A very warm welcome to everyone, wherever you are in the world, to the Fresenius Medical Care Capital Markets Day. My name is Dominic, and I will have the pleasure to guide you through the event. Today, all members of the Fresenius Medical Care management board came together to reinforce our overall strategic plan, share for the first time the financials and their view on the respective new operating segments, as well as the turnaround plan to achieve our 2025 margin ambitions. After the presentation, all will be available for Q&A. For your information, we have just published the accompanying press release to the Capital Markets Day, which includes the unaudited 2022 financial data in our new reporting structure. There is no need to look at it right now, as all will be covered by today's presentations.
To positively support the event experience for all of you, I would like to start with some housekeeping remarks. In case, which we don't hope, you experience technical issues with the access, please notify us via our email address, ir@fmc-ag.com. With regard to the Q&A session, I would like to point out 2 things. To be able to ask questions you have to be registered for and dialed into the telephone conference that runs simultaneously with this webcast. The registration link for the conference call was sent out to the 5,000 investors and analysts that have subscribed to our distribution list. Those of you who regularly join our quarterly earnings calls will know the procedure well. Through the conference call system, you will be able to notify us of your questions. You will be called by name when it is your turn to ask live.
Thank you for your understanding that due to the time for Q&A and being limited to 45 minutes, it is not possible to open the Q&A session to all webcast participants. You will, of course, be able to follow the Q&A via the webcast without being dialed in. To ensure that as many participants as possible get the opportunity to ask their questions, we will limit the number of questions to a maximum of 2. We might encounter a situation where we run out of time, or maybe there will be no further questions as everything was presented so well. Just as a precaution, I do already apologize should we not be able to take all questions. All slides presented today, as well as the replay of the entire event, will be available on our investor relations website shortly after the event.
At this point, I have to cover my most favorite part of the introduction and mention our cautionary language that is in our safe harbor statement, as well as in our presentations. For further details concerning risks and uncertainties, please refer to these documents as well as to our SEC filings. Just in case you have started wondering what these white lines on our slides and on the background are, those are the famous polysulfone fibers out of which our dialyzers are made, the base and heart of our innovation history. What is awaiting you today. Let me first introduce today's speakers in the order in which they will be presenting. With me today is our CEO and Chair of the Management Board, Helen Giza, who is at the moment also our acting CFO and Chief Transformation Officer, and to make it shorter, I usually call her CXO.
Helen joined Fresenius Medical Care in 2019 as CFO, and took office as CEO in December 2022. You all know Helen very well already. Helen will guide you through our concrete plans on how we unlock value as the leading kidney care company, and she will share with you for the very first time our unaudited 2022 financials in the new reporting structure. Also with us today is Dr. Frank Maddux, our Global Chief Medical Officer. Frank is an expert nephrologist and healthcare executive with more than 30 years of experience in healthcare. He joined the management board in January 2020. Frank will provide insights on various medical aspects that influence the patient volume development. We have here with us Bill Valley, who is the CEO of our new Care Delivery segment that covers healthcare services globally. Bill has more than 30 years of experience in the dialysis industry.
He joined Fresenius Medical Care in 2009, and was appointed to the Management Board in 2017 as the CEO of the North American business. Bill will provide insights into the new operating segment, the turnaround plan, and the strategic ambitions for this important segment. Last, but for sure not least, we have Dr. Katarzyna Mazur-Hofsäß with us, who is the CEO of our new Care Enablement segment, in which we have consolidated our healthcare products business under a global MedTech umbrella. Katarzyna is a medical doctor by education and has gained extensive international experience in executive general management positions in the healthcare industry in the last 25 years. She joined Fresenius Medical Care in 2018 as Management Board member for EMEA.
Katarzyna will provide insights into the new operating segment, the heavy turnaround plan, and the strategic ambitions for this new segment. After Katarzyna's presentation, it will be finally your turn. In the joint Q&A session, all presenters will be available to answer your questions. Having said all of that, we can now start. We very much hope you will enjoy this Capital Markets Day, and if you do not, please don't tell anyone. I will now hand over to Helen.
Welcome, everyone, to our 2023 Capital Markets Day. Thank you for joining us for this virtual event, and thank you for your continued interest in Fresenius Medical Care. It is great to be here with my fellow colleagues from the management board. Echoing Dominic's introductory remarks, the goal of today's event is to give you deeper insights into the operational turnaround we are undertaking to improve profitability. We have a clear aspiration to unlock value as the leading kidney care company and a clear path to achieve that. Before I go into the details of this broad and comprehensive turnaround plan, which is already under execution, I would like to begin by highlighting the great assets and market-leading positions we already have today. Now we have the opportunity to further capitalize on this strong base as we embark on the next chapter in the company's history.
As the leading worldwide vertically integrated kidney care company, we run the largest dialysis network, serving around 345,000 patients at over 4,100 dialysis centers globally. In the U.S., our largest market, we are creating and expanding the market for home hemodialysis treatments and are the market leader for value-based care in the renal space. Our very strong position in the service market is complemented by our market leadership in the renal med tech space. Our products serve around half of the world's dialysis patients, with a presence in 153 countries. We are the clear number one for both in-center hemodialysis machines and home hemodialysis machines. We have a smaller but still meaningful market position in peritoneal dialysis machines, ranking second worldwide.
What really makes Fresenius Medical Care a great company is how all of our employees around the world are united behind a common vision of creating a future worth living for patients worldwide every day. The care and commitment of our employees is incredibly inspiring and widely acknowledged by our patients. There are so many wonderful stories I could share from the heroism of our teams in the Ukraine and in Turkey, and infinite everyday examples of how our employees go above and beyond for our patients around the world. I think it's more powerful to hear directly from one of our patients, in this case, Raymond.
The doctor sits there and tells you your kidneys have failed. This doctor was talking about the different types of dialysis, but I wasn't hearing him. All that was going through my mind was: How long do I have to live? What's gonna happen to me? What's gonna happen to my family? 25 years I have never been neglected. All you need is someone to just listen for a second, you know, just to have an understanding. You guys are having an impact on dialysis patients' lives and families throughout the world. Thank you for the late nights that you were at work. Thank you for your dedication and your discipline. May God continue to bless and shine his grace upon you and your families.
Hearing directly from our patients keeps us all grounded in our purpose. Our purpose-driven, patient-centric approach extends to our broader commitment to sustainability. We keep accelerating sustainability in our business. We successfully completed our three-year global sustainability program, during which we implemented global sustainability standards and measurements. Based on the results, we committed to a new set of 2023+ global sustainability targets and have sharpened our priorities. We focus on enhancing the quality of care and access to healthcare with the goal of improving patient outcomes and experience while providing high-quality services. For example, we aim to keep our patient Net Promoter Score at its current excellent level of 70 or above. I'm also proud that we have signed the Zero Health Gaps pledge to underpin our commitment to health equity. A key priority is to build the best team to serve our patients.
This is a global commitment and senior leadership responsibility. We want to increase the share of female leaders in the first and second levels below the management board to 35% and 45% respectively by 2027. Just last week, we signed the United Nations Women's Empowerment Principles as a sign of our commitment to gender equity in the workplace. A further focus is on engagement of our employees worldwide. Our target is to increase the employee engagement score to the industry average of at least 63% by 2027. We have expanded our set of targets to reduce our environmental footprint, and last year, we had announced our commitment to achieve climate neutrality for our operations by 2040. Over the coming years, a strong focus will lie on assessing the sustainability performance of our portfolio and making our products and services sustainable.
Many of you will have heard me say this before. I'm a firm believer that culture eats strategy for breakfast. None of our turnaround measures will be successful if we do not have a winning culture in place. At the heart of that is our commitment to diversity, equity, and inclusion. Our DE&I strategy is broad and intentionally exclusive with the belief that advancing DE&I benefits all employees and our business. It is imperative to be able to attract, retain, and develop a world-class group of employees at all levels. Many of our initiatives in this respect have been pioneered in the U.S., such as the creation of a corresponding council and establishing the opportunity to create or join employee resource groups. The next step involves expanding established programs across our global footprint.
We strive to become the employer of choice and advance on the KPIs I just described. I'm sharing a slide that you all know by now, but we have updated the projection range from the historical 2000-2030 to the more relevant timescale of 2020-2035. I remain encouraged by the fact that the underlying key drivers of our core dialysis business are strong. The global population continues to age, and we continue to see increasing incidents of hypertension and diabetes. With that, we see growing incidents of end-stage renal disease, and as there is no alternative therapy, the increasing need for dialysis treatments. Yes, we experienced a temporary disruption in our patient growth due to the unfortunate impact of COVID-related excess mortality.
This disruption was further exacerbated by unprecedented labor challenges, hindering our ability to grow patient volumes at the levels we would like to. However, these disruptions are temporary in nature, and our latest forecast for growth in the dialysis population worldwide remains solid. We have Frank with us today, and he will go into more detail on trends in the growth of patient numbers during his presentation. To recap, the leading market positions in structurally sound and growing markets provides us with a solid base to profitably grow. In February, I shared my overarching strategic aspiration to unlock value as the leading kidney care company and to improve shareholder return. Our strategic roadmap starts with having an optimal structure in place. This includes a simplified governance structure and our already implemented global operating model, which now allows for financial reporting transparency on our two different businesses, services and med tech.
As previously committed, with the reorientation of the company from regions to segments, we are now in a position today to disclose the profitability of these two businesses. While this is a historic moment for the company, you will see that the baseline profitability in both of our segments falls short of our aspiration. We will outline the building blocks of the turnaround plan supporting our 2025 margin target. This will include our FME25 transformation program, as well as additional operational efficiencies and other measures. Another important step is taking a rigorous approach to capital allocation, and I have implemented a disciplined financial policy to drive the much-needed improvement in our return on invested capital. I will share later how I'm thinking about the portfolio optimization while limiting distractions from our core businesses, and we're already executing on this as we speak.
As I described earlier, it is imperative to have a winning culture in place to be able to achieve such aspirations. Beginning with our governance structure, the announced intent by Fresenius to deconsolidate Fresenius Medical Care and the proposed corresponding change of legal form to a German stock corporation would significantly simplify the governance structure of Fresenius Medical Care. With this change, we would move from a controlled structure with several decision-making boards to a standard German two-tier system with one supervisory board and one management board. This will strengthen the rights of the free float shareholders. Additionally, there are important business relevant benefits. This proposed governance structure would enable faster and more agile decision-making, and it provides more optionality on our future strategic direction. The potential change removes the operational and coordination burdens of being part of a larger group organization.
