DaVita Inc
NYSE:DVA
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DaVita Inc
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Good morning. My name is Amanda, and I will be your conference facilitator today. At this time, I would like to welcome everyone to the DaVita Third Quarter 2022 Earnings Call. [Operator Instructions] Thank you. Mr. Ackerman, you may begin your conference.
Thank you. And welcome, everyone, to our third quarter conference call. We appreciate your continued interest in our company. I am Joel Ackerman, CFO and Treasurer, and joining me today is Javier Rodriguez, our CEO.
Please note that during this call, we may make forward-looking statements within the meaning of the federal securities laws. All of these statements are subject to known and unknown risks and uncertainties that could cause the actual results to differ materially from those described in the forward-looking statements. For further details concerning these risks and uncertainties, please refer to our third quarter earnings press release and our SEC filings including our most recent annual report on Form 10-K and 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, Joel. Good morning, everyone, and thank you for joining our call today. Q3 was a challenging quarter for us. While natural COVID statistics have been declining, the cumulative impact of COVID on the ESKD patient community continues to grow. Despite the economic challenges, we continue to deliver high-quality clinical care for our patients. We remain incredibly grateful for the amazing work of our frontline teammates who are unrelenting in their focus on caring for our patients.
While our commitment to patients is a constant, it is particularly highlighted when a community is in need. As you know, on September 28, Hurricane Ian made landfall in Southwest Florida, subjecting the community to sustain 100-plus mile per hour wind and significant flooding. This led to many health and safety issues for the people in the area, especially people who require life-sustaining dialysis treatment.
DaVita operates 230 dialysis centers in Florida with approximately 14,000 patients and 3,250 teammates. Through our comprehensive preparedness planning, I'm grateful that 100% of our patients were accounted for and all had received dialysis within days of landfall of the hurricane. We deployed water tankers, generators, fuel tankers to quickly restore operations in affected areas as well as to provide dialysis to patients from across the kidney care community.
Now turning to our financial results. As I mentioned, it was a challenging quarter. For Q3, our adjusted operating income was $351 million, and adjusted earnings per share was $1.45. Adjusted operating income was down sequentially by $88 million from Q2 and was below our expectations for the quarter.
The headwinds in volumes have persisted longer than we assumed and contract labor costs and productivity did not begin to improve in the quarter as we had expected. We are now assuming these pressures will continue longer than previously anticipated. As a result, and given the continued uncertainty from COVID and the labor market, we are lowering our guidance for the year and our outlook for 2023 as well.
We are reducing our 2022 adjusted operating income guidance to a range of $1.375 billion to $1.45 billion and our 2022 adjusted EPS guidance to $6.20 to $6.70 per share. For 2023, we're updating our outlook for year-over-year adjusted operating income growth to negative $50 million to positive $150 million as outlined in our press release for this quarter.
As we have said in the past, volume and labor continue to be the biggest drivers of uncertainty in our results. Let me walk you through the details on what we have seen on each of these and what we're assuming going forward.
Let's start with the three main drivers of volume. Census growth before excess mortality, net treatment rates and excess mortality. I will cover each of these individually. First, on census growth, excluding excess mortality, we have seen a decline in patient admissions during each COVID surge, followed by a rebound after each surge. The decline we saw earlier in the year was attributed to Omicron search which we anticipated would rebound in the second half of the year as it has in prior surges. We did not see the expected rebound in Q3 and are assuming continued pressure on admissions in Q4 and through 2023.
Next, net treatment rates. As we discussed during our Q1 earnings call, as a result of Ominicon search, mid-treatment rates had increased and we're having a meaningful impact on the change in our treatment volume. We anticipated these increases would return to seasonal norms after the win in search and they have not. As a result, we are now assuming these will remain elevated through the end of this year and through 2023.
Finally, on excess mortality. While COVID mortality rates in 2022 are down from prior years, access mortality remains a challenge for us. We expect this to persist in Q4 and into 2023. The magnitude of the impact will depend on the size and the severity of COVID surges this winter and through the rest of 2023.
Taking these three metrics together, volume remains the biggest source of uncertainty in our forecast for Q4 2022 and 2023.
