary team that includes social workers, dietitians, nurses and other specialists to try to help them with their therapy. Today, we see that their outcomes are generally better. Some of this may be selection of patients that are highly engaged and so forth, but it is very clear we see lower hospitalization rates. We see lower rates of medication needs for this population. We see mortality being lower in this population. We see transplant rates being higher in patients that are at home. Finally, from the standpoint of depression and social determinants of health care outcomes, We think that patients who feel empowered and are very engaged in their own success have that intellectual purpose to, in fact, actually be very, very knowledgeable and involved in a successful therapy for them. And so with the other elements that we've identified as social determinants of health care outcomes that include food security, stable housing, community, whether that's faith community, peer community or family community, kinetics and being mobile as well as intellectual purpose offers the opportunity for patients at home to really thrive as much as they can. And finally, we think that overall, the cost to the system should be less because patients are somewhat healthier. But we also have to recognize that we've got to invest in these therapies. We've got to build a system of care that is as deep and capable as our in center system of care is for those patients at home, whether that's transitional care units, whether that's respite facilities, whether it's supporting caregivers environment as well as the patients and recognizing that not only their ability to be at home is a medical therapy, but it's also trying to dovetail into the life that they live at home and the life with purpose that they want to have. If we move on to Slide 22, we think that remote patient care management is one of the fundamental changes that has occurred in this generation with technology. And this concept of connected health allows us to create an environment where patients are home but not alone. And in fact, they are able to be monitored and managed through an environment where we are still receiving details of their therapy that we might receive in the in center therapy today, but we also can receive at home. And these are things like the Next2Me app, which is an application that provides clinical data to the care team on each individual treatment. We think this avoids patients feeling isolated, and this isolation will allow more patients to be confident, comfortable and less anxious choosing home as a modality. Moving on to my last slide, which is Slide 23. I want to talk a little bit about what we see as innovations in the areas of innovations. I think that cardiovascular system protection will be a core element of the development of our device strategy as well strategies. And I want to make sure that we're thinking about the products that we build as being a combination of three primary elements, both therapeutic elements, diagnostic devices and elements that give us a picture of how well the patient is doing both physiologically and in their environment at home as well as connected health devices that are connected deeply and allow patients to not feel isolated because they aren't sitting in a traditional healthcare facility. Secondly, as many of you know, we've made a substantial investment in Humacyte, and we feel that the human acellular vessels that are being developed by Humacyte will be a fundamental game changer in the ability to reduce catheter contact time for patients and the opportunity to create a vessel that becomes self of the patient. It literally becomes invested with the patient's own cellular elements, tissues and is one of the more compelling innovations in regenerative medicine that we've seen in many years. We think the development of membranes and artificial kidneys, and we applaud some of the activities that are being scientific community to evolve the science of combined biologic and chemical membranes to look at where there are opportunities to try to reduce inflammatory events for patients and to create an environment where the development of these new complex membranes can come to market and have a place to flourish. And then finally, we are watching with great interest and with support of the recognition that the transplant community and the community that has begun to scientifically advance genetics of immuno compatibility may offer an opportunity for there to be a greater opportunity to address organ availability. And we have watched a number of small companies and academic institutions aggressively begin to look at these areas. And we think that's an area that requires substantial development, but it's a huge opportunity for the field and for our patients. With that, I think I'll stop and turn it back over to Rice to give us a picture of the outlook. Thank you, Frank. I'd like to give you a little bit more insight, broad brush, if you will, as to where FMC is going and what we think we are capable of doing in order to enhance this opportunity. You've heard me say multiple times, we believe value based care is an important part of our business model in the future. And yes, still some of the elements and the ways are still in the pilot phase, but we're coming closer. I'd like to elaborate on some things here that should be of importance to you. Lifespan, care coordination. Our vertical integration enables coordinated care that provides different treatment options that meet the evolving needs of our patients' lives throughout their entire journey with chronic kidney disease. We believe even the patient that gets diagnosed and is able to transplant, they still go through life with kidney disease. And we need to be there for them whether they're being treated by us or not, we need to be available and helpful to them as they move down