It frees up time and capacity of the executive and management team and enables them to focus solely on Fresenius Medical Care and the tasks at hand that we are presenting today. The conversion of the legal form, including the preparation of the carve-out and all the administrative filing requirements, are progressing as planned. The one-time costs associated with the change of the legal form and corresponding carve-out measures are assumed to range from EUR 50 million-EUR 100 million, which we will treat as a special item. A key component of our FME25 transformation program was to install a new global operating model. Since the beginning of this year, we have been operating in this new model. We now have two operating segments with complete end-to-end P&L responsibility. Care Delivery, our dialysis service business, and Care Enablement, our med tech business.
This new model positions us to truly realize the full extent of benefits from our vertically integrated business model. We are now able to leverage infrastructure and fully allocated leaner global G&A functions for the first time. At the same time, we continue to utilize the latest scientific developments, data technology and connectivity driven by our global medical office across both segments. On the services side, our Care Delivery business benefits from early access to innovation in dialysis MedTech, as our Care Enablement business continues to pioneer dialysis of tomorrow. On the MedTech side, our Care Enablement business benefits from predictability and scale and supply chain as internal sales are a meaningful component given the size of the clinic network we operate in Care Delivery. Altogether, as a vertically integrated business, we are able to set the standard of care for the dialysis industry.
Our new operating model allows for a simplified reporting around our two global business segments, which enables us to show the capabilities of Care Enablement by showing internal revenues as well. This way, a comparison directly to our peers should become easier for you. As you can appreciate, the administrative burden of reorienting our financial reporting has been significant. We just published our unaudited new segment view for full year 2022 and the first quarter of 2022 to enable you to understand and potentially start modeling in the new reporting structure. On this slide, we highlight our new reporting framework for revenue. While the number of data points is less, the data points provided are based on the new structure and are more relevant to the way we run these businesses. Care Enablement will report its total global revenues, including internal revenues, to enable a peer comparison.
Care Delivery revenues will be reported as US and international. This should enable the most requested peer comparison basis on a revenue level. In this new setting, we are now able to share a clear picture of the profitability of our two global business segments, which also enables a better peer comparison. This has been such a massive undertaking. This is step one in many ways to the level of transparency we have all wanted, and we will continue to evolve over time. Internally, we now have a transparency we have never had before, and that was much needed. This is the basis to drive targeted improvements in our business performance on which we are already executing. Previously, we reported operating income on a regional basis with a rather large bucket of corporate costs, which included functions like manufacturing and R&D.
Manufacturing and R&D have moved to Care Enablement and G&A has been fully allocated to the two segments. Our corporate bucket is significantly reduced. We are able to show a comprehensive operating income breakdown between Care Delivery and Care Enablement, and thus the underlying margin. We thoroughly evaluated options of how to present income margins on a more detailed level. We are trying to strike the right balance of transparency and competitive insights. You all know I'm clearly unhappy with where our total profitability stands today. In particular, the Care Enablement margin of 1.9% is nowhere near where a margin for a leading med tech business should be. Clearly, the inflationary environment has significantly weighed on profitability. However, finally having the transparency into these operating income figures enabled us to focus on where we needed to improve and to develop targeted initiatives.
With our new operating model in place, we have been able to identify extended opportunities for savings as part of our FME25 transformation program. As communicated in February, we expect increased sustainable savings of EUR 650 million by the end of 2025, with one-time costs of up to the same amount. We have talked for a while about the margin pressure that our Care Enablement segment faces. For that reason, it does not come as a surprise that the increased scope of the FME25 program comprises additional opportunities to improve the profitability in Care Enablement. Around 48% of total program savings are expected to come from Care Enablement and relate to increased manufacturing efficiencies and improvements in home and critical care portfolios.
Care Delivery is expected to contribute around 7% of total program savings, primarily from volume growth and increased efficiencies in the U.S. clinic business. Finally, G&A across the entire company is expected to contribute around 45% of total savings. This comes from globalizing functions like IT, finance, and procurement improvement measures. These are not just numbers in a plan. I'm really proud of what we have already achieved with FME25. Through 2022, we spent EUR 270 million in one-time costs and already achieved EUR 131 million in sustainable annual savings. We are well on track with the execution against our plan. To date, G&A efficiencies have been the greatest contributor. In addition, we have achieved savings from clinical operational efficiencies in Care Delivery and the first savings on organizational and productivity efficiencies in Care Enablement.
These are important proof points of our commitment and our ability to execute. Now that we are running our services and med tech businesses as the distinct businesses that they are with full P&L responsibility and leadership accountability, we have identified additional opportunities to increase operational efficiencies within each of those businesses, and we have identified the key drivers for the turnaround. In Care Delivery, the turnaround will be supported in the US by increasing the operating leverage and by improving rate and mix continuously. Of course, further growth and operational efficiencies in Care Delivery international are an important driver. We are growing our value-based care business with InterWell Health, and we see this as a key strategic success factor supporting our core dialysis service business. It is a profitable business and contributes to profit growth.
By nature, it comes with a lower margin due to the significant pass-through element of the medical cost under management. In Care Enablement, we are tackling further measures to counter inflation and drive margin expansion. These include pricing, contracting, and direct procurement. Market growth in the non-U.S. markets will be an important contributor to enhanced profitability. Additionally, we are executing in some other identified cost improvement areas like PD logistics. In the important U.S. healthcare services market, we are continuing to progress our key strategic growth drivers. The reimbursement model for dialysis patients continues to shift towards value-based arrangements as both U.S. government and private payers focus on way to improve clinical outcomes while reducing overall healthcare costs. We are playing a leading role in transforming this space.
Our resources and know-how to treat ESRD patients holistically is second to none with our market leading database and AI capabilities. With the three-way InterWell Health merger finalized in 2022, we have significantly stepped up our capabilities to manage CKD patients as well. By 2025, we expect to manage roughly $11 billion of medical costs, generating around $2.3 billion in revenue in this space and covering around 270,000 patient lives. An important differentiator is that we are already profitable in managing value-based contracts. Although the nature of value-based accounting is margin dilutive, our growing value-based care book of business will be operating income accretive overall and ensuring a smooth transition of CKD patients to dialysis, reducing the number of patients that crash into dialysis.
Home dialysis represents another key strategic initiative for our business, one that goes hand in hand with value-based care and the goal of improving patient outcomes while reducing healthcare costs. We are uniquely positioned to support and expand our dialysis patient population being treated at home, I am proud of our leadership in this space. Home dialysis is not only important for patients, as it has demonstrated higher patient satisfaction and improved quality of life, it also supports margin improvement for our Care Delivery business, as it substantially reduces labor costs and provides the opportunity for additional treatments per week. Around 16% of treatments in the U.S. are currently done in a home setting.
Our aspirational US home dialysis treatment target of 25% is potentially delayed by 18-24 months due to the longer than assumed continuation of the pandemic in 2022, and unprecedented impacts from labor shortages. We have a clear execution path to the margin improvement that we are showing here. This includes meaningful margin improvement in each business segment. We expect 2023 to be a year of level setting, with an operating income margin below 2022. By 2025, we expect to see a significant increase of our operating income margin to a range of 10%-14%. Care Delivery will increase from a 9.5% margin to a 10%-14% range by 2025, and Care Enablement will grow from a 1.9% margin to an 8%-12% margin range by 2025.
FME25 will be an important contributor to the margin expansion. On top of that, we have targeted plans to drive operational efficiencies in each of our business segments. Bill and Katarzyna will walk you through the individual drivers in more detail in their prepared remarks. I'd like to share with you our assumptions for our 10%-14% margin target. Given the midterm nature and the size of the range, I won't provide detailed numbers as I usually do for the actual year. However, I think it's helpful to share some key assumptions, and my colleagues will provide some more color in their presentations around those as well. Of course, we expect that we continue to execute on our FME25 program. We assume across the universe of Care Delivery, only moderate reimbursement increase. Those will of course, vary significantly by payer and country.
From a volume recovery, we carefully assume that we will return in the U.S. to a moderate growth in patient numbers within the guidance timeframe, and a normalization in the U.S. to 2%-3% at the latest by the end of 2025. Furthermore, we are assuming that the labor situation and inflationary cost developments are not disappearing, but stabilizing after 2023. The already mentioned expected strong growth in our value-based care business has a margin dilutive effect and consequently contributes in a meaningful way to the size of the margin range. Clearly outside our margin guidance range, due to uncertainty of timing and opportunity, are our activities around the portfolio optimization. We will treat related costs and proceeds as special items.
To turn around our business performance, we need to reduce distraction and focus on our core businesses, as well as to focus on the right R&D portfolio. This slide gives you an idea of the portfolio analysis we have carried out across the assets we own, as well as some major investments. This includes our core assets like dialysis services U.S. as well as international, and the three areas in our MedTech portfolio in center, home, and critical care. Additionally, it includes the other assets and investments we own. For each asset, we have evaluated their growth potential as well as their strategic value to Fresenius Medical Care. This includes proximity to our core dialysis business, the level of vertical integration, the revenue and profit profile, as well as the ability to scale the businesses globally.
While none of these assets fall directly into the divest category, quite a few are under assessment. Here we will determine if it makes sense to turn the business around or if they might be better off with a different owner. Additionally, our portfolio optimization also includes a full review of our R&D and manufacturing portfolio. Where we do not see commercially viable and profitable product offerings, we will quickly close down existing R&D programs, and consequently, we will write off the associated capitalized R&D investments and treat it as a special item. This is one of the clear steps towards a disciplined financial policy and return on invested capital focus. In addition to the operational improvements and portfolio optimization, we are also working towards strengthening our financial position with a disciplined approach to capital allocation and improving our return on invested capital.
Given our current leverage position and the high interest rate environment, deleveraging is a primary capital allocation priority. We are committed to maintaining our investment grade status and to managing our net financial leverage in the self-imposed range of 3 to 3.5 times. Any potential proceeds from portfolio optimization will be used to de-lever. We are committed to a dividend policy in line with our earnings development, and as such, have proposed a dividend reduction. Finally, with a clear focus on driving organic growth in our core portfolio, our investment activities will be limited. Our current return on invested capital is not acceptable, and we have a clear ambition to significantly improve our ROIC by 2025. Our ambition is to double it from where it stands today. We are quite comfortable with our current credit profile and do not anticipate any changes in our financing strategy.
Over the last year, we have successfully increased our average maturity as well as our share of fixed rate debt as we took a conscious decision to benefit from the attractive interest rate environment. Currently, 87% of our debt is at a fixed rate, and our average interest rate is 2.2% with an average maturity of 4.7 years. Our long-term refinancing needs are relatively limited until 2026. That brings us to the final slide of my prepared remarks. I've spent a lot of time talking about 2025 and our path to margin improvement. While I am not going to introduce a new strategy post-2025 today, I do not want to leave you with the impression that we are not thinking beyond 2025.