Moving on to labor. I will cover three drivers: wage rate, contract labor and training costs. As we've talked about in the past, we've been assuming significant wage pressure in 2022 with some offsets from lower benefit costs. Overall, we expected a headwind in 2022 of approximately $100 million to $125 million. Year-to-date, our results are consistent with this forecast.
We had also seen significant pressure from contract labor costs in the first half of the year. We expect these to remain elevated in Q3, although at levels below Q2. In fact, the contract labor cost in Q3 increased relative to Q2, and we're now forecasting that, that decline will be later and slower than originally anticipated.
On training, we went into Q3 with elevated costs as a result of more hires, which is consistent with increases we have seen in past during hiring peaks. Training costs accelerated in Q3 and which resulted in approximately $20 million higher costs in the quarter than expected.
Because of the elevated turnover, this has not yet resulted in the magnitude of positive impact we would normally expect on contract labor or staffing level. As a result, we expect training costs to remain elevated in Q4 and early 2023.
In response to these challenges, we continue to work on a number of cost-saving initiatives for 2023. First, we expect to deliver meaningful savings from our new contract from anemia management. WE will begin to transition to our new contract for Mircera in 2023.
Second, we are optimizing our clinic [ph] footprint for the current operational environment, which we expect to result in higher capacity utilization and better leveraging of our clinic fixed costs, including labor costs.
Finally, we have initiatives underway to reduce our G&A in several areas of the business while investing in our future. As discussed, the cumulative and continued effects of COVID and labor are the key drivers of the shift in our outlook for the balance of 2022 and through 2023. We have anticipated that volume declines from COVID and labor market pressures would impact our revenue growth and margins in 2022, so we had expected release from both dimensions in 2023.
We are now assuming these challenges will persist longer than expected, which is what accounts for the change in our guidance. As we step back, we remain confident in our strategy and we are focused on responding to the current industry challenges.
We're dedicated to delivering high-quality care of our patients, creating a great place to work for our teammates and sustaining our investment in the future to drive growth in integrated kidney care, have more patients treated home and increase access to transplant.
I will now turn it over to Joel to discuss our financial performance and outlook in greater detail.
Thanks, Javier. Let me first give a few more details on Q3 results before I turn to the rest of 2022 and 2023. As Javier mentioned, we continue to experience treatment volume pressure and higher labor costs in Q3. These challenges were partially offset by lower spend on the ballot initiative than expected and lower losses than expected on ITC in the quarter.
Spend on the ballot initiative this quarter was $28 million as compared to $23 million last quarter. We recognized the benefit in IKC of approximately $8 million related to shared savings revenue that was anticipated in Q4 and we anticipate could be offset with higher ITC losses in Q4 than expected.
U.S. dialysis treatments per day were down 0.4% compared to the second quarter. Approximately half the decline was the result of elevated miss treatment and half from lower census. Revenue per treatment grew quarter-over-quarter by $2.13, primarily due to favorable adjustments, increased acute treatment as well as the continued shift to MA plans, partially offset by the reinstatement of Medicare sequestration.
Patient care cost per treatment was higher by $8.72 quarter-over-quarter, primarily due to higher wage rates, training expenses for new teammates due to increased hiring and timing of teammate health benefit expenses.
G&A expense was up approximately $56 million versus Q2, $46 of the $56 million is the result of three items. First, in Q2, we had a onetime gain related to some self-developed properties of $22 million. Second, in Q3, there was $11 million of expense recognized related to closure charges. This $11 million is excluded from the adjusted OI. Third, there was our $28 million contribution to the industry campaign against the ballot initiative in California, an increase of $5 million over Q2. The balance of the quarter-over-quarter change is related to higher compensation expense and typical fluctuations in G&A spend.
As I've discussed on previous calls, we've identified a number of initiatives to lower our fixed cost structure and our G&A. As part of these efforts, in Q3, we recorded $40 million of expense including accelerated depreciation and the write-off of the net book value of assets related to certain centers we closed as we seek to optimize our clinic footprint. These expenses are excluded from our adjusted operating income. We anticipate additional expenses will be excluded from our adjusted operating income in our guidance for both 2022 and 2023.
