Good evening. My name is Michelle, and I will be your conference facilitator today. At this time, I would like to welcome everyone to the DaVita First Quarter 2023 Earnings Call. Today's conference is being recorded. If you have any objections, you may disconnect at this time. All lines have been placed on mute to prevent any background noise. After the speaker's remarks, there will be a question-and-answer period. If you would like to ask a question during this time, simply press star then one on your telephone keypad. If you would like to withdraw your question, please press star then two. Thank you. Mr. Eliason, you may begin your conference.
Thank you, and welcome to our first quarter conference call. We appreciate your continued interest in our company. I'm Nic Eliason, Group Vice President of Investor Relations, and joining me today are Javier Rodriguez, our CEO, and Joel Ackerman, our CFO. Please note that during this call, we may make forward-looking statements within the meaning of the federal securities laws. All of these statements are subject to known and unknown risks and uncertainties that could cause the actual results to differ materially from those described in the forward-looking statements. For further details concerning these risks and uncertainties, please refer to our first quarter earnings press release and our SEC filings, including our most recent annual report on Form 10-K, all subsequent quarterly reports on Form 10-Q, and other subsequent filings that we make with the SEC.
Our forward-looking statements are based on information currently available to us, and we do not intend and undertake no duty to update these statements except as may be required by law. Additionally, we'd like to remind you that during this call, we will discuss some non-GAAP financial measures. A reconciliation of these non-GAAP measures to the most comparable GAAP financial measures is included in our earnings press release furnished to the SEC and available on our website. I will now turn the call over to Javier Rodriguez.
Thank you, Nic, and thank you all for joining the call today. 2023 is off to a strong start for DaVita. We enter the year with a cautious balance of optimism about our ability to execute against our plan and uncertainty about treatment volume in a challenging labor market. In the first quarter, we performed well on our key metrics, and our results benefited from an improving macro environment. While some external uncertainties remain, the continuation of current trends would put us on a path to deliver strong results for the full year. Before I get into the details about the quarter, I would like to elaborate on an area of our long-term strategy, which is to connect transitions of care through solutions for our patients across each step in the kidney care continuum. That leads me to our clinical highlight around CKD education.
Periodically, we have provided updates on our community education program called Kidney Smart. Raising awareness through education in the kidney care community is critical, particularly given the fact that one in seven American adults have chronic kidney disease and the majority of these people are not aware. Our Kidney Smart program is designed to help those patients understand and manage their kidney health and is frequently recommended by nephrologists as a go-to resource for patient education. To help remove the barriers to health equity, we've offered these classes in ten different languages. In 2022, over 33,000 CKD patients attended a Kidney Smart class, a best ever for the 12-year history of the program. In 2022, DaVita patients who attended Kidney Smart classes were more than twice as likely to choose a home modality in consultation with their nephrologist and care team. Transitioning to our financial performance.
In the first quarter, we delivered adjusted operating income of $352 million and adjusted earnings per share of $1.58. As we discussed in prior quarters, we implemented a number of initiatives in the second half of 2022 to respond to the pressures associated with lower volumes and higher costs. These plans, combined with a strong operating rigor, translated into positive results in the quarter, and we're now seeing some of the operating metrics that impacted margin in 2022 begin to normalize. I'll start with the biggest driver of Q1 outperformance, labor. We made good progress on labor costs in the quarter, which reflected a combination of operating diligence and improvement in the overall labor environment. As we have said in the past, successful labor management requires effectively managing the interplay between wage growth, contract labor, and training costs.
Our operators continued to improve on the permanent staffing levels within our clinics, which has enabled us to drive further reduction in contract labor costs during Q1. We're tracking ahead of plan in our efforts to cut our full-year contract labor expense in half relative to last year. The increase in permanent teammates, combined with elevated turnover, resulted in training costs in the quarter above historical norms, although below the peak we saw last summer. This is in line with our expectations. We anticipate improvement in our training productivity in the back half of the year. This will largely depend on successful teammate retention, which has historically tracked closely with the health of the broader labor market. Moving on to treatment volume. Quarter-over-quarter treatments per day were up approximately 1% and better than the middle of our expected range.