Rather, I believe we are just at the beginning of a new chapter in Fresenius Medical Care's history, and I would like to share at least some ambitions beyond creating direct shareholder value. We want to be the partner of choice, setting the standard in kidney care with industry-leading returns. That means in Care Delivery, we are the service provider of choice for all stakeholders across the renal care continuum, and we lead the market in therapies, digitalization, value-based care and home dialysis, and of course, are operationally excellent. In Care Enablement, we will profitably shape the global dialysis market with our leading digital portfolio in renal therapies and continuing our long history of pioneering the renal care of tomorrow. On top of that, we will have the most cost-efficient manufacturing in the industry with a future-proof product and services ecosystem.
Through support from the global medical office, we will achieve high quality outcomes for patients worldwide by advancing the application of clinical science, utilizing the world's largest kidney care dataset with longitudinal clinical data. When we describe ourselves as the leading kidney care company, this additionally includes a world-class G&A organization being the employer of choice and comprises a culture of sustainability, compliance, and innovating for the benefit of our customers while generating industry-leading returns along with a mindset of continuous improvement and operational excellence. All the while, we will retain our purpose-driven, patient-centric mission. We certainly have our work cut out for us as 2023 is a year of level setting. Thanks to our clear turnaround initiatives supported by our 130,000 employees around the world, we have a bright future ahead. With that, thank you.
I now would like to hand over to Frank Maddux to share the insights from the global medical office.
Thank you, Helen. My name is Frank Maddux. I lead the global medical office, including our clinical, medical, and scientific teams that support both the Care Delivery and Care Enablement operating segments of our business, as well as our enterprise medical and healthcare strategies. Our company's work depends on information we have or know about our patients, their caregivers, or the environments in which care is provided. Data influences the approach to our products that keep people alive with critical organ failure, medications that influence the needs of people with advanced kidney disease or in the day-to-day care of people living their lives with a critical illness.
The data we utilize is the largest repository of kidney disease care information on the planet and allows us to reference longitudinal clinical data on over 2 million people treated, hundreds of millions of treatments provided in 50 countries around the world, as well as billions of lab measurements and medications provided to people with kidney disease. We use this information to enhance the insights that are provided to patients and their providers about the journey they are on to live with advanced kidney disease. This summer, we will launch the Apollo research database, which will afford access to a fully anonymized data set on detailed clinical information that is both HIPAA and GDPR compliant.
This database will speed our ability to study and gain knowledge about the patients we are treating and to respond to the varying needs of patients, providers, and health systems around the world through this research data set that will expand our ability to collaborate on real-world evidence studies of people with kidney disease. Our medical office connects our enterprise health interests and strategies to the two operating segments under the new model. We provide medical and clinical care support to our Care Delivery network through our clinical affairs team and medical expertise for Care Enablement through our medical affairs team. Binding these segments is a team of physician leaders, scientists, epidemiologists, and advanced analytical experts that generate new research and development insights that support both product development and our model of Care Delivery.
Our education and information teams educate and inform our field about not only kidney disease, but also the comorbid conditions which are associated with kidney failure. We see chronic kidney disease, end-stage kidney disease, transplantation, and end-of-life care in the scope of our expertise and guidance for the company. Our patients suffer from multiple comorbid conditions which influence the challenges they must navigate. We have seen during the pandemic how vulnerable this group of people are through both the direct impact of the virus and the disruption of routine healthcare. These factors have had substantial influence on the development of the population of people living with advanced kidney disease. Whether hypertension, diabetes, cardiovascular disease, anxiety, depression, or physical health challenges, we know our patients suffer from the protean impact of having lost significant kidney function.
We now are covering knowledge of how social and environmental conditions in which our patients live have tremendous impact on how well they live with the disease, ultimately also their outcomes. It can be easy to take for granted that remarkable fact that our kidney replacement therapies keep people alive when their own bodies cannot. We have routinized dialysis therapies to a point that we can easily forget that this life-sustaining treatment, which is very physiologically complex, now is made to seem simple. The profiles of our patients are unique to the health systems in which they live, and we track both aggregate outcomes and those that are health system and geographically distinct. As the company has migrated to the 2 operating segments, we have also moved to a quality index, which includes looking at key factors in the clinical care of people on dialysis.
The effectiveness of the treatments delivered, along with the management of their life-sustaining vascular access and the degree to which inherent anemia of chronic kidney disease is managed, are combined to form the basis of the index, which we track across all health systems and geographies where we care for patients. We now study diversity and how standards of care influence the overall outcomes of patients. We can routinely show that organized and standardized care across diverse populations provides the best opportunity to achieve higher quality outcomes and address health equity for our patients. Our premise is that an optimal model of care from the start of a kidney replacement therapy is leveraged by measurement to achieve better outcomes through advancing the visibility and accountability for these outcomes by providers, patients themselves, and the systems of care where they receive that treatment.
People with advanced kidney disease were highly impacted by the COVID-19 pandemic. As we exit the acute phase of the pandemic, we are seeing numerous improving clinical trends today and several that need continued work. Annualized mortality is recovering to levels that are close to pre-pandemic levels or in some geographies, even periodically below. The excess mortality seen in the first three years of the pandemic is now embedded in our ongoing annualized mortality, and improvements are visible each month. We are continuing to watch and work to improve our permanent vascular access use as this was one of the most difficult areas to maintain as health systems struggled to meet these surgical and interventional demands in the face of the pandemic. This too is improving. Our measures of treatment, including dialysis adequacy, fluid management, anemia, and mineral metabolism, are all at or close to baseline levels.
We saw a drop in the typical causes of hospitalization during the pandemic as routine care was disrupted. We see routine visits slowly coming back to normal. The 10.6 days of hospitalization annually has a very wide distribution when looked at country by country. Bacterial infections remain lower than a decade ago and is one of the substantive success stories over the years. Our patient population remains highly influenced by age and diabetes. In the United States, the average age of our patients is about 63 years old and over 60% are diabetic. In other markets, both age, comorbidity, and diabetes are substantially different.
This slide shows the patterns of excess death during the pandemic in our two largest markets. In EMEA, the mortality rates are back to baseline, and in the U.S., this trend is rapidly approaching the same point as we move toward the end of the first quarter of 2023. Improvements in mortality are the quickest and most significant ways to get back to growing our patient population and treatments. We see this improving in all parts of the world. We get many questions about the interest in kidney diseases by the pharma industry and the expansion of interest since the executive order by the U.S. President in 2019. I wish to provide several comments about a few of these medication classes that are expected to have an impact on the population of people with kidney failure.
You may have seen reports of companies with cell-based therapeutic products in their pipeline that have begun to advance their clinical trial programs. These novel treatments show some promise to alter the course of someone's life with advancing kidney disease. None have yet to show curative properties, and the mechanisms of action are not fully understood, but the ability to provide someone with cells that have regenerative capacity may help slow disease progression and keep people healthier longer. Today, cell-based therapies are fraught with difficulties, including logistics of providing the therapy, as they require multiple invasive procedures to harvest cells that must undergo additional modifications and being reinfused as cells that having properties to heal inflamed kidneys. These cell-based therapies will take some time to fully understand their role and impact on the field.
The SGLT2 inhibitor class of drugs have a counterintuitive impact on our population of kidney disease patients. In the short term, they slow the progression of kidney disease without stopping it. Their greatest impact is the improvement in cardiovascular health, which is the biggest risk to the mid-stage CKD patient. In our modeling of these drugs, if we assume a high uptake of these medications at an early stage of CKD where they're indicated, we see that the impact of reduced cardiovascular-related deaths is the dominant effect and expands the population of patients with CKD with an opportunity to progress. I wish to comment about the GLP-1 agonist drugs that you've read about related to weight loss. These drugs also show on balance cardiovascular benefits that will also likely expand the population of patients with the opportunity to live long enough to have their kidney conditions evolve.
The direct impact on the number of people with type two diabetes is yet to be understood, and our modeling teams continue to work to understand the off-target effects of these drugs that might impact the progression of kidney failure. It is also not clear whether the weight loss itself has impact on insulin resistance beyond the reduced burden of obesity itself on the disease or whether the microvascular insults from type two diabetes will change and have significant impact on the development of the associated kidney disease. To summarize my prepared remarks, I see an improved outlook with the return to a more normal patient pattern of flow into and out of our ESRD population.
I'm encouraged by the degree to which I see our nephrologics analytical platform showing CKD patients coming back to our practices for care and the falling mortality in our core population, which need our services. We continue to develop our platform of advanced artificial intelligence analytics to assess the impact of novel conditions in the market and have studies underway to detail our assessment of both the growth in CKD and the ESRD populations following disruptions from the pandemic. Thanks. I look forward to your questions later in today's program. I'll now hand it back to Dominic.
Thank you, Frank. Thank you, Helen, for your insightful presentations. We will see you again later in the Q&A session. We will now have a break for all of you to get a coffee or a tea or something stronger. We'll be back in 15 minutes. I'm happy to see that you are all back. For those who manage various events in parallel, this is the Fresenius Medical Care Capital Markets Day. We will now get insights in our two new global operating segments, Care Delivery and Care Enablement. We will start with Care Delivery. Bill, the floor is yours.
Thank you, Dominic. I'm Bill Valle, CEO of Care Delivery. Our Care Delivery business is the global market leader in dialysis services with around 340,000 patients in 50 countries. We do over 52 million dialysis treatments per year and operate more than 4,100 dialysis centers globally. More importantly, we provide superior care for our patients. They value the services we provide, as evidenced by our Net Promoter Score of 71, with 78% of our patients highly recommending our services. I am incredibly proud of those results and would like to acknowledge the exceptional team that makes this all possible. Additionally, we are the leading provider of renal value-based care in the U.S., with $6 billion in medical cost under management for ESRD and CKD.
Our value-based care programs provides better clinical outcomes, a better experience for our patients while resulting in lower costs for payers. I will discuss our clinical excellence in more detail in a few slides, but as a snapshot, over half of our value-based care patients transition to dialysis through an optimal start versus only 20% for the national average in the U.S. Care Delivery is managed as a separate operating segment as part of our new operating model, providing a comprehensive and integrated offering of renal care services. In addition to our core dialysis services, Care Delivery also includes vascular access placement and maintenance through our Azura business, pharmaceuticals, a dedicated clinical pharmacy, cardiology-focused Ambulatory Surgery Centers, a renal dedicated lab, wraparound value-based care capabilities, and multi-specialty ASCs in Australia. In total, Care Delivery had nearly EUR 16 billion of revenue in 2022.