this path, very similar to what Vanessa was able to talk to you about with her own individual experience. Devices and therapeutics. Our world leading portfolio of dialysis equipment, medical devices, pharmaceuticals and therapeutics does create the foundation for superior kidney care around the world, as Frank highlighted for you. Technology in general, connected health technologies, enhanced systems interoperability and connecting the therapeutic and diagnostic devices to caregivers enables care delivery without any borders walls, and it gives access to real time care information caregivers for not only the patient, their family members, their care staff as well. Public policy alignment, advancing more home based dialysis therapies aligns with patient informed choice and policymakers' interest in reducing the overall cost of ESRD patients. There is no better example of the stars and the moon beginning to line up than we are seeing in The U. S. At this point in time with the comments that we're seeing from CMS and CMMI, as Frank has pointed out. And to follow on to another comment from Frank, cardiovascular protection. The efficacy of therapy must address chronic disease management dominated by cardiovascular disease, and we adapt the appropriate therapies in order to improve outcomes at a lower cost. Precision medicine. Research, data driven insights, advanced analytics and evolving science help better tailor and personalize therapies for patients. It also helps us as a company understand where it's prudent to take risk and how we can evolve our care models and our training and education in order to put patients in the best position to thrive in their care. Moving to Slide 26. In December 2018, as we already outlined, we said 2019 will be an investment year. Will What are we going to do? We're going to increase the number of clinics where we can train our patients for the six weeks of intense care that they need to learn and understand in their training regimen before they can start dialysis in their home. We will increase the number of nurses qualified to do home trainings and supporting home treatments and will further strengthen our back office network to be able to support patients around the clock. We're going to continue to improve our PD machines, our home hemodialysis machines and innovate to achieve even better medical outcomes as well as become easier to handle all of this equipment by our patients or their caregivers. By further developing our connected health programs, we're going to increase the comfort level that our patients can and should have at home. By increasing awareness monitoring CKD patients better, we can avoid patients crashing into dialysis, and we can enable them to start with PD instead of hemodialysis. Our transitional care units can help patients transition when they've been diagnosed with ESRD in hospital to consider all the other available options, which obviously would include home hemodialysis. Transitional care is critically important. Please remember that phrase. As Frank has already mentioned, we will enable our peritoneal dialysis patients to move to home hemodialysis at that point in time that they are not able to continue to do dialysis, as Frank pointed out, by virtue of the fact their peritoneum or their filter is no longer filtering, and so they have to have a different therapy. Turning to Slide 27. Seven. As you've heard me saying in my introduction, home is not a U. S.-only topic. Being a global and vertically integrated company, we see in the midterm tremendous potential for our home hemodialysis machine, especially in the developing economies. At this point in time, the lack of infrastructure in some countries forces patients to stay on peritoneal dialysis therapy longer than it is medically reasonable, as I just mentioned mentioned on the prior slide. Having the option to switch to home hemodialysis will be a huge benefit for patients in these countries when it is time for them to leave peritoneal dialysis therapy. Moving to Slide 28. Please rest assured, we will not stop looking at ways to help our patients, may it be our own innovation or by our venture funds where we involve ourselves in potential interesting developments from a medical or technological perspective. FME Ventures has been established in 2016, and we've closed at this point six investments in six companies. FME Ventures has been installed to complement existing activities and sources of innovative products. Beyond just what we do internally, beyond just mergers and acquisitions and partnering, we think there has to be yet another another avenue for us to pursue. Think Our investments are focused primarily by our strategic goals, technology transfer, access to innovative technologies, creation of options for future products, cost sharing with external partners for potentially risky early stage in development. That's code for not going it alone. That's code for having people of similar investment mentality working together. We tend to focus on Series A and B investment rounds. Minimum requirements for us are a Board observer role and information rights. And generally, a maximum investment for us would be ownership stake. The investment focus, current core business of Fresenius Medical Care and in the adjacent fields such as comorbidities of our dialysis patients, as Frank has mentioned to you. And additionally, we look at medical devices, services, pharmaceuticals, diagnostics, regenerative medicine, e health and digital, as you can gather, if it touches a dialysis patient and in some way can help them in their outcome, we're interested and we're evaluating. So with this small mention of the things that we are doing in the future, I think it's appropriate to hand this back over to Dominic. Thank you, Rice. Thank you, Frank, for the presentation. Before we open the lines for the satisfied analysts, kindly be