This was driven by net census gains due to both higher admits and lower mortality. Because of the annualization of excess mortality from 2022, we still anticipate a reduction in overall treatment volume on a year-over-year basis, and we continue to assume excess mortality over the balance of this year. That said, we're encouraged by our first quarter volume results. If what we saw in Q1 proves to be a trend, we would expect to finish the year in the top half of our volume forecast range of down 3% to flat relative to 2022. Transitioning to a couple of strategic topics. On April 1st, DaVita and Medtronic announced the launch of Mozarc Medical, a new independent device company focused exclusively on innovative kidney health technologies.
Mozarc's current products and its R&D pipeline, ranging from kidney access technologies to advanced home dialysis and acute therapies, are intended to improve the overall patient experience and increase access to home-based care. This investment reaffirms our commitment to realizing scaled transformation in kidney care and allow us to fuel innovation in partnership with Medtronic, a global leader in healthcare technology. Finally, a note on integrated kidney care or IKC. We continue to make progress consistent with our business plan and demonstrate that our model of care is improving the health and well-being of our patients. I'll highlight two examples of this. First, across our IKC program, more than half of our patients achieve an optimal start, which means the patient initiates dialysis treatment at home or appropriate vascular access in place.
Optimal starts reduce costly and difficult hospitalizations and on average, lead to a reduction in the continuing cost of care in the months and years that follow. Second, recent data continues to show an encouraging differentiation in hospitalization rates from patients in our IKC program versus our overall patient population. As we continue to scale our IKC business, which is measured by the total dollars of medical spend in our program, we will continue to focus on driving our net saving rate while pursuing a cost-efficient model of care. In summary, looking across our most important operating metrics, we're seeing progress at a faster rate than assumed in our initial forecast.
Therefore, we are revising our adjusted operating income range of $1.4 billion-$1.6 billion to a range of $1.475 billion-$1.625 billion, and revising our adjusted earnings per share range of $5.45-$6.95 to a range of $6.20-$7.30. Aside from the COVID disruption in the labor market, other important factors for the remaining of the year include continued progress against our cost-saving initiatives, which Joe will elaborate on, and of course, our continued effort to restore patient benefit protection through our advocacy efforts. I will now turn it over to Joe to discuss our financial performance and outlook in more detail.
Thanks, Javier. I'll start with some additional commentary on first quarter results. Then I'll add detail on our expectations for the remainder of the year. As Javier said, Q1 adjusted operating income was $352 million. Adjusted EPS was $1.58. Free cash flow was $265 million. Overall, the results were at the high end of the range of our expectations for the quarter, driven roughly equally by three things. First, strong operating performance in the U.S. dialysis business. Second, timing of certain items in our IKC results. Third, some normal positive variability in a couple of cost items that we are not forecasting to recur in the rest of the year. With that, let me provide some additional detail. First, U.S. dialysis treatments per day were up almost 1% in Q1 compared to Q4.
As Javier mentioned, this was due to higher patient census. Mistreatment rates remained elevated compared to pre-COVID levels and were consistent with our expectations. Revenue per treatment was down $0.16 quarter-over-quarter, driven by normal seasonal impact of high patient responsibility, offset by annual increases in Medicare fee-for-service rates that begin in January, growth of MA, and seasonal increases in acute treatments. On a non-GAAP basis, patient care cost per treatment decreased by $1.18 sequentially. The biggest drivers of the change were pharmaceutical cost savings from our anemia management transition to Mircera, reductions in our contract labor spend, and positive variability in health benefits and insurance costs. These were offset by higher compensation costs and two fewer treatment days in the quarter. On a non-GAAP basis, G&A expenses were down $24 million quarter-over-quarter, largely due to normal variability in our G&A spend.