While most of this came from the US and our core dialysis services, our Care Delivery platform gives us the ability and flexibility to scale these other services. Most importantly, the seamless integration of these services allows us to provide superior care to our patients while simultaneously reducing the total cost of care. This positions Fresenius Medical Care as the partner of choice for pay, payers and physicians, and the provider of choice for patients while ensuring strong financial performance in an increasingly value-based care world. We are the only provider serving patients throughout the entire journey, differentiating our service offering and enabling us to deliver on our ambition to set the standard of care in the industry and to improve the quality of life of every patient every day.
Every time I say that, it brings a big smile to my face, and the reason why it's a big call-out to our extraordinary teams who bring our mission to life each and every day. Our breadth of renal-focused services enables us to fully manage our patients across the care continuum. This includes caring for CKD patients to keep them healthier and more engaged in their healthcare, slowing disease progression, and if required, ensuring a smoother transition to preemptive transplantation or dialysis. It also covers the placement and maintenance of permanent vascular accesses to reduce the risk of infections, related hospitalizations, and mortality. Of course, it covers dialysis services that span acute, in-center, and home. The renal lab testing to monitor the progression of the disease and provide the necessary information to nephrologists to help them make adjustments in prescribed therapies is also part of our services.
We also work to improve patients' adherence to their medications and set the standard of care for renal pharmaceuticals, such as our pioneering practice of leveraging long-acting ESAs to treat anemia caused by CKD, which are now an industry standard. Regarding transplants, we support the candidates with our referral-ready wait list management program, helping to streamline the transplantation process and accelerate their ability to receive a transplant. On this slide, you also see InterWell Health, our value-based care partnership with over 1,600 physicians, which engages and supports our patients throughout their journey. Well, InterWell Health was formed in 2019 and merged in 2022 with Cricket Health and Fresenius Health Partners, our value-based care division, to form the leading renal value-based care provider.
InterWell Health enables us to lower the total cost of care across the entire continuum while providing a higher quality of care and experience for our patients. More about it later. An important goal for us is supporting patients in their transition to home dialysis. While home dialysis penetration slowed during COVID, we are confident we can return to our pre-pandemic home growth rate. Our aspirational target is 25% penetration by 2025. Home penetration slowed down during COVID and was further impacted by the unprecedented labor challenges in the healthcare industry. It might be delayed by 18 to 24 months. It's important to understand why we prioritize home dialysis. For me, the answer is simple. First and foremost, for our patients.
It is proven to improve the quality of life of our patients, and it lowers the total cost of care. From an operating perspective, it helps mitigate some of the labor pressures experienced in the healthcare industry and enables us to grow in an asset-light model. While there's still a lot of work to do to reach our goals, we have several levers we are pulling to accelerate home growth. As the labor market stabilizes, we are better able to shift patients from in-center to home dialysis and accelerate the adoption of our transitional care units. These TCUs enable us to increase training for new home dialysis starts and focus on patient retention in the home program, all while strengthening our relationship with physicians. Driving margin improvement is critically important for us.
We are laser-focused on improving profitability, which requires improved treatment volumes, reimbursement rates, and operating efficiencies, with the latter representing our greatest opportunity. With respect to rate, the two key levers are price and mix. We anticipate pricing adjustments in every segment, whether through a broad-based market basket adjustment by CMS or built-in escalators in many of our commercial and Medicare Advantage contracts. Mix continues to trend favorably as well. We currently have approximately 50% of our patients in commercial and MA plans and another third in traditional Medicare. This Medicare Advantage mix is expected to continue to grow as more and more Medicare-eligible patients transition to Medicare Advantage. We also expect commercial mix to remain stable.
Lastly, we have initiated an ambitious pricing program in our acute business to offset the higher labor costs we have experienced over the last three years, including a significantly higher rate of contract labor utilization. At the same time, the headwinds we have been facing for many years have not gone away. Rate pressure from payers, including increases in co-pays, are prevalent headwinds for the foreseeable future. In the aggregate, we believe tailwinds are more powerful and rate and mix will contribute approximately 100-175 basis points of margin improvement in the coming years. The next key margin improvement lever is treatment volume. While our growth was impacted by COVID, we have continuously outperformed the broader U.S. dialysis market in growing our patient base.
Now that we are coming through COVID and the related knock-on effects, we are well-positioned to take advantage of the rebounding market to grow our patient and treatment volumes. While we assume moderate growth through 2025, we assume a return to normalized growth by 2025. Several key indicators, mortality, labor turnover, mistreatments, and capacity, are all trending positively and returning to pre-COVID rates. For example, our patient mortality rate is down by 10% from the COVID peak, coming close to our pre-pandemic rate of 17%. The rate of mistreatments is also trending positively as patients make it to their appointments more regularly after the spike during COVID. Monthly nurse and patient care technician turnover has dropped significantly. We are close to pre-pandemic turnover rates as our nurses and patient care technicians with less than 1 year tenure have stayed on with us longer.
This labor stabilization is critical for us, enabling us to increase capacity and accept new patients, reopen previously constrained clinics to new patients, and operate in an overall higher level of efficiency. It's no surprise that our costs have increased over the past year, few years because of significant staffing shortages and resulting wage inflation. The good news is both of these forces are abating. We are well on our way to improving our costs. Labor is the biggest component of our cost. We have already made significant strides stabilizing our labor force. As I mentioned, direct patient care turnover is stabilizing and returning to pre-pandemic levels, which lowers our recruiting and lowers our training costs. The stabilized labor market has also enabled us to drive labor savings by reducing agency spend, premium pay, and retention bonuses.
Our continued and accelerated home growth, specifically in-center to home transitions, also lowers the overall labor burden. Numerous additional operational initiatives are driving improvements in productivity. We are already seeing strong signs of accelerated improvement. Key focus areas include a flattening of the organization, increasing leverage of technology, including scheduling optimization, and improving the frequency and quality of training of our new and tenured direct caregivers and our field leadership. Pharma and ancillary expenses are the next big bucket. We are able to leverage our vertical integration and procurement excellence to drive cost savings, all while our medical office and FreseniusRx drive medication efficiency and effective adherence. Lastly, the volume recovery we discussed is improving our operating leverage.
Clinic consolidation efforts have closed approximately 50 clinics across Care Delivery in Q4 of 2022 alone. Optimizing our overhead cost through FME25 all work to reduce our cost base. With our new operating model, we are able to leverage our U.S. dialysis service capabilities globally. We are implementing a similar operating structure in our international segment. As a global services organization, we know how to efficiently run clinics. Following these best practices inconsistent across the globe. Under our new global service model, this will change. Adherence to best practices will not be optional. In fact, it is already changing, helping our ex-U.S. markets run more efficiently, operate at higher margins, and remove unnecessary structural and overhead costs. I'm extremely proud of how we are transforming value-based care with InterWell Health.
No one else offers a comparable network of high-performing physicians supported with best-in-class analytics, a nephrology-focused EHR, and cutting-edge patient engagement platform. Our business is unrivaled. We have more than $6 billion of medical costs under management, which we expect to nearly double by the end of 2025. Our traction with payers continues to accelerate as they recognize the value of our comprehensive and integrated value-based care offering. Our contract mix will increasingly shift towards full risk arrangements and expand upstream into CKD. In total, we expect nearly $2.3 billion in revenue by 2025. Interwell isn't only leading the market in its capabilities and size, but also in its outcomes. Their clinical results significantly exceed national averages while patients having better outcomes.
In sum, today we have the physician network, we have the experience, we have the data, the technology, and the track record to continue our rapid growth in value-based care and maintain or expand our already leading market position. The leading indicators we are seeing make us confident in achieving our operating margin band of 10%-14% by 2025. Across the levers I've shared with you today, we plan to raise our operating income margin by approximately up to 450 basis points. The FME25 contribution to margin expansion is largely driven by cost savings across both the U.S. and our international business, as well as G&A cost reduction. The volume recovery aspect of the margin improvement I've already covered in the previous slides. The most significant contributor next to FME25 is improving our mix and rate per treatment.
We also expect margin improvement from increase in our volume and increase in operational efficiencies in our international segment. As mentioned, value-based care is a critical capability for us to continue as a leader in the kidney care industry. Through InterWell, we will significantly contribute to revenue growth and will contribute to operating income growth. It comes at a lower margin and therefore will be margin dilutive. From an international perspective, operational dis-discipline and leveraging our U.S. Care Delivery capabilities will allow us to improve margins outside of the U.S. even before we optimize our geographic footprint. What is not shown is the further potential improvement as we optimize our portfolio in the U.S. and internationally. As part of our portfolio optimization efforts, we are taking a closer look at our international services business.
The optimization will follow a disciplined, rigorous, and methodical approach to ensure we are a leaner, more effective, and efficient organization by 2025. We are in many countries that are subscale or have significant structural challenges. We are evaluating each country operations to ensure we can profitably grow and are planning to exit ones where we cannot. Our filters to assess divesting are simple. First, does the market currently support or can it achieve sufficient scale to achieve profitability? Second, does the regulatory and geopolitical environment support our business and our reimbursement rates high enough to cover the cost of care and provide an acceptable return on invested capital? If a market does not meet these criteria, we will plan to exit, and some of this might come with some book value write-offs. We have identified a sizable share of our markets as candidates for divestment.
Although leaving these markets will result in a revenue hit, it will additionally increase our margins, improve our focus, and simplify our business. We are optimistic about the future of Care Delivery. Looking beyond 2025, our goal is to be the provider, partner, and employer of choice for all stakeholders across our ecosystem. That includes patients, providers, our staff, payers, and everyone else we interact with. We seek to continue to have best-in-class clinical outcomes across our entire renal care continuum. We want to continue to lead the market in value-based care and continue to push forward and drive the market towards this model. We will continue to accelerate the shift to home dialysis to improve patient outcomes and quality of life, as well as reducing costs, all while maintaining our operational excellence. This ends my prepared remarks. Thank you, and I hand over to Katarzyna.
Thank you, Bill. Good morning, good afternoon, everyone. This is the first time that I have an opportunity to present to you in my new role as CEO of Care Enablement, our global technology segment and market-leading renal company. We are proud to claim leadership in this arena. With around 40% market share in dialysis products overall, we are number 1 globally. We are number 1 practically everywhere in over 150 countries around the world where we sell our products. Additionally, we are also clear leaders in 2 important growing markets, acute dialysis and home hemodialysis. Our major strength are the most differentiated dialysis products. Those are machines and dialyzers. It is differentiation that drives the value of product. It is not accidental that we retain the highest market share in exactly dialyzers and machine.