reminded that we focus on the strategic and medical aspects of home dialysis. As I mentioned earlier, today, we will not ask a question on any financials, reimbursement or cost per treatment. As you've seen, we have also no CFO with us today. So that's the idea of the call. I would like to ask you from refraining those asking those questions and leave it open for many questions, which I know might not be your home turf of questions. But nevertheless, we would now open the lines. Stuart, please. Thank you, ladies and gentlemen. At this time, we will begin the question and answer session. Session. The first question is from the line of James Bain Tempest from Jefferies. Please go ahead. Hi, thanks for taking my questions. Just one if I can please. You don't want to talk about financials or try and phrase in a different way, but I understand one of the key benefits of Homecare and you talk about the cost effectiveness of it. And I do understand that some of the shifts that you can shift some of the costs of the patient and there's potentially kind of lower labor costs involved. But I just wonder if you could talk through in terms of given the expansion plans that you've got more from a strategic perspective, how you plan to address sort of the different logistics with Home Care, the distribution sort of upfront costs of machines? And how we should think about resourcing needs as you plan to kind of deliver on the strategy over the midterm, please? Hey, James. Thank you for your question. It's Rice Powell. So as we have been in the home business for my entire twenty two years with FMC and most of that time, as you know, is in The U. S, here's what I would say. As we look at our largest market, we have our own fleet today of trucks, be them large 40 foot trucks that you can get on the road, vans, shorter trucks, where we deliver product. So we have a warehouse network around The U. S. We deliver products to the clinics. We have very special delivery protocols for taking products to patients' homes. We actually carry the product into the home. We place it where the patients like it. We rotate their stock for them. So it's really not just a truck driver, but it is a conduit or connection to these patients that we maintain every two weeks, three weeks, whatever the delivery cycle is. So I would say to you, the basic infrastructure is there. We have the equipment. We have the warehouses, etcetera. Now obviously, as this population of home patients at FMC grows, we'll add more trucks or whatever we need to do in order to make that work. And honestly, it's a little more expensive to deliver to the home versus going in center. We understand that. But then obviously, the flip side of that is there's less labor component from a caregiver standpoint in the home setting because we don't provide nurses or technicians in the home, but we have them in the clinics, obviously. So we do see kind of a yin and yang among those various components of home delivery or home treatment versus in center. And I guess just a quick follow-up to that. That's my second question then. So in terms of, I guess, looking at the overall return of a machine, I guess, rather than having a machine which can potentially kind of look after multiple patients in center, there's always going be one machine in someone's home. I guess how do you I guess, what's the payback period in terms of having that sort of larger upfront investment? Yes. So I think the simplest way to answer that, so we don't drag ourselves down the rabbit hole here is for equipment that's been placed in a patient's home, whether it's a PD cycle or a home hemodialysis machine, that's a piece of of that's rented and it stays in the home as the patient uses it. And it's part of, if you will, a monthly billing that's done for disposables and then a certain portion goes to the rental of the machine. Generally, the effective life of that equipment, if it's been maintained appropriately, etcetera, is somewhere in the seven to eight, ten year time frame. That's great. Thanks very much. Next question is from the line of Michael Jungling from Morgan Stanley. Please go ahead. Thank you and good morning, good afternoon. I have two questions. Firstly, when it comes to home HD machines, can you comment a little bit about the competing technologies to NxStage? And I'm referring, let's say, to Outset Medical or Quanta. Why is NxStage perhaps going to be the leader going forward in home HD? Second question about nephrologists and their incentives. As far as I can tell, there are different incentives for nephrologists between home and in center. And typically speaking, I think they can make more money or be financially more incentivized when you visit patients in an incentive versus going to someone's place in an outpatient setting. How do you get around the nephrologist being more incentivized going forward to recommend home dialysis on the HD side? Thank you. Hey, Michael, it's Rice. Good afternoon. I'm going to take number one, and Frank, since he's the only nephrologist in the room, will take number two. Relative to the competition, so one thing I think is obvious for folks, NxStage has been on the market for twelve, thirteen years. They've got a long history of great equipment and disposables that are used in the home hemodialysis setting. You can find your way into a dialysis patient chat room, and there are several of them in The U. S, people are pretty emphatic about how much they love remember, at this point, they are looking not at home. They are looking at self care centers. So I think if that's their first path to commercial success, then I think they're going to come back around and consider So I do think there's twelve, fifteen, sixteen year head start that we've got with NxStage in that situation. And then Quanta, I don't know as much about them. I know they're UK based. We have a little bit of familiarity with