I also want to add some details about 2023. As Javier mentioned, we've updated our year-over-year adjusted operating income growth estimate to negative $50 million to positive $150 million. The change comes primarily in our assumptions around the continued headwind on treatment volume. We've also made small adjustments to two other drivers.
First, we've changed the outlook on labor costs, primarily associated with training costs of new hires now pushed into 2023 as a result of 2022 performance and inflation. We've also lowered the range for year-over-year improvement in IKC operating income by $25 million. This is due to outperformance in 2022 rather than a change in the outlook for 2023.
Finally, during the quarter, we repurchased approximately 2.1 million shares which brought the total for 2022, thus far to approximately 8.1 million shares. Looking forward, we expect the pace of our share repurchases to slow significantly. We currently plan to focus more of our capital deployment to lowering our debt levels to get back to our target leverage ratio of 3 to 3.5 times EBITDA.
Operator, please open the call for Q&A.
Thank you. Our first question comes from Andrew Mok with UBS. Your line is open.
Hi, good morning. I’ appreciate all the color on the headwinds. When I look at the guide to it implies a Q4 range of about $240 million to $320 million of OI which is a pretty material step down from recent quarters. Can you maybe help rank order the headwinds you laid out for us in terms of what's driving the sequential decline? And what are you assuming with respect to COVID and its impact on treatment and labor in Q4? Thanks.
Sure. Thanks, Andrew, for the question. So if I were to bridge Q3 to the middle of the range for Q4, First, we have the benefit of ballot. So that's in the high $28 million benefit. In terms of the headwinds rank ordering them 1 and 2 are salary wage and benefit would be number one. And that's higher training costs, wage rate increases and some benefit seasonality.
Number two would be volume, which is an accumulation of the census miss. So the kind of the full quarter's worth of the lower census we experienced in Q3, plus some additional census headwind as well as a spike in the mist treatment rate. Historically, mistreatment rates are lowest in Q3 and Q4 - I'm sorry, in Q2 and Q3, they go up in Q4 and then again in Q1, partly due to weather and flu season and then also partly due to holidays.
And then third would be RPT. We had some favorable variability in Q3, that will come down, and we typically see a bit of a decline in commercial mix from the middle of the year through the end of the year. So those would be the big ones.
I think there's a little bit of stuff in depreciation and amortization. I think IKC will come down a bit again as well, and there is some seasonality in G&A. So that would be the bridge in terms of what we're assuming here for Q4, we're assuming continued excess mortality, we're assuming the - the mistreatment rate that we've seen being above historical norms persists. And we're assuming some of the admissions or the - the, call it, organic growth challenges that we saw in Q3, we're assuming those persist as well.
Got it. Okay.
Andrew, let me just add a little color because of what you speak of as a magnitude. I think it's important to note that underlying all the assumptions that Joel just went through we had a philosophical change in how we look at the future.
So in the past, we were building in a rebound, we were assessing the uncertainties, but we thought that they would taper out by around Q3 and well into Q4. So now we're assuming that COVID remained and the uncertainty on labor and volume stays longer. And so that really shifts the models in the dramatic way that you're trying to bridge.
Got it. Okay. That's helpful. Any color on how much higher the mistreatment rate is in 2022 versus historical levels?
Yeah, it's about 100 basis points higher - so you can think of that as just a 1% headwind on our treatment volume. And just to give you a number, 1% of treatment volume is worth about $50 million of operating income.
Got it. And then you mentioned contract labor costs increased sequentially, which is a somewhat surprising trend. Was that driven by higher utilization or higher rates? And were there specific markets driving that sequential increase?
Yes. Let me grab that one. The reality is there is no one market. It is spread across the country. And the reason why that variable, i.e., contract labor is behaving a little less predictable than usual is because normally you would look at your training as a leading indicator of the decrease of contract labor in the future, i.e., you're training a teammate and that person is going to hit the floor in whatever, 3, 4 months.
And then you would, in essence, model your contract labor decreasing because of persistence in turnover, unfortunately, our leading indicator of training is translating to lower contract labor and therefore, we're having higher contract labor and higher training which, of course, is the double whammy that we're speaking of.