The majority of dialysis patients all over the world are therefore using one of those products coming from Fresenius Medical Care. This is a great responsibility because continuity of production, continuity of supply, is a condition for life-saving therapy. We are truly relevant to global healthcare. Our new operational model works well for Care Enablement as this med tech company within company. I'm sure you realize that in 2022, we have managed a massive organizational change from regionally led to vertically led organization with three business units, in-center, home, and critical care. Those business units are now having full end-to-end responsibility for their P&L with all the costs transparently allocated. This allows us to see in a very, very detailed way where we do make money and where we don't.
While for competitive reasons, obviously, we are not planning on reporting this differentiated margin split, I would like, however, to share with you that the gross margin differ substantially by the type of customers, by business unit, and by geography. In the new reporting structure, we have much better internal visibility of those different margins, and this is the basis for fast and better-informed decisions as far as resources allocations is concerned and capital allocation is concerned. We have a base now to objectively assess and prioritize projects and investment, and choosing those we want to focus on, and consequently withdraw resources from less value-creating ones. The new organization also assumes end-to-end responsibility for product life cycle. From cradle to grave, from development throughout launch, commercialization and sunset.
Already we took a fresh and sharp look at the current and future portfolio, and we already decided to stop and write off some R&D projects, as well as bring some products to orderly exit from the market. My global commercial organization is focused on executing against the strategy and fully embraces the principle of commercial excellence. This means for us, first and foremost, pricing and contracting excellence. In manufacturing and supply chain, we've already initiated thorough review of the current manufacturing footprint, and we are working with a very detailed plan towards significant margin improvements to come from productivity, efficiency, specialization of sites, and yes, also consolidation of manufacturing sites. We were building efficient organization globally and reorganizing and leveraging support functions such as G&A, but also, for instance, quality and regulatory. We have been already realizing substantial savings from synergies and from streamlining processes.
This is largely what you saw in Helen's slide on the FME25 savings achieved until the end of 2022. Our portfolio, it's a natural ecosystem of products and services. Obviously we provide dialysis products for all modalities of kidney replacement therapy in the hospital, in dialysis center, and at home. We also provide water installations, technical support, logistics, training and education. All this is connected by our digital platforms. We are touching every aspect of kidney replacement therapy, and we are offering full package. This is key differentiator and very, very appreciated by our customers, internal and external. Majority of our global revenues come from sales to external customers. Slightly less than 30% relate to internal sales, but this is very important. Stable volume, efficiency, and stability factor for our supply chain.
Let me now highlight some key elements of our portfolio. I would like to start with the heart of dialysis, with this special, very high-tech device called dialyzers. It comes in many different forms and shapes because it addresses individual needs of patients and enables to achieve different therapy goals with the same dialysis machine. This depends on surface of, and parameters of membranes or fibers that you see in the background today. The great news is, from the moment of discovery, from the first innovation in membrane technology, we, Fresenius Medical Care, have never lost our innovation leadership. There were attempts to make some inroads in this field with significant capital investments, customers obviously decided to agree with the message on the slide.
We are covering all current needs, and our innovation continues in two critical dimension: costs of care as well as performance, particularly biocompatibility. I have already described dialyzers as machines as the most differentiated elements of our renal portfolio. Also here in machines, our portfolio caters to very different market segments present globally. We have very solid pipeline of innovation and clear plan for geographic deployment or expansion. We will be launching new or updated technology in some key markets, including United States. The key is to retain what our machines are truly famous for, reliability and excellent fit to the daily practice of dialysis center. This is clearly a collateral benefit of vertical integration, our proximity to end user, proximity to customer.
I'm moving to home therapies now and starting with home hemodialysis. This is a fast-growing niche market where we have strong leadership globally with our NxStage systems, as well as with conventional machines, which are also used for home dialysis. We all know that home hemodialysis is the most beneficial for patients, and also the most cost-efficient solution for providers and payers. However, success of home HD depends on the willingness and ability of the respective healthcare system to encourage, to nurture, and to reimburse this therapy. Our key focus market remains United States, and it's followed by several selected international market, which are offering attractive conditions for us. Peritoneal dialysis. This is a business where we do not hold the number one leaders badge, and this is not even the main issue.
When we look at economics of this business, not with the lens of vertically integrated company where this is highly profitable, but as the med tech business that I run, then the economics end up being very unfavorable in the United States. This is a big issue. I would say this is the single biggest issue, and it's heavily weighting on our Care Enablement margin. PD is a business where scale is very important, where efficiency in manufacturing matters a lot, and where logistics and service costs are major factors to consider. I can only tell you there is a room to improve our cost base in every of those aspects. The recent inflationary cost increase further worsened the situation, so this triggered an even more immediate need for change.
The turnaround plan for this business is under execution, and it focuses on all the mentioned cost factors. Efficiency in manufacturing, efficiency in logistics, efficiency in services, including servicing our own technology and its reliability. We are focusing on pricing because pricing has to recognize value of our product. At the same time, we will not lose focus on those many international markets where we have economically viable business and profitable business model for PD. We are therefore closing some portfolio and technology gaps, which will make our offering in international markets much more competitive. Finally, our critical care products. This is another highlight in our portfolio. We have a very competitive machine and fluid portfolio.
Customers in this market are particularly focused on value, appreciating the quality and medical outcomes, as well as reliability of delivery, particularly during COVID pandemic, and the level of support that we offer. We do offer high level of support, and we like the reward. We hold a market share north from 30% in acute dialysis. This market share is higher in those markets where we have focused our efforts so far. We see quite strong opportunities in further geographic expansion. This will be enabled by our strong global presence. Our heart and lung business, albeit small, played a major role in ICUs all over the world, saving lives in the most severe COVID cases with ECMO technology. This seriously tested our ability to scale up production, scale up support.
We passed this test, this supported also the economics of this business. I could not close this portfolio brief overview without talking about digital strategy. We of course, like every other company, we have digital ambitions, but we also have a digital already existing, very strong portfolio in the market, and it is part of the ecosystem of each of our product business units. This slide shows what our digital products do. Why do we need them? In Home, it is all about connectivity, support, training for patients, et cetera. In other words, it's connected health area. This is key success factors for the future growth at Home. In In-center and Critical Care, it is about managing therapy, automation of processes, decision support, also documentation and logistics. In other words, this is technology-enabled care package.
Across all products, all products offering, it is big time about data. Every dialysis machine is a data center, and our ability to collect and to process data has already enabled the next generation of digital solutions. For instance, artificial intelligence underpins applications which are managing dosage of therapeutics in clinics. That's not a vision of the future, that's existing solution. Our data pool additionally serves as digital twin to model new therapies to test innovation. This is a different way of showing the same content. I have no ambition to describe all those products. I just wanted to give you an impression of our existing software systems and applications per business unit, which we use and which we commercialize, either as a part of a bundle, which admittedly was the old way of doing things, or directly as a high-value MedTech product.
The digital portfolio is not a gimmick. It adds value. It clearly adds value for patients and for healthcare providers. Via our commercialization approach, it also increasingly adds value to shareholders. It adds additional high-margin business to our mix and supports our top-line growth. Importantly, it also enables more individualized therapies, and it's connecting therapy to precisely measured outcomes, so it is also compatible with value-based care. Successful execution of our digital agenda makes us fit for the future. Before we reach the future, let me come back to the biggest task at hand today. We have to improve our performance. Our margins, or more specifically, our gross margin, is below external benchmarks. It is below your expectations. It's far below our ambitions. Here comes the good news: it's also well below our possibilities, our realistic possibilities.
I'm a medical doctor by education, I have this habit of starting with diagnosis before administering therapy. By now, I have high level of confidence that we have a clear, precise diagnosis of the problem. Our manufacturing footprint is not optimal, nor is our portfolio. We have a loss-making business in our portfolio, I called it out, and those underlying issues were additionally exacerbated by inflation and by selective, at times, very substantial increases of cost for some specific supplies that we need for our production. Here is the therapy that we are administering. Manufacturing efficiency. We have reviewed and started already to organize the manufacturing footprint. Efficiency, specialization, consolidation, labor arbitrage, as well as direct procurement actions are part of the detailed plan. On portfolio, we have reviewed and took some decisions already on the portfolio of products, as well as ongoing R&D projects and programs.
Peritoneal dialysis in the U.S., it's a major turnaround project, and it has been stood up with clear structure: leadership, accountability, timelines, defined milestones, defined targets. It's progressing well. Offsetting inflation and cost pressure. Well, we need to reduce cost of doing business, and the new operating model is realizing direct saving, but it's also focused on gaining efficiency in processes. Most importantly, we have to pass on the cost in pricing, and this is something that is absolutely on the top of the list and top of the mind of commercial teams globally, pricing and contracting. We can get better here, and we are already seeing first positive effects of our actions. We are addressing all the identified issues. We have mapped the areas with specific actions and prioritized those with a faster payback. Most of them are in the scope of our FME25 initiatives.
Additionally, pricing, geographical expansion of profitable businesses, additional identified improvements, those will be key drivers for margin improvement. We will deliver on our plan to add 600 to 1,000 basis points of margin by turning around our operating performance. This is what you absolutely can expect from Care Enablement to deliver until 2025. Furthermore, we have assessed our portfolio of assets. This includes the review of the R&D pipeline, innovation programs. We assessed our venture initiatives and product portfolio. We have identified businesses and projects that we want to retain and invest in with clear ROI improvement contribution in view. How do I see the future of Care Enablement? We will boost our operating performance by executing plans we have built to address key issues.
We will optimize the manufacturing footprint, rationalize portfolio, fix economics of PD in the U.S., and counter inflation impact with cost efficiency and improved pricing. We will grow our business above the market using the strength of our organization and strength of our portfolio, including digital platforms. Again, as a medical doctor, I can say it with confidence, dialysis will remain a life-saving therapy for a growing number of patients. It is going to be deeply transformed by technology, moving to more personalized therapies and data-enabled based care. We are ready to lead this move. Dialysis also comes with ecological cost by using water and producing waste. Customer as well as regulators are increasingly evaluating the sustainability aspects and are embedding this also as criteria for purchasing decisions. This is playing in our hands because we are advancing innovation, leading to more green dialysis.
Finally, sustainable dialysis means also addressing key global healthcare issues, labor shortage and access to care. Technology, digital solutions, business model innovations are all focusing on addressing those topics. Key is to reduce the requirements for healthcare workers presence during the dialysis treatment and to enable accessible, sustainable, affordable kidney replacement therapy for an ever-growing number of patients. Thank you. With this, I hand back to Dominic.