IKC's adjusted OI for the quarter was approximately the same as Q4 and better than expected. The quarterly IKC results benefited from revenue that was forecasted to hit later in the year and the deferral of certain expense items that we expect will be recognized in Q3 and Q4. Excluding these items, IKC results were in line with our expectations. International adjusted operating income was up $12 million relative to Q4, driven roughly equally by foreign exchange and acquisition related expenses in Brazil during Q4. Looking at our capital structure, we ended the quarter with a leverage range of approximately 3.9x EBITDA. We did not buy back any shares during the quarter as our focus continues to be to get back to our target leverage ratio of 3x-3.5x EBITDA.
In the last week of April, we closed on a successful $2.75 billion refinancing of our revolving credit facility and Term Loan A despite a challenging capital markets environment. Looking forward, we still expect interest expense of $100 million-$110 million per quarter for the rest of the year. The April first launch of Mozarc Medical, our partnership with Medtronic, will result in approximately $20 million of pre-tax losses below the OI line in Q2. This is less than previously shared due to timing shifts of certain standup costs. In the back half of the year, we still anticipate $15 million of negative impact on other income per quarter. As we shared previously, we expect Mozarc's OI to trend towards breakeven in approximately the next three years.
Regarding the savings initiatives we've talked about in the past, we're on track to realize year-over-year savings within the range of $125 million-$175 million, consistent with prior expectations. This is primarily driven by a reduction in pharmaceutical costs and our ongoing facility consolidation. During Q1, we initiated our conversion to Mircera, which will continue to roll out over the remainder of the year. In Q1, we consolidated 20 centers and currently anticipate consolidating another 40-50 centers over the remainder of the year. We continue to achieve high patient and teammate retention rates related to these shifts as the majority of patients at consolidated centers have transitioned to nearby DaVita facilities. That concludes my prepared remarks for today. Operator, please open the call for Q&A.
Thank you, sir. At this time, you may press star one on your telephone keypad to ask a question. If you would like to withdraw your question, you may press star two. One moment please for the first question. Justin Lake with Wolfe Research. You may go ahead, sir.
Thanks. Appreciate all the color. Joel, maybe you could talk a little bit about what you're seeing. You talked about higher turnover and lower, you know, temp labor costs. What's going on with turnover there? What are you expecting for the rest of the year? How are labor costs tracking versus kind of the headwind that you had laid out for us? Maybe given the upside in the quarter, what are you projecting for the rest of the year relative to Q1? If you do hit these numbers, when do you think you get back to kind of, your target leverage ratio and therefore, you know, the potential to buy back shares? Thanks.
Well, there's a lot in there. Let me just pull up for a second, and then Joel can answer some of your follow-up questions. Justin, this is Javier. First, on labor, we started to give a little more color when we had more volatility in some of the underlying metrics. I think it's a good time right now to pull up as you ask, which is a bigger number. Just so we're clear on all of the metrics, when you talk about SWBs, you take into account wages, productivity, benefits, training, and contract labor. Within wages, there's obviously you can double-click on that. You've got overtime, shift differential, and other things, but let's stay with those five.
In the third quarter of 2022, we had a spike in training and contract labor that we called out because they were outliers to our historical numbers. As we fast-forward to today, we worry that people aren't facile enough with the math to calculate the interplay between the five. Let me see if I get to your number, and if not, you can follow up with a question. From 2018- 2022, we had a CAGR of roughly 2% in SWBs. In 2022, which of course had that outlier that we were just talking about, that number went to roughly 8% growth. In 2023 over 2022, we expect that number that incorporates all those variables to be more in the 4%-5% growth.
Does that answer the question on labor, or do you wanna ask a follow-up on that?
Yeah, just mostly on labor. What I'm trying to figure out is versus that 4%-5%, if you continue at this pace, where do you think you end up?
I'd say, Justin, we're thinking we're about $25 million ahead of where we thought we would be on the total labor cost. If you
Think of our guide increase at the middle of the range of $50 million. I'd say half of that is labor and half of that is volume. That's how I get to $25 million.