Got it. It's helpful. And then you mentioned..
Just to add on to Javier, it's more about the number of contract labors and less about rate.
Okay. That's helpful. Last question for me, and I'll hop back in the queue. You mentioned that you plan switching your ESA regimen from Epogen to Mircera [ph] in 2023. Can you help us understand the pace of that transition?
Yes. We've gotten a lot of questions on that. And as you can imagine, safety is utmost importance and we want to do it at the right pace. We will be done by 2023, but of course, the doctors have to review all the protocols and make sure that it's proper for their patient population. And so we don't have a particular goal. We're just saying, please review the documents and get the proper prescription for your patients.
Okay. Thank you.
Thank you.
Thank you. Our next question comes from Kevin Fischbeck with Bank of America. Your line is open.
Great, thanks, I wanted to ask a little bit about the miss treatment dynamic, I guess, is this something that you have seen happen in the past before? What would cause people to miss treatments on a consistent basis, it seems like something that it really can't happen for any extended period of time. So has this ever happened and how long does it normally take to come back? And what are the causes in your view of why it's happening now and persisting longer?
Yes, Kevin, thanks for the question. Miss treatments are common at certain volumes because just life happened transportation vacations, et cetera, where you missed one treatment. I think you are right in assessing that there's not what I'd call a chronic miss that you can go too long without dialysis.
But when we studied the data, we found that it is consolidated, meaning roughly 15% of the patients are causing 70% of the miss treatment. And so when we started to look into that, we found that roughly half of the miss treatments are hospitalizations. And the other half is a popery of things from the patient, him or herself being ill with covet or something else, so stay in home, transportation issues, either due to staffing or other things and then scheduling scheduling either due to the patient or our center.
And so there's a lot of things that go into the mistreatment -- and what we're trying to do right now is make sure that we double down on our processes to reschedule the patients, but this is where it's all connected. If you have a tight labor market and staffing is tight, sometimes it's harder to get that rescheduled - so we're working on it. And basically, we had never really talked about this treatment because it was pretty flat year-over-year. And then with the COVID sort of introduction, if you will, that number started to move, and we thought it would revert back to normal, and we're now seeing it stay elevated.
Okay. That makes sense. And then, I guess, what drove the commercial mix in the quarter. I think that was a headwind this quarter, but a tailing year-to-date. So anything going on there? Any update or thoughts on what the Marriott is impacting pricing at all?
Yeah. No. Commercial mix was flattish, and it was down. It was down in what I'd call normal material way on the commercial side. And you got to remember that mix is a numerator denominator and because of excess mortality and particularly in our older population, which is Medicare that number is moving a little unusually as well. But there's nothing to report on that.
About pricing is Marriott having any impact there?
No. On pricing, I remember, our contracts are set for an extended period of time -- and so if you were going to say the negative of our long-term pricing is that, of course, they didn't incorporate the inflation that we're experiencing. If you're going to look at the positive and we've talked about this, is that we have very predictable and stable relationships with our payers. And therefore, you're not susceptible to the bumps of everyday life, you can plan with with a 3-, 4-year time horizon.
All right. Great. Thank
Thank you. Our next question comes from Pito Chickering with Deutsche Bank. Your line is open.
Yeah. Good morning, guys, Thanks for taking my questions. Going back to sort of 2Q when you reported in sort of our results beginning of August, I'm just sort of curious what changed in August and September versus what you saw through July that relate to the so dramatic miss in kind of guidance?
Yeah. Let me grab the high level, and I think I'll be a little repetitive -- the main thing, Peter, is the philosophical change in guidance. And so if you start to think we had this rebound that we thought a lot of these numbers that were high would revert to normal. We've spoken of a couple, in particular, training and miss treatments already - and so when you grab all those numbers and you say they're going to revert to normal.
And instead of that, it actually goes to an all-time high, meaning it goes the opposite way. then that starts to open up a big gap -- and then instead of assuming, well, maybe the rebound is going to happen a quarter from now, we just said, we don't have any data that would make us any smarter on on really predicting where this will change. And so we had conversations internally and we had a couple of options. We had 3 options, right?