Thank you very much, Katarzyna and Bill, for your inspiring presentations. Investors and analysts who want to ask a question during the Q&A session, which is now, should now, at the very latest, be registered and dialed into the parallel telephone conference. Anyone who wishes to ask a question may press star followed by 1 on their touch tone telephone. If you wish to remove yourself from the queue, which I do not hope, you may press star followed by 2. For operator assistance, please press star followed by 1. If you are using speaker equipment today, please lift the handset before making your selections. When it is your turn, I will hand over to you and you will be live in the conference to ask your questions.
As mentioned in my introductory remarks, we kindly ask you to limit the number of questions to a maximum of two. You can queue again, if you want to ask further questions. During the Q&A session, you will only hear my voice, and you will see the people that matter on the stage. Anyone who has a question may press star followed by one at this time. To allow the queue to build up, I will now start with a quick question as a warm-up. Helen, how confident are you in achieving these 2025 margin targets?
Yeah. Thanks, Dominic. Great question. I feel really good about the target and achieving it. We've worked really hard since 2021 on the transformation to our new operating model. This model really provided us with the insights and the profitability of all parts of our business, and it enabled us to develop concrete strategies and measures for the turnaround of the business. I hope you saw today these are not theoretical plans. We're really in the middle of this execution, and I'm confident that we can get in the margin band. With the identified portfolio opportunities we have, we may even have some upside, but we will treat that as a special item.
Okay, great. Thank you very much. We will now go live into the questions. The first caller is Veronika Dubajova from Citi. Veronika, please ask your questions.
Hi, good afternoon, thank you all for taking my questions. I have two, please. First, on the services business, if I look at the margin ambitions, Helen and Bill, that you've outlined for 2025, that 10%-14%, the low end doesn't seem particularly demanding. You're very close already. The top end, you'd be pretty close to a peer that has a much smaller OUS business than you do. Just maybe if you could contextualize for us how you're thinking about that 10%-14% range when it comes to the services business and sort of what gets you to the lower versus the upper end, that would be helpful. My second question is on the product presentation. Katarzyna, thank you so much for all the detail you've given us.
I'm gonna push you, if that's all right. If you could give us a bit more color on the gross margin between the in-center home and acute care businesses, and sort of really where the biggest opportunities other than the U.S. PD business, which you've called out already. From the slide that you've presented, it looks like there you might be open to some divestitures in the products business, if I've understood it correctly. If you could comment on that as well. I'm gonna be really annoying and ask a technical follow on, which is for both of the margin figures that you've given us for 2022, any chance we could also get them for 2019 so that we have a sense for what the businesses were like pre-COVID and some of the inflationary pressures?
sorry, and thank you.
Okay. Thank you, Veronika. I think the first question on the margin ambitions for CD, I think go to Bill and Helen. The second one obviously goes to Katarzyna on the CE gross margin. The overall 2019 CFO question goes to our CXO, Helen.
Thanks, Dominic, and great question, Veronika, on the margin range for CD. The way I'd look at this.
I think the wild card within that range of margin band of 10%-14% is really labor. I think both Helen and I have said, we're seeing that stabilize. We're seeing some abatement. I think as we look at trends more longer term, you know, we recognize there is going to be a healthcare staffing shortage. We think we're well positioned for that. I'd say that is where we will, you know, depending on how we can manage our cost increases across this planning horizon, that's where we would essentially fall within the range. I think the rest of the assumptions we're making, we feel really confident about, hence a narrower range for each of the other items.
Yes. Veronika, thanks for your question and nice to hear you again. Well, I of course have to disappoint you because we will not be disclosing margins per business units. I outlined or kind of highlighted a bed business geographically and per business unit as PD U.S., and that's probably as far as I can go. I also during my presentation mentioned that we have real stars in our portfolio, geographically and product-wise. Critical care is definitely one of them. That's as far as I can go in my differentiated love for different type of types of businesses in my management area.
Hi, Veronika. I'll take the last part of that, of your the third question that you had on going back to 2019. I'm going to disappoint you also. It's been a Herculean effort to reorient the business and the financials into these operating segments, as well as reorienting all the G&A functions. We are restating to 2022, and we'll do this, you know, quarter by quarter as we go through the year as well. We may end up with a 2021 benchmark, but we won't be going back to 2019 or, you know, pre-pandemic. We're trying to kind of get as much color as we can along the way here.
Okay.
Understood. Thank you, guys.
Thank you. The next question comes from Graham Doyle from UBS.
Hi, guys. Thanks a lot for taking my questions. Just two around volume in terms of the services business. You talked a little bit more confidently, I suppose, about volume recovery, although to be fair, it doesn't look super optimistic or super bullish. Just could you give us a sense of how you're seeing the funnel now, so the sort of pre-dialysis patient population, how's that progressing? Just a sort of broader question on volume. You also talk about having some unprofitable services businesses and maybe reducing footprint. Could you give us a broad sense in terms of volume today of patients treated and where you think that will get to by 2025? I mean, could it feasibly be flat to down? Is that how we could be thinking about it, obviously profitability up?
That'd be super helpful. Thank you.
Thank you, Graham. I would say, the first question on volume, Frank, if you could take this one. The second one I would ask Helen and Bill.
Great. Well, thanks, Graham. I appreciate you asking a question about CKD. What we are seeing today is that the impact of advanced kidney disease that the pandemic had shows that we're refilling that pipeline of CKD patients that are in late stage. We actually see a growing population of overall CKD patients, and we see the later stage patients also growing in that regard. I think that many of the signs that we're seeing in our overall population that are also quite positive is the fact that growth and volume growth is so much dependent upon this reduction back towards normal and hopefully in the future, even, further reductions in mortality in the population.
This will be one of the quickest, shortest term impacts on being able to develop and grow our volume of treatments as we continue to grow the volume of patients.
I'll cover, Graham, the second question you asked, and I think there was kind of 3 parts to that. We, in my prepared comments, I talked about the acute business. Just to give you a flavor for that. Currently, we have about 1,000 contracts with acute care hospitals. About 30% of those are unprofitable. We are, you know, in a very direct manner renegotiating rates in some of those areas. Most of those hospitals use a significant amount of contract labor to keep them staffed. We've been successful in the past working with our customers to responsibly raise prices so that we can continue to provide the higher value of service. That's number 1. You know, to frame that's probably about only 30 basis points of growth just from that perspective.
As far as clinic consolidations, the way we think about that, you know, we obviously can't create operating leverage, if you will, if we don't retain patients. As we look at clinics to consolidate, I mentioned we've, you know, closed some 50-plus already in the fourth quarter of last year. We're able to retain
About 70%-80% of those patients, and that's where we truly create that operating leverage. The third piece is our international business. We're not gonna comment on markets, but I think I indicated that if we're shrinking our business by, you know, 15 to 25 or so countries, volume will go down overall. In our core markets, we still should see our growth within the band that we've already provided to you of that, you know, 2.5%-3% in 2025.
Okay. That's super clear. Thank you.
Okay. Perfect. Thank you. The next caller is Victoria Lambert from Berenberg.
Thanks for taking my questions. I have two. The first is just on the pricing power in the products business. Our understanding was that a few years ago, you know, the products business was actually seeing a decent sort of margin compared to peers. When did this change? How do you guys feel about negotiations going forward? Then the second question is just on your market share and home hemodialysis. Again, our understanding is that this is pretty high, and that you probably have a relatively high pricing power in this space too. Thank you.
Okay. Thank you, Victoria. I think both questions go to Katarzyna on the products margin, what has changed since the historical margin perception, and about the market shares in the home setting.
Historically, Victoria, typically, for MedTech area, there was a price erosion was kind of classical phenomenon. Long-lasting contracts with stable prices was considered a sales success. That was before inflation. When inflation hit, our world changed pretty dramatically. Pricing, I said it's on the top of the minds of commercial organization, but I also want to make it clear that it was a quite a change management process. Starting from change of mindset in commercial teams through change of skills and teaching people new skills through very thorough and methodical review of contracts and using all opportunities that we have in those typically long-term contracts to move the needle and to pass the costs that we encounter more towards customer.
That's pricing situation. Inflation and the selective increase of cost of certain elements changed our cost position very rapidly, and I think faster than anybody could have expected. Your second question was related to our high global market share. Yes, we are interested in keeping high market share and keeping an increasing market share and growing above the market when the market offers profitable conditions for our products. We are also interested, and it's very possible for us to grow market share in a premium segment through premium solutions, so improving mix of our products.
We see numerous examples of this being successful in international markets, where we really, with our 6008 machine, we have established very solid and growing premium market, where with hemodiafiltration, we have a premium therapy, which is higher reimbursed and higher rewarded also therefore in price by customers. Changing a mix of products is also a way of increasing share and improving economics of the business. I hope that that was satisfying your question.
Victoria, if I may, this is Helen. Let me just add one more kind of color commentary.
Mm-hmm.
To the to the products business. Let's not forget, and you asked about what has changed and what was it historically. Let's not forget, this is the first time we've really been able to see an end-to-end profitability of our products business. You know, Katarzyna has completely reoriented this business. In the past, manufacturing and R&D weren't allocated to the, to the regional margin contribution. You know, while we recognize it's a very low number, we also recognize it's a very, it's a transparency that you've all been asking for, but it's on somewhat a different basis. Now we have a real full allocated end-to-end P&L for this business, where we can really drive targeted improvements across all aspects of Katarzyna's business.
Not just a total products P&L, but across her three verticals of in-center, home, and critical care. I think that is, I recognize that everyone is asking where was this and where has it come from? We really never had this view that we now have today.
Thank you very much. The next question comes from Lisa Clive from Bernstein.
Hi there. Thanks for the presentations. I have a question for Frank and a question for Helen. Frank, the commentary on the mortality trends was very helpful. Talk about now that the mortality trends from COVID-19 are normalizing. There were just some odd, sort of data points I think that would be helpful to get clarity. Could you just remind us now that we've had a few years of COVID mortality, whether there was sort of a difference in the excess mortality rate between your U.S. and international patients? I'm particularly curious about this because the slide you showed about the proportion of international patients with diabetes and hypertension shows that they're on average, sort of quite a bit healthier. Just curious as to how that death rate sort of differed?
Also on the, in the U.S. in particular, the mortality within the Medicare population and the private population, where at least at the beginning of the pandemic, it seemed like the mortality rate was pretty similar, whereas we should have expected the Medicare rate to be higher because the patients sort of skew older. Really, what I'm trying to get at through these questions is understanding whether we could potentially see lower mortality in the next 12, 18 months because we've had a sort of pull forward effect of some of the sort of older, sicker patients having passed away because of COVID, and how we should think about that over the sort of nearer term. Then second question I guess for Helen is the CKCC program, sort of how...