them. But again, this is a company that's just getting into clinical work. And here, NxStage has been on the market for twelve years. So I think there's a tremendous head start. But as we always do, I mean, at FMC and and Nextage, even before we connected with them, there's no arrogance here. We take every competitor serious. We look at what they're doing and we prepare accordingly. So hopefully that helps. And Frank, I'll turn it over to you for the next question. Sure. Michael, thanks for the question. I think nephrologists who are managing end stage renal disease patients work under this monthly capitation payment arrangement. And the incentives for that in center, obviously, are dependent on number of times they see that patient in center. The opportunity for us to set up a system where there is an opportunity for nephrologists to thrive in either a value based care environment, a transitional care and training environment for patients and to be reimbursed for those are all part of the evolution of the system to recognize that today it's been built around an in center delivery system predominantly. And as we evolve the investments that allow for organization of what's required to adequately clinically support, we think that there additional opportunities for nephrologists to be well compensated for the work that they do in managing these patients. And whether that's through the government payers, through the value based care programs that we see We think there will be opportunities to create an equal system of care that's appropriate for these home patients. Thank you. Just follow-up, on to Doctor. Manak's reply. Do we need some regulatory changes and some changes from CMS to make this work even better, these home care HD solutions? So it's a good question. And I would tell you, I think some of these regulatory changes have already occurred. There have been enhancements to training. There's been enhancements to the telehealth provision that allow for physicians to be connected to their patients when they're not sitting in a healthcare facility. Do I believe there are other regulatory changes that would enhance this? I do think there are. And we've been actively in conversation with our colleagues, certainly in North America at CMS to try to help them understand some of the things that would make the system more amenable to an organized system of care and delivery system for patients being at home more successfully. And that includes the impact of that the clinical caregivers and nephrologists would have interacting with that system. Thank you. The next question comes from the line of Oliver Metzger for Commerzbank. Please go ahead. Yes, hi. Thanks a lot for taking my questions. My first one is just on the penetration rate. So there are different groups of stakeholders starting from the patients or service providers. Where do you think is or which group is the most effective to be addressed that to increase the penetration rate? Do you think you need to educate the patients to a strong extent that they demand home dialysis for, to a strong extent, orders come from Navas side? My second question is on your data collection, which you basically do for many years. So you commented in the past a couple of times about the huge amount of data you collect at every incented dialysis treatment. Here on Slide 22, you just scratched the topic a little bit. So what's your view on it? Do you think you will be able with the systems within Connected Care to collect the same amount of data you do already in in center also to react faster to changes in the health conditions of the patients? Or how should we think about this? I'll take that one, Oliver. Thank you for those questions. So I think when you think about which patients are most amenable to home therapies, I think it is a very individual decision between patients and physicians. Generally, as a practicing nephrologist, when I was caring for patients directly, it was very clear that these unique decisions with patients, families and their nephrologists are ones that probably are easier done for the new patients to dialysis in choosing home when they're educated well and so forth than in converting a patient that has already been in center. But frankly, we see evidence of both that can occur and it highly is dependent upon the local system of care and the ability to help people understand what their choices are. And these choices really have to be guided by the kinds of things in their regular life that they want to, in fact, be able to achieve. And in many cases, home becomes sort of a preferred place for many people that want that degree of empowerment and that degree of control of their therapy. But we think probably the larger number of new patients to home will come from the incident population of patients and patients that can go through adequate training and education about what their options are and to make sure that this concept of transitional care units offers an opportunity for people to see to what degree they can be participating in their care. For your second question, the data collection needs, I think, continue to be of great interest to us. And we think in the home environment, whether it's peritoneal dialysis or home hemodialysis, the ability to collect individual treatment level data as well as data about the environment in which the patient is either getting their care or at home offers opportunity for us to have actually enhanced data sets from what we get strictly in environment. The Next2Me app, as an example, offers an opportunity for us to collect detailed treatment information from the treatment and add that to our various data warehouses for sort of analytical use. And I would say the team at NextStage that has developed that has done a really, really nice job at creating a very usable tool as well as one that provides a wealth of information for our