Is that just for the first quarter, Joel? I'm kinda trying to think about, like, if this continues, does that mean you're $100 better?
In the labor line itself, there were some items that we don't think will recur. They were good guys in lines like benefits and workers comp that I'd strip out as you think about annualizing things. The 25 would be a full year number. In terms of where we need to go from here, we're expecting continued wage pressure as the year presses on. There will be a little bit of improvement in contract labor, but we've seen most of the improvement in contract labor that we're likely to see because it just happened faster than we thought. On the productivity side, we haven't seen much. We're off the peak that we saw in the middle of last year, but we're still well above pre-COVID levels.
What we're currently building in is some progress in the back half of the year, but ending the year still above pre-COVID levels. That's really driven largely by the turnover that we're seeing.
That's helpful. I'll take the rest of my questions offline, Joel. Thanks.
Thank you. Our next caller is Kevin Fischbeck with Bank of America. You may go ahead, sir.
Hi, this is actually Nambia Gutierrez on for Kevin. Thanks for taking the question. I had just another quick question on labor. You said you expect continued wage pressure in the year. What are you assuming for wage inflation this year, and how does it compare to last year and pre-COVID levels? Thanks.
Yeah, I think, you know, it was really answered a little bit with Justin, so let me make sure we're asking the same thing. We just basically said that if you take all of the variables into account, that we think that SWBs will be 4%- 5% higher, 2023 over 2022. Does that answer your question?
Yes. Thank you.
Thank you.
That's all. Thank you.
Thank you. Our next caller is Andrew Mok with UBS. You may go ahead, sir.
Hi, this is Thomas on for Andrew. Thanks for taking the question. Javier, could you walk us through the underlying drivers of the treatment growth beat in the quarter, as well as provide an update on how missed treatment rates are tracking sequentially? Thanks.
Thanks for the question. I like to use the treatment per day number, and you'll see that that number is up about 90 basis points quarter-over-quarter. That is largely driven by census increases, and that's the result of admissions increases in Q1, offset by continued excess mortality, which is way down relative to prior years, but remains higher than it was pre-COVID. In terms of mistreatment rates, it continues to trend well above the pre-COVID number. It can move around from one quarter to the next. There's a lot of seasonality and other impacts in it, but we are still seeing it running roughly 100 basis points higher than what we saw pre-COVID.
Got it. That's helpful. A quick follow-up. I wanted to ask about the ESA switch to Mircera. Specifically, are there any KPIs you can share to track the transition, and do you have any update on the cadence of the rollout? Thanks.
We do not have any disclosures on it. All I can tell you is that the rollout is going as well as we expected, and that from a clinical perspective, we are seeing the results that we wanted. It's going as planned.
Great. Thanks again.
Thank you.
Thank you. Once again, if you would like to ask a question, you may press star one. Our next caller is Peter Checkering from Deutsche Bank. You may go ahead.
Hey, good afternoon, guys. A follow-up here on Justin's question. On the $50 million operating raise, you said half was labor and half was better volumes. You added almost 60% new lives into IKC. I guess, any changes on how that is tracking versus your previous guidance? On the guidance raise, can you walk us through why $50 million of operating income, transitioning into $100 million of free cash flow? Is that just working capital or anything else in there?
Let me take the first part of that, and Joel can take the second part of that. On IKC, as you can imagine, it is a growing business. While we're making really good progress, it is clearly in the investment phase of the business. There is no change in what we see the full year. We had a bit of timing in there, so the number looks a little better on a quarter to date than it will on an annualized basis. We're still on target to what we've said.
Yeah, Peter, on the free cash flow, as you pointed out, obviously an increase in OI helps that. The other two things are, one, cash taxes, are trending better than we expected, and the second is working capital. You see the DSOs were down considerably, so we think we'll get a bit of a tailwind to that as well for the year.