The first one is you just don't give guidance at all. because it is just too much to predict for 2023. The second is you try to predict the unpredictable. -- and really try to make an educated prediction about when COVID and labor markets regulate. And then the last one is you assume the current environment doesn't change until there's clear data.
And so we used to take something closer to Option 2, which is we had assumptions of COVID in volume, and we thought they would get better at the back end of '22 and improving into 2023. And now, we're taking closer adoption 3, which is we assume these dynamics that are strange in COVID volumes and the labor markets continue until we have further data.
So Peter, let me fill in Javier's high-level view with just a little bit of quantification on the details. So if you look at our '22 guidance today versus where we were three months ago, it's down about $150 million at the center of the range. That is - the biggest component of that is volume, which is, I'd say, roughly split 50% from lower census and 50% from a higher miss treatment rate. And on the mistreatment rate, it's not that it's going up further. It's just that it's not coming down the way we had anticipated, so that's 22.
Looking forward to the change on 2023, it's really much more about volume. Again, census being the biggest driver on that and miss treatment rates also not coming down with our new philosophy. And then the other big component would be labor. Tow thirds training one contract. And that's really about pushing out from the second half of this year to the first half of next year when we start seeing the benefits of some of the new hires that we're putting in place and the reduction in training costs and then ultimately, lower contract volume. So those are the numbers.
Okay. On the treatment assumptions or actually on treatment, I guess, during 3Q, sort of ignoring the mistreatments for a second. If I should breakout for the three key drivers here, it's instance rate of new ESRD patients, patient mortality and excess patient mortality from COVID. I guess can you just break down what you saw this quarter in these 3 buckets? And is there a slower incidence rate, which could be leading to lower promotional mix in the quarter, back half of the year?
Yes. Let me grab those because you've got the components right. So let's just start from the top. You start with new admit. The new admits are down roughly a couple of thousand patients then you subtract transplants, which have been flattish and then you subtract mortality, which as we've discussed has been higher.
And then you subtract the miss treatments, which we've already discussed, has been higher, roughly 100 basis points depending on the starting point. And so that's the entire equation. The next question, which we've been really studying is why are new admits down what is happening with the population upstream, which is sort of the natural question. Unfortunately, that leads to a dissatisfying answer, and that's because of what we've talked about all along which is there is very low visibility to the CKD population, and roughly half of the patients actually crash into dialysis.
So you start getting into a lot of different data sources and data sets -- and what we've looked at isn't conclusive. And so right now, the hypothesis, one could have a good hypothesis that says there happen to be a bit more depth in that patient population.
There are others that think that, that might be offset over time because the volume and the pace at which someone will progress from CKD into ESKD will be bigger post time as COVID progresses. And so right now, unfortunately, again, the upstream is the one that we have the least visibility in the other variables we've already discussed.
Okay. Got it. I know you don't give revenue guidance for 2023, but after so this pretty large decrease of OI guidance. Can you help guide us to what revenue growth you assume in 2023 over 2022 with all these changes that we're making?
Yes. So I think the best components to think about would be RPT and volume. And I think at a very high level, they will offset each other next year. So again, I don't want to get into too much specificity, but I think thinking about RPT in the maybe a little bit better range and then a volume decline, if you take everything we've said at the middle of the range would be about a 2% volume decline -- so those would offset each other and wind up at kind of flattish revenue
Great, thanks so much.
Thank you. [Operator Instructions] Our next question comes from Justin Lake with Wolfe Research. Your line is open.
Thanks, good morning. Just a quick follow-up first on the volume question. So volumes down 2% for next year is what you're assuming, guys, just to be clear?
Yes.
That mix treatments?
Year-over-year, there's no mistreatment impact because what we're basically saying is it's running 100 basis points higher than normal in 2022, and we're assuming that it will continue to run at that 100 basis point higher than normal level. So it's 100 basis points relative to pre-COVID, but year-over-year, it's no change.
Got it. So this is 100% coming from new admits below mortality?
Yes. I mean it's a combination of new admits running below historical plus continued excess mortality -- and then I think the other important thing to recognize is as as we have excess