medical office scientists to look at. And then finally, I would say on the data collection side, the opportunity to embed systems through the connected health environment that give us the chance to use our advanced analytics identify people with special needs will allow us to direct our caregivers in a much more specific way to those patients with the highest level of need. And that's an enhanced area that will occur with any of these modalities that we've talked about today. Okay, great. That's very helpful. Thank you. The next question comes from the line of Veronika Dubajova from Goldman Sachs. Please go ahead. Good afternoon, gentlemen, and thank you for taking my questions. I also have two, please. My first one is Rice, you alluded to 2019 being an investment year and you're ramping up the number of clinics, the number of nurses. When you think about the business on a five year and the sort of objectives and ambitions you have in home, how much more investments will you need to be making beyond 2019? Are you going to be one third of the way there, two thirds of the way there, 100% of the way there by the end of this year? If you can talk to that, that would be helpful. And I'll ask a follow-up after that. Veronica, it's Rice. So I would say that I think investment as we've talked about investment year, I think we see that in 2019. I think there'll be some spillover in 2020. I don't really believe that we even know today exactly every dollar we're going to spend and exactly where it's going to go. We have a good feel for 2019. There'll be some things that we probably decide we need to shift investment in, in 2020. And part of that's circumstantial. I mean it could be that we decide we need to do something different in the distribution network or not. So we'll have to see exactly where that goes. But I think on a five year window, I think we invest 2019. We do some investment in 2020. And then I think we see where the growth in the percent of treatments at home is and how that's evolving and then where do we go from there. As you well know, if you look at the basis of the assets that we have today, usually about 50% of our capital budget is for maintenance and things like that. That may shift. That may go down some. We may do a little more because we're spending more time doing some innovation on data capture or things of that nature. I think it's something that we can easily guide you on as we go year to year. But in your my simplest answer to your five year window is expect investment over 2019 and some into 2020 and then we'll see where it goes from there. And I think we can comment on that. No, that's very helpful. And then my second question was, there has been have been some statements from CVS about their intentions to move into the dialysis market and primarily through home. I mean, how do you think about sort of these disruptive players, if I can call them that way, are thinking about mostly building at home infrastructure with very limited in center footprint? What would that mean for you? So I'll give you a general comment and then let Frank be probably more specific. Yes, we see what CVS talks about. It is, in my personal opinion, a moon hot that you're going to think you're going to take the pharmacy that's on the corner of Main Street in Brookfield in Andover, Massachusetts, where I go, and you're going to have patients going in there, and they're going to get checked out by a general practitioner, not a nephrologist. You're not going to treat them there. So what's going to happen with that? It's a great story. I haven't seen a lot of detail around that story and how they're going to get licensed to do that, etcetera. So I have lots of questions that I could ask. But on the side of appearing to be just too negative, I won't do that. But we have a gazillion questions that I would say, Veronica, about how they really pull this off. And I do call it a moonshot because there's no infrastructure, there's no technology. So it doesn't mean they can't partner or go with somebody, but I think they've got a lot of work to figure that out. But as a physician, Frank is far better to answer this from a CVS perspective perhaps than I can. Veronica, thanks for the question. Patients with end stage kidney disease and the comorbidities that they have are complex patients to care for. These are not people that you can adequately do sort of a quick superficial assessment and actually necessarily know how to help them best. So our view is that I think for all of the startups that have whether it's CVS or others that have begun to develop initiatives, they are highlighting the needs of patient centered care. And that level of patient centered care and the complexity of it, we think we are still in the very best position to provide that combination of technology, therapies, diagnostics and services that allow choice for patients across the broad spectrum everywhere from transplant to supportive care. And I think that the opportunity to put the whole picture together in one end to end frame is our greatest opportunity as an organization. And frankly, I don't know whether others can do it. They can certainly develop techniques to try to help patients and evolve that. But we still think we are in the best position to try to make this highly scalable for any patient that's in need. And that's our goal as well as making sure that as this begins to evolve in other markets around the world that we are there to meet the needs as that delivery system begins to recognize patients that need power and choice for their therapy. That's great. Thank you, Val. The next question comes from the line of Chris Gretler from Credit Suisse. Please go ahead. You. Morning or afternoon. Ries, Frank and Dominik, I have a question related to drugs actually. Could you discuss the use of dialysis related drugs for home hemo dialysis patients versus in central