Can you remind us how big that is now? Is it as big as ESCO was when that shut down, which I believe was around 50,000 patients? More importantly, are the economics shaping up how you expected, or is that sort of too early still? Thanks very much.
Thank you, Lisa. Obviously the first question about mortality difference between international and U.S. is for Frank and commercial versus Medicare as well, and mortality where it goes. The CKD question, I think, goes to Bill because he manages InterWell Health.
Great. Lisa, thanks for that question and I appreciate you asking it because it is one of the things that we've been watching very closely from the beginning of the pandemic through the pandemic and now, what's been different around different parts of the world. First of all, I would say that all patients with end-stage kidney disease are highly vulnerable to this virus and some of the disruption. I would say some of the differences that we saw between different parts of the world, and certainly between Europe and the U.S., mimicked some of the differences that we actually see in the patient populations. For example, our diabetic population in Europe is 50% of what our diabetic population is in the U.S.
We have some age differences a little bit. We further have some differences in the types of treatment that people are receiving. In many of our ex-US countries, we utilize hemodiafiltration. I think that high-flux hemodialysis and hemodiafiltration are in the midst right now of a trial that we'll report out very soon, called the CONVINCE trial that will help try to determine whether a therapy that uses both diffusion and convection has different results from a therapy that is the standard therapy of just diffusion. I think the bias of the populations, the selection bias, has created some of the difference. I think some of the other difference may be that as the, as the pandemic evolved, different areas of the world had recovery times that were slightly different.
That recovery time was somewhat reflective of when we began to see some improvements. I think in our EMEA population, we saw that the improvements in mortality began a few weeks to a few months earlier than it began in the US, where we had a lot of very diverse practices in isolation. Not isolation of our patients, but sort of isolation and practice of vaccination in the general population. All of those things I think play a substantial role. With regard to the final point that I'll make is with regard to your question about will mortality go lower than what the baseline is. I think the best answer I can tell you is we see pockets of that happening some. We don't see it consistently always going to a lower state.
In various geographies, we have clearly seen that the population of patients that we're treating did change slightly. Either the age changed slightly, the proportion of comorbid diseases changed slightly. I do think we will look for those opportunities where we can lower mortality below the prior average, where we'd spent 10 years working very distinctly at lowering mortality from where it was in the mid, you know, 2025-2010 range. I think there are opportunities for us to continue to lower that. I will again say, and don't wanna, I wanna make sure we emphasize this. One of the quickest ways to growing our volume of treatments is to be able to create clinical care opportunities for patients that either make them healthier or live longer. Those opportunities, I think, are real in the coming years.
Great. Thanks for that.
Hey, Lisa, I'm gonna take your question on CKCC. First, just to get grounded, the ESCO program was ESRD only, and attribution occurred at the centers. The CKC is both ESKD and CKD, and attribution occurs within, you know, affiliated nephrology who participate in the program with us. As far as total attribution or enrollment in the program, it's about the same. The big difference being now in CKCC, we're about a 50/50 split between the ESRD and CKD. We've seen a little bit less enrollment on the ESRD side, I'll remind everybody, we've also seen a big shift to MA, we're picking up that risk on the MA side of the equation.
As far as right now, we have 2 quarters from year 1, so we're 1 year through, I guess 5 quarters through the ESCO or the CKCC rather, at this point. What we're seeing is that our performance is quite strong in the ESRD risk and improving in the CKD. I'd say by and large, we're, you know, the most of the practices who've been with us, there's lots of experience. We, you know, continue to get better and better at reducing hospitalizations, improving optimal starts, all the things that will make us superior, reducing readmission rates, et cetera. The CKD, I'd say is, you know, somewhat similar to our, you know, first few years in the ESCO program.
We're learning, we're working with our nephrologist, and we will get better and better, and we have some practices that I can tell you are best in class, and others that are coming along that journey with us. We're excited about the program. We're, you know, the teams are operating and executing. When I say the teams, it's now a multidisciplinary team. It's not just us, our case managers. It's us working in a very, very collaborative and coordinated manner with our doctors.
Okay. To that, Helen.
Thank you. The next question comes from Oliver Metzger from ODDO BHF .
Good afternoon, everybody. My first question is on value-based care. In the past, you said you make around 1% EBIT margin for medical cost under management. In 2025, you will have $11 billion medical cost under management, and that should mean $110 million EBIT at revenues of $2.3 billion. That's a margin of roughly 5%. By 2025, your value-based revenues should make up around 14% of the Care Delivery revenues. If I calculate the dilutive impact from the midpoints of the guidance, I see rather a dilution of 100 basis points. Can you help to understand why you calculate just this smaller 0-50 basis points dilution? Does it mean that the underlying profitability is higher, or how should I solve this explanation?
Second question is on home dialysis. Basically in home dialysis, you combine PD and HHD, which are basically completely different regarding also when they are applied to patients. PD, we talk about the expansion of a market, while HHD at the end helps you on the labor side. Can you first talk about the growth ambitions how to grow PD separately, and second, also disclose where your current HHD share is in isolation, please.
Okay. Thank you very much, Oliver. I think the first question on InterWell Health goes to Helen and Bill. I think the second one goes to Katarzyna.
Oliver, I'll take this. As said, we're sitting here trying to follow your math a little bit and, so we're having a little bit of a re-
We'll tag team it.
We'll tag team on the reconciliation. I think, you know, the way you're thinking about this, we have talked about, you know, a margin which is really not a true margin, but 1% margin as a percent of medical cost under management. You backed into essentially the right number. Your math is correct to that point. We're also seeing some growth of margin in our core business, we'd have to do the math, and I'm sure Dominic or somebody will get back to you with that. That's. You're in line, and again, remember we gave you a range of 0 to -50 basis points. We do believe there'll be some scale, um, achievement in the business as we take on more and more risk.
Then there's gonna be a shift in terms of how we can account on a rev rec basis to get to that math, and that becomes real tricky. We've tried to give you a real clear metric that you can run with, which is % of medical cost under management. It gets a little trickier when we get to the rev versus the operating margin. We'll try to provide clarity around that as the business evolves and progresses.
Yeah. Nothing further to add. Katarzyna?
ng to, uh, PD and HD then. Oliver, our market share of home hemodialysis is much higher than our market share of PD, and we have also different strategies geographically. Home HD, U.S. is a strong focus for us. That's a strong focus market followed by several selected markets internationally. In PD, however, we have, as I said, economically viable, profitable business in many international markets, and there, our market share is low. You always can say it's low for a reason. Yes, it's low for a reason. We know this reason, and we are closing those competitive gaps that I think will put us much more on par in this market when growth opportunities are much bigger for us, which is international PD, while fixing economics of PD in the United States
O-okay. Uh, can I just-
A follow-up regarding the second answer. Can you just tell us about where your current HHD share stands?
Unfortunately, I can't. I can only say that we are very proud from the share, and it's both in the United States and internationally.
Let me ask differently. You have this target of 25%. Is it fair to assume that the PD share will remain more or less stable and that the growth comes primarily from the HHD share?
Yes. In the United States, yes.
Okay. Thank you.
Okay. Thank you very much. The next question comes from Hassan from Barclays. Hassan.
Thank you for today's session and taking my questions. I have two, please. Firstly, following up on Care Enablement margin questions and historics here, maybe put another way, I mean, do you think you have exceeded the margin expectation that you have for 2025 historically? Are there any other key drivers of margin degradation outside of the recent high inflation that you talked extensively about? Going forward, has there been any improvement in pricing, contracting or procurement already in this business over the last, you know, 6-9 months that gives you confidence on the 300-400 basis points improvement that you have out to 2025? Secondly, maybe a question for Bill.
Can you talk about utilization in the U.S. clinic setting today, how this compares to pre-pandemic, and how you're thinking about improving this over time as volumes recover, but specifically the optimization potential in the clinic footprint in the U.S.? Thank you.
Okay. Perfect. Thank you. The first question obviously goes to Katarzyna, on the margin upside potential, and the second question goes to Bill on footprint and operational leverage.
Okay. Hassan, thanks for the question. Without, you know, sounding defensive, see, it was not managed in the way that would make transparent this level of so our overall economic performance in the past. Now, I do understand, you know, healthy skepticism around any promises because proof is in the pudding. Importantly, we have already tested the pudding because to your question, do we see trajectory of pricing turning? Yes, we do. The answer to your question is yes. Have we seen improvement in procurement? Here, it's a mixed bag because inflation is front-loaded. It has already happened. Do we see it easing slightly? Yes. Do we see us getting better in sourcing direct material? The answer is yes. We are measuring those two things kind of independently.
What has already happened and how it's goes through our P&L and what we can do moving forward to improve the situation. In both those aspects, we see progress. Although we have to go through inflation valley, right? Clearly. Yes, we see those trends going in the right direction.
Hassan, I might just add, one more comment to that. Obviously, the inflation has been a significant challenge for us in 2022 and 2023, along with supply chain and distribution disruption. As Katarzyna has outlined the clear plans to improve this margin, you can see that we are touching overhead, we're touching manufacturing efficiencies. I would say those were there before. Now with the view that the focus that we have and the view of this P&L that we have, we're able to target it much more specifically, because in the past, it was a little bit on an island. Look, I think that is the fact that we're addressing it kind of acknowledges that we see the problem and now we have a plan to fix it.
You know, you asked about where these margins are and is 2025 where we would expect it to be or maybe what we thought it was historically. There's a real tangible set of actions to get us to 2025. That's not to say that that is our end state aspiration. Katarzyna, as she's looking at the manufacturing footprint and looking to see what she can do on the product offering and in R&D, some of these programs do take a little bit longer to see the benefit. In CE, it's not as easy to turn on a dime some of these bigger initiatives. We aspire to have world-class leading MedTech margins.
We clearly recognize that's not where they are today, but we will continue to evolve and grow on these margins past 2025. The key here would be to execute at pace and speed where we can.
Okay. Hassan, I'll take, I guess the last question on operating leverage. From a capacity utilization standpoint, we typically measure capacity utilization based upon 6 shifts, obviously we saw a drop in that. We were probably running in the range of 61%-62% pre-pandemic. We dropped into the 56%-57% range. If you look at our planning cycle, we plan to build additional capacity well in advance of putting that capacity in place. We're looking at about a 10% range. We've dramatically slowed down building new centers, quite frankly, and we anticipate that that will continue for the foreseeable future. Number 1, we've talked already about clinic consolidations, those do provide great operating leverage, especially when we retain the patients, as I outlined.