Just Cigna IKC for a second, you know, realizing that when you add on, you know, 50, almost 60% new lives, that's gonna be sort of a drag as you guys think about those coming online. Any sort of color on sort of how the medical trust, you know, trends are tracking for your people that you had coming into the year. I mean, we've seen spikes of, you know, utilization in other areas of healthcare. Just curious kind of how that class of 2022 was tracking during the first quarter.
Yeah, it's as you said, we agree. It's a little hard to say because we have so much noise and volatility because of COVID. There's not a lot to report. What we're seeing is that the savings are coming in line to where we expect. The model of care is a little less efficient than we want. We need to build more scale, and we need to standardize a whole bunch of these things that right now are manual. We're still work in progress. We're growing a lot of things that we wanna be, and we're still expecting to be break even in 2026.
One last question here, which won't shock you. Looking at the NAG growth, you know, sort of flat year-over-year, definitely a lot better sort of trending than we've seen sort of in the last, you know, several quarters. Baxter was talking about sort of similar normalization of utilization. I guess, any color that you can give us on how many patients you guys added this quarter, how did that sort of track versus, say, 2022 versus pre-COVID? Any more, you know, color you can give us on, you know, where mortality is tracking on the current patient base today?
Yeah, so let me walk you through some numbers Peter here. So the net census growth in Q1 was about 1,350 patients. If you compare that to what it was in Q1 of 2022, that was negative almost 500 patients. So an almost 2,000-patient swing. Most of that is explained by the change in excess mortality, although some of it is also the result of a better admit quarter this quarter than we saw last year. So on both the mortality side and the admit side, we saw progress.
So on the admin side, I guess to give the color for the 1Q 2023 new ads and how that was to 1Q 2019, just as a comparison on a pre-COVID.
If you were to look at this excluding excess mortality, I don't have the numbers in front of me, but I can tell you, it was definitely higher this quarter than it was Q1 of 2019. That said, I would be cautious before we start extrapolating this out. This is one quarter of data. This metric historically has been variable quarter to quarter, and I'd wanna wait to see what happens for a few more months before we're ready to really declare a trend here.
I mean, just a last question on that one. Sorry to sort of keep going there, but you're looking at the USRDS data. We go back, you know, for many years, the incidence rate of end-stage renal disease has been fairly consistent for, I mean, nearly a decade. Are all the signs you're seeing that we are returning to normalization of incidence rates or it's just too soon simply to call it at this point?
It's a little too early to call it. We've been studying and evaluating all different data sources, and we're not ready to draw any conclusions. You know, there's a lot of movement upstream on the CKD population, in particular with COVID. We will look because, as you know, there's some things that are making progression slower. On the other hand, there's things that are expanding life expectancy. Our math is not leading to any conclusion at this point.
Last piece there, I promise I'll stop here, at least for now, is on mortality. I guess any comments on where the normal mortality was and excess mortality, and sort of how we should think about both of those continuing in the back half of the year, I'll stop there.
Excess mortality was about 900 patients in the quarter. We have brought down slightly our expectations of excess mortality for the balance of the year, but we're still looking at a number somewhere between 2,500 and 3,000 patients in terms of what's built into the middle of our guidance range.
All right. Great. I'll stop there.
Thank you.
Thank you. Our next caller is Gary Taylor with Cowen. You may go ahead, sir.
Hi. Good evening. I think just two quick number ones for me. Joel, you had mentioned, or at least in the release, some favorable items in G&A, including a advocacy refund. Just wondering if you could size that for us. On IKC, I know there's a ton of moving parts there, but I was just trying to sort of foot how the revenue was down $4 million sequentially from 4Q, but you said you had or some early revenue there and some delayed expense. Just trying to sort of foot down, but still, including some early revenue recognition.
Sure. Six million is the ballot number you're looking for. In terms of IKC, we saw about $20 million, roughly half in the revenue line, half in the expense line, that we were expecting. We were just expecting it later in the year. In terms of the timing of the revenue, we generally view IKC revenue to be back half of the year loaded. As you think about the claims lags filling up or maturing and then ultimately the calculations on shared savings being done, that usually happens in the back half of the year, and that's when we'll recognize the shared savings dollars. That's why you see the decline from Q4.