dialysis? Is that any way different on average? And do you see actually no difference in compliance rates among those patients relative to in center dialysis? Yes. So I'll take that question, Chris. The direct utilization in our patient population at home today, they require a few less medications. We, many of the adjacent diseases that we are treating with patients with kidney disease, we found some oral equivalents that we've been able to provide to patients that make it a little bit easier to administer them. And I think with our anemia management, we found that the long acting agents, even for our home population, have worked well because the intensity of having to provide those medications and the opportunity to use a prefilled syringe has been logistically much easier. So with all of that in mind, I think that the end stage kidney disease patients doing renal replacement therapy, the goal is to try to create a treatment and a precise prescription for them so that their drug needs are as minimized as possible. It's one of the debates that I mentioned earlier around the frequency of dialysis is highly related to the amount of high blood pressure medicines that people take and the opportunity to control that subtle volume increase that drives more medication usage. So we're very active in the looking at the science around that and trying to be substantial contributors into the debate that's going on with regard to how to manage these subtle volume changes in patients and protect their cardiovascular system. We know there are other drugs coming onto the market that may have cardioprotective effects. We know that there are some that we don't yet whether they will in fact have any cardioprotective effects. These are all some of the things that we're actively looking at both from the scientific side of our medical office, but also from the standpoint of the ventures group that Rice mentioned. All right. Thank you. Appreciate it. Next call comes from the line of Julien Dormois from Exane. Please go ahead. Hi, good afternoon gentlemen. Thanks for taking my questions. I have two. The first one relates to the Slide number four, where you highlight that patient growth of the home hemo should accelerate toward 11%. What is your degree of confidence in that, bearing in mind that it has slowed quite a bit of late? Is that a direct consequence of the investment that you are putting into the space? Or should you should that contribute also from the investment of others? And the second question relates to the how you will judge the success of this home initiative. What are your KPIs on that side? Is it about the treatment the percentage of treatment that will be delivered at home? Is it about the revenue growth in that space? Or what KPI do you have in place? Julien, hi, it's Rice. So what I would say relative to the growth that we see for home hemodialysis and the fact that, yes, we're up in double digit as we project out 2018 through 2023. If I take just a simple indicator of looking since we actually closed the NxStage deal nine weeks ago, ten weeks ago. First full month we had, we saw the highest percentage of starts at home education and training for patients that we've ever seen. So I think that, that is a figure. I would say low double digits, somewhere in there. I think that's a rational way to look at this. We believe that it is absolutely going to be doable as we go through time. And remember, this is on a worldwide basis. So let's not just get too myopic, if you will, just on The U. S. Even though we're sitting in Boston today talking to you, it's a global figure. And then I think secondly, what I'm going to say, and I'll pass it over to Frank relative to how we judge the success of home. I think one of the key things there will be do we see a growing percentage of our treatments done at home because if that's growing, it tells me that it must be good for patients and they their physicians and their families want to do it. And then obviously, I think for me, the clinical outcome, if we are truly able to see that patients are healthier, mortality rates are lower, there's less hospitalization, we view all of those types of parameters, which are really no different than we see in center. We measure those same sorts of things. That tells me we're seeing success. And if that's working, then the P and L should work. But Frank, you may want to give a more sophisticated answer than I did. Thanks, Rice. I'm not sure, Julien. It's more sophisticated, but I would say I go back to our value equation. Our value equation is quality, service and cost and recognizing that if we can enhance the quality of life for patients, their experience at living a life with kidney disease and their satisfaction with the therapy choices that they make and have, it offers us the opportunity to have that side of quality advance. If we look at the harder outcomes of hospitalization and other things that impacts value as we look at a value based care environment and recognize that some of this is stimulating choice and empowerment of the patient and whether that occurs through product internationally for home therapy as an option or whether that occurs in a value based care payment system model like we are testing through the ESCO environment here in The U. S. And then finally, the ability to I think we will judge success a little bit by the ability to lead in the development of a new organized delivery system that is cost effective for patients in treating them at home. We have developed a very deep and extensive set of KPIs for in center hemodialysis and that's part of how we look at the business. And we think that the system of care for home patients will be as deeply evolved as we understand the components of that organization, what really is required to work. Thank you very much. We have a follow-up question from the line of Michael Jungling from Morgan Stanley. Please go ahead. Thank you. I had two more. Firstly, when it comes to NxStage, when will you commercialize the company's home PD solution? I don't think I either I missed it or you didn't mention it in this call. And then question number two is in relation to employee health plans. Can you talk about the willingness for them to pay five to six treatments per week, please, sort of the trends in The U. S. With respect to these employee health plans? Michael, it's Rice. So on home PD or online PD, if you will, the simple answer for us, looking at where NxStage was prior to the acquisition, I think I'll say this correctly. They were probably somewhere around two to three years out of believing they were going to be able to commercialize that. We had a product that we were looking at. And so what we've done since we've gotten together is we're kind of looking at both sets of those ideas and which is the best way to go forward and how are we going to do it. So I'm going to leave it with probably that two to three year time frame. I would also say that probably one of the largest, if not the largest unknowns in here beyond just the technical feasibility is what the clinical trial ideas are that the FDA is going to have because obviously that will be key as well. So we've had some discussion with FDA and they don't know exactly yet what they want to do. So we'll have to see where that goes. And then secondly, on employee health plans or just more multiple treatments, if you will. Obviously, what we expect and what we see from time to time is we know that with appropriate medical justification, we see the U. S. Government will pay for a fourth treatment. So as long as the physicians are writing and communicating in the right way, we see reimbursement there. To go more than that, five or six times, it really depends on the benefit that the payer sees from lack of hospital days, better outcomes. You have some of that that goes on in some cases. So I do think it will come back down to where the payers want to see this go if they believe paying for an additional treatment gets them x percent of improvement in terms of less hospital days, etcetera, I think all of those things come to work in our favor. But I'll turn it back to Frank as well because he may have a comment in a little more detail. Yes. Michael, my only comment is I think the evolving science that's occurring is something that will help us determine whether, again, these more frequent methods and to which patients the more frequent methods will, in fact, have the greatest clinical impact. And in doing that, the opportunity is to try to make sure that policy stays in sync with science as the science advances and that the opportunities to try to understand which patients are going to benefit from which kind of treatments. As you know today, with peritoneal dialysis, it's every day. It's happening seven days a week. And the question will be how do we create the environment that we're working closely enough with policymakers and advocating to recognize that as the science evolves to really understand what is most cardioprotective for this group of patients that we, in fact, make the have those options available to patients and have a system of care that will allow for that. So if look at Slide four and I look at your patient growth profile for home HD, are you making the assumption that you'll start to see an improvement in these employee plans going to maybe four, five, six per week to help the adoption? So Michael, no. Quick answer is we've taken a position of conservatism and seeing it predominantly be three, maybe four times. We've not run ahead ourselves and try to pump a bunch of optimism into what we think the frequency will be in those figures that we're showing you are under the same assumptions of what typical home is seeing today in terms of how many treatments in the course of a week. Thank you. Next follow-up question is from the line of James Van Tempest from Jefferies. Please go ahead. Thanks for taking my follow-up questions. Just one, if I may. Can you remind us, how should we think about your network of clinics as more patients are treated at home? Should we anticipate an increasing rate of closures? What do you plan to do with the excess capacity? Hey, James. Good question. So I think you should save that question, and we'll come back and ask us in three, four years. We'll have a better idea of where that's going to go. Well, look, here's as Frank and I tried to convey, here's the way I look at this. If we are going to be the company that stays with a patient from the beginning to the end, whether it be the example that we saw with Vanessa who was in center, transplanted, came back, etcetera, we want to be there for them. That's always going to mean that we're going to have clinics. And what we may find is that those clinics, because we have a larger percentage of patients at home, those clinics have a little spare utilization capacity. And so we're able to create opportunities for a home patient that maybe doesn't want to put their spouse through having to continue to do the connection for them if it's a home hemodialysis patient. And he says, I'd like to have a couple of weeks off. I want my wife to get a break. We'd like to have enough freed up capacity in our clinics that we can have them come and do that. So we don't know exactly yet. We are not sitting here trying to plot, well, how many clinics can we shut down and what do we do. We're going to take that as it comes. But inherently, we believe the clinic some clinics will close. We may open up clinics up in other areas where populations have shifted. Net net, it will take time for us to see where this goes. And we're looking at and interested in being able to manage labor better. So yes, that gives us an opportunity if we grow home. But it's not so much that we want nurses to leave and not be with us. We'll have them doing other things that are higher touch for patients. And maybe we create enough headroom in clinics that we can have people come in and get their treatment in center if they want to respite from being at home or if they've left their machine at home in Boston and they've gone to Florida for a month because they're down there for the winter and they need a spot in the clinic, we want to be able to do that as well. That then kind of creates a situation where we have to make sure patients have the right access for hemodialysis or peritoneal. We have to be flexible in what we offer them, but we believe beginning to end, there'll be some of all of these things that we'll offer patients. It will take us some time net net to decide is that a significant change in the number of clinics that we have over time. Thank you. Next follow-up question is from the line of Veronika Dubajova from Goldman Sachs. Please go ahead. Thank you for taking my follow-up. I have two please. The first one is just, Rick, can you remind us where are you with your sorbent technology, if anywhere I recall we talked about that a lot a few years ago, but I'm not entirely sure how far that's progressed. And then my second question is not really about Home, but Frank, since we have you on the phone, it'd be great to get your thoughts on whether you think that CMS and regulation can do anything to shift transplant rates. I think your biggest peer and competitor has highlighted that they see rates kind of going up, and that's had an adverse impact on volume growth in the market. How are you thinking about it from here? So Veronica, here's what I would say. We've gotten very comfortable and very happy with the sorbent cartridge as it's developed, and we've been pleased with it. What we've been working hard on and haven't been completely or even that much successful is using that cartridge and finding the right hemodialysis equipment to drive the process through the cartridge, if you will. Fortunately for us, we've had a chance to talk about this with NxStage. They've got some great ideas on the machine side. And so the engineering groups from both companies or the two previous companies are talking and looking at it. But comfortable that the cartridge and the sorbent will do what we wanted, but you can't run the car without wheels. So we've got to have the piece of equipment that will give us the most repeatable performance in a time window that we think makes sense and would be of interest to patients in terms of the duration of their treatment. And this has proven to be harder than we thought. But I always thought the cartridge would be harder. But we've done really well with that, but we've got to get the right equipment to drive it. So still in process, but I'm feeling better because we've a lot more smart folks involved looking at it. So we'll see where it goes. Frank, I'll give you the number two. Sure. So Veronika, thanks for asking about transplantation. Our view and my view of transplant is that it is for many patients, it can be a preferred therapy for end stage renal disease. But the transplant patient is still a patient with advanced kidney disease. And the opportunity has changed a little bit. We have seen transplant rates increase a little bit, but it's still quite an imbalance of the number of people waiting for a transplant to the organs that are available. Mentions elsewhere that the opioid crisis has made large difference. It has changed the background of the patients that are getting organs from cadaveric transplants. There have been in the past year slightly fewer living donor transplants. And today, we have a little over 30,000 patients going on to waiting lists and about 30,000 being removed from waiting lists. This year is one of the first years where we're beginning to get measured on transplant waitlist status. And I would tell you in my conversations with transplant programs and surgeons, there are some harmonization that needs to be done between the measure systems for transplant programs and the measure systems for dialysis facilities. So there's quite a bit of work to be done to avoid unintended consequences around transplant. But we think transplant as a method of treating end stage renal disease continues to be a very, very important one. And we are investing some of our activities within the company and trying to open a continued dialogue with our transplant colleagues and understand what our role is in affecting better waitlist management, in affecting better desensitization and in identifying potential donors. And with that, we think that there will be a role that Fresenius Medical Care can play in the transplant community and the transplant process going forward. We aren't seeing any fewer end stage renal disease patients due to transplants in our clinics today. We still recognize that a fair number of our new patients to dialysis are patients who are returning from a failed transplant. And the care for those patients continues to need to have some special clinical needs and some highlighted tension, and that's one of our other clinical agenda projects. That's great. Thank you, guys. Okay. So thank you, everyone, for participating today. We have no more questions. I hope we have been able to increase your understanding of the medical background and our business a bit more. Please be informed that the next Meet the Management event is a site visit in St. Wendel in Germany on June 27. So this is a physical event only. So there will not be a webcast or transcript available. That's a little bit difficult on a tour. We hope to see you there. And Jose, thank you for participating. Thank you. Appreciate your time on a Monday morning or a Monday afternoon. Thanks a lot. Ladies and gentlemen, the conference has now concluded and you may disconnect your telephone. Thank you for joining. Have a pleasant day. Goodbye.