We've also went through a process of, over the last couple of years, for sure, of restructuring a number of leases. When you look at capacity utilization, that's one of our biggest costs, the cost of the bricks and mortar, if you will. We've brought our property expense down, and we continue to attack everything, including our overall G&A costs. Home is also gonna be a big lever in restoring that operating leverage. Thirdly, the work that we have started internationally will be a big support for improving our operating leverage in our international business. We, you know, we have a good plan. We know what we need to do, but the number one fix for operating leverage is the growth that Frank talked about earlier. You know, we were, you know, winning share in the market.
We are getting back to winning share again, and we need to do that to restore the operating leverage that we lost during the pandemic. Hopefully, that answered your question.
Very helpful. Thank you.
Okay.
Perfect. Thank you. The next question comes from Sezgi, from HSBC.
Hi, thanks for the presentation and thanks for taking my questions. I have two, please. First of all, in Care Delivery, thank you for sharing all these figures. In terms of markets to be exited from 49 markets to 19-36, it's quite a reduction. My question here would be, first one, some of these markets, I'm assuming you would be exiting the ones that are less profitable. In terms of selling these, the multiples might be tough. What percentage of this would be, or, like, what ratio would you be targeting selling, and how much of these would be winding down? If there are any winding down plan, is this planned within the EUR 650 million restructuring plans that you've already shared?
My second question is relating to the Care Enablement segment. There, you mentioned the market leadership position, with the exception of the Morpheus HSD, and also the pricing in your margin breakdown or margin path to 2025. You have the gains planned from procurement, as well as, contracting. Being a market leader, I'm just wondering what kind of steps you took already in terms of improving procurement and what other steps are there left that you can easily take care of in the run-up to 2025?
Okay. Thank you. I think the first question about the winding down of parts of the Care Delivery international markets goes to Bill. I think the second question's on additional opportunities in procurement in Care Enablement goes to Katarzyna, please.
Okay. I think I caught all the aspects of your question first. The wind down expenses that I referenced in my prepared remarks is not included in the EUR 650 at this point, and we will disclose in the ordinary course as these transactions progress. That's number 1. I think I'll just confirm what I heard your comment to be. These are the less profitable markets or subscale markets. Absolutely, every one of these exits that we're looking at at the moment will be margin accretive as we execute on the strategy. Just timing is a little bit difficult. It's a little bit of country by country. There is, you know, unique regulatory process that we need to navigate as we execute the plan. Anything?
Yes. Looking at direct procurement as a major improvement opportunity that we clearly recognize as such. This has you say we are market leaders, so it kind of indicates that we should have a major purchasing power versus our suppliers. That's not necessarily the case. The number of parts that goes into the machine is very similar to number of parts that goes to a car. The volume of machines that we are producing is like small manufacturing sites for the car. Our purchasing power versus, you know, other industries is rather minimal for each and every of those components separately. Additionally, to have a supplier means to license him, to audit them, and to have him as a part of registration of a product.
Changing it is a process, and having more than one, more diversified suppliers base is a cost factor. We are walking a very narrow path between what's possible economically and regulatory-wise. However, I'm absolutely not suggesting that there is no room to improve, because we discovered there is a room to improve in the process of direct procurement, which we scaled up, upgraded, verticalized, and professionalized. Secondly, our major R&D effort has been redirected to how we build our products. What exactly components we need, and where do we source them. This was one of very interesting shifts in our R&D effort as we have written off some programs and relocate resources to this very important topic, because it will end up in our product having different cost base two, three years from now.
Thank you. As we run out of time, our last question comes from James Vane-Tempest from Jefferies.
Yeah, hi. Thanks for taking my questions. First one is, please can you give a bit more color on the Care Enablement margin again? Apologies to come back to that at 1.9%. From my calculations, I think around 50% of that has come from what you say have come from savings from FME25 in this business at the end of last year. Are there any embedded advantages which go to your Care Delivery segment here, and are any factory closures included in your midterm margin in this segment? My second question is just on U.S. mix and rates. I think you said you're looking for a 100-175 basis point margin benefit, and expect the commercial mix to remain stable.
What makes you so confident there won't be any impact from the DaVita Marietta ruling, which could have an impact on some smaller plans from as early as 2024 in your guidance? With increasing MA, are you anticipating increasing leverage by payers in negotiations? If I can just squeeze in a follow-up. You stated the result of new pharmaceuticals, patients are healthier and dialyzing for longer with fewer crashing into dialysis. As we look over the next few years, do you expect any delay in new starts due to phasing, even if you may ultimately be treating patients for longer? Thank you.
Thank you, James. I think the first question on CE margins would go to Katarzyna. U.S. rate mix is of course Bill and Marietta. New pharmaceuticals, I would hand to Frank.
James, 600 basis point improvement coming from FME25 is until the end of 25, as you know. That was part of Helen's slides of what has been already delivered in 22. And we are not looking directly at phasing. Logically, we of course have front-loaded investment and back-loaded effect. That's the nature of the game. Those two curves are crossing probably somewhere in the middle of this period. Additional improvements are coming from growth, particularly in international markets. As I said, the growth will come not only from direct share increase, but also from much better mix of products and businesses. Plus additional improvements of kicking in long-term programs in manufacturing and procurement.
James, you asked again a few questions there. As I stated in my prepared remarks, we're at 50% today. We anticipate that the payer class of commercial and MA will grow to 60%, primarily driven by MA with commercial mix remaining stable. We've been more and more successful in being able to negotiate escalators into our both regional and national contracts, both on the MA side and the commercial side. We're getting some tailwind from that effect as well. Our contracts are of a longer-term nature, as you know. We try to lock in rate. That's not to say that we're getting escalators on all. We still have some where there are fixed rates for some, you know, period of time.
Again, we're gonna see higher mix of what we call the more profitable treatments, primarily driven by MA. Relative to Marietta, I think it's important to point out that we are working on a legislative fix. This will not be rulemaking. This will not be resolved through rulemaking. It's also important to point out that, you know, both the majority and dissenting opinions on the Supreme Court decision all pointed to a legislative fix being needed. We are getting ready to introduce a new bill that will go to the CBO for scoring. We believe it will score as a saver for the government. We have strong bipartisan support in the Senate as well as the House around that legislative change. That's not to say that, you know, there's may not be some noise.
We haven't seen a lot of that as of this date, as we had indicated we wouldn't see for this year. We're, you know, we constantly have negotiations with payers. I will tell you that has not come up as a negotiating issue. You know, again, as I mentioned earlier, we are moving those discussions more from a rate discussion to a value-based care discussion. We're seeing payers more and more interested in delegating the risk. I'm not saying there's zero risk, but we think we're managing it well. I think the last thing I'll point out is that, you know, we're ensuring in our contracting that when a, you know, employer group health plan accesses the contract, you don't get the network on your own terms. When we negotiate for a rate, we provide a network.
You can't have one without the other. We think of this very much of a contractual issue. But again, I think the kidney care community as a whole is coming together, trying to drive this legislative change because it's the right thing for patients.
James, thanks for asking the pharmaceutical question. I think there are a couple of factors we've got to look at here. One is none of these pharmaceuticals come into the marketplace in isolation of other factors that impact both what the incident rate of patients that we start new to dialysis are and how well they start, from an optimal start standpoint and do better. As you know, the incident mortality in the first 90 days is higher than the general mortality. The opportunities that we've learned from value-based care to have an optimal start actually allow more of those patients that do start to survive longer. That mitigates some of the effect that might occur from slower progression and that delayed phasing that you speak to.
The second part is these drugs predominantly are designed for either very specific disease states or relatively early in CKD. The early-stage CKD patients are, in fact, taking three to five or more years to progress to End-Stage Kidney Disease anyway. During that time, I would expect that we will be seeing the ability of the cardiovascular effects to actually take hold. I don't think the phasing effect will be quite as predominant as it might seem in that regard. Finally, I would say that the long-term cardiovascular benefit, I think, is going to be one of the most profound changes that occur today. Four out of five patients with mid-stage CKD never actually survive to the point where they have End-Stage Kidney Disease.
If that changes even a fraction, that fundamentally changes the way that we look at the input population of people that are available alive to progress. I think it is a complex calculus. I do think that the progression delay that many of the drugs will have will be good for patients, and it will, in fact, I think, be mitigated by our ability to manage those patients through better starts and better care in the early stages of their kidney failure.
Thank you. A quick clarification question on the first one I asked on the Care Enablement business. Are the in terms of embedded advantages that go to the Care Delivery segment, are there any of that there which would help us benchmark that business to comparable businesses? When you're looking at the margin improvement, are there any factory closures included in that midterm assessment? Thanks very much.
Okay. That question goes to Katarzyna. I'm not entirely sure, James, if I got the question.
I'll take the first half of the question.
The second part I didn't get. I'm sorry.
Um-
Ask her to repeat.
I think I have both.
Fine.
The first part of the question was if there's any embedded advantages in the Care Enablement margin for Care Delivery. When you look at that Care Enablement margin, that does include the intercompany profitability, if you will, from Care Enablement to Care Delivery. However, when you look at the total company margin of 10%-14%, it's eliminated at that point. What we're trying to do is to be able to review a Care Enablement segment that stands on its own margin for the internal and external business. That margin is at fair market value and transfer price. In terms of the second part of the question, which was manufacturing closures included in the current numbers, it is not. There is some manufacturing efficiencies included, but we are continuing to review the manufacturing footprint.
As that work, kind of continues to get underway, to the extent that there are planned impacts, we will bring that forward as a special item. Thank you for the questions.
With that last question and the follow-up question, our Q&A session for today is concluded. Thank you very much to the entire management team for being available. We have received a lot of questions and did our best to answer as many as possible. I'm sorry that we didn't make all of them. Thank you nevertheless for the really inspiring discussions, and I'll now turn it over to Helen again for her closing remarks.
Thank you, Dominic, and thank you all for the great questions today. In closing, I'm gonna share this slide again, as it's really important to me that you take away the following from today's event. Fresenius Medical Care has leading market positions in structurally sound and growing markets. We have a clear, streamlined operating model in place that enables us to run the two segments as the two distinct businesses they are, med tech and services. We have a detailed turnaround plan to significantly improve our operating performance. We can now execute on a disciplined financial policy, adjust our portfolio, and significantly improve return on invested capital. We will not only drive shareholder value, but the proposed change of legal form will also strengthen rights of our free float shareholders.
I am confident that by continuing the execution on the plan shared today, we will unlock value as the leading kidney care company. Thank you for joining us today.