Mm-hmm.
with still a call it a positive timing surprise.
Got it. Perfect. Thank you.
Thank you, Gary.
Thank you. Our next caller is Peter Chickering with Deutsche Bank. You may go ahead, sir.
All right. Sorry, guys. I just had a couple ones I wanted to come back to you on. Revenue for treatment, sort of, you know, flatted sequentially, primarily due to sort of the seasonal co-pays. Just curious, sort of two questions, I guess. What are you seeing from managed care on cost of living updates? How should we think about revenue per treatment sort of going through the rest of the year?
Thanks, Peter. A couple of things. We're not seeing anything to report on from the managed care negotiations. Just to refresh you, we've talked about our contracts are multi-year. In any given year, we negotiate roughly about 20% or so of our portfolio, and we're not seeing anything different in this year. What we've talked about in Q4 2022 that we said that we would get a revenue per treatment increase year-over-year from 2%-2.5%, 2023 over 2022.
Okay, great. On the efficiencies from closing centers, you guys sort of closed 20 this quarter. You talked about consolidating another 40-50 centers. I guess, how much sort of savings do you think you're gonna realize in 2023 from those center consolidations just solely on that line? How much of that then should trend through for 2024?
Yeah. We haven't quantified the number. We've always said it'll be part of the $125-$175, but not the biggest piece. The biggest piece of that is Mircera. That'll be in 2023. There'll still be some amount that'll roll over into 2024, but we'll get most of it in 2023.
Okay. Sort of last one here for me. Maybe I missed it, but what was the contract labor dollars, this quarter? What are you seeing for the rest of the year? Any color on what your, what your hiring was and net hiring was in the first quarter?
I think what we said was that the, in the year, last year, remember, contract labor was running around $100 million, and we said for the year this year would be half of that. Now today we move that we are moving better, at a better pace. That number will be more like $35 million. Again, I would point you to the beginning of the conversation where we said the most important part is the interplay between all the variability of all those metrics, because of course, training, productivity, wages, benefits and contract labor are all intertwined. That's the number.
I guess the second part is just, you know, can you quantify for us the number of hires you had in the quarter and what the net hires was after turnover and how that should trend throughout the year? You mentioned about lower training costs as this batch sort of comes online. Just helpful if you can quantify that for us.
Yeah. Here's the way I think about the training costs. They peaked last year as a result really of two things, higher turnover combined with the need for us to net add staff. Those combined to a high training level. As we sit here today, the turnover remains elevated. It's gotten better on with some classes of labor than others, but it still remains elevated. We're expecting continued high training levels until that comes down, we're modeling the back half of the year. We are much closer or at fully staffed. Some of the training associated with getting the staffing levels back up is now done, and that will mitigate some of the training costs relative to the peak we saw in Q3 last year.
When you talk about sort of the 4%-5%, you know, increase in SWB, I guess how much of that is sort of more of a one-- It comes from the training costs that are embedded within the guidance that should sort of roll off as we think about 2024?
Not a lot. The change in contract labor is a much bigger tailwind relative to 2022 than the training productivity. That's, you know... It's partly because we're not gonna see the training productivity improve till the back half of the year. It's also partly because in the beginning of 2022, training productivity was still low. We saw the spike in Q3, but that was only one quarter.
Okay, great. thanks so much, guys. I appreciate it.
Thanks, Peter.
Thank you. At this time, I am showing no further questions.
Thank you, Michelle, and thank you all for the questions. As I hope you've heard today, we have some positive momentum to start the year. If the results of Q1 prove to be a sustainable trend, we're excited about the implications for our patients, our teammates, and our financial performance in 2023 and beyond. Thank you all for joining the call and be well.
Thank you. This concludes today's conference call. You may go ahead and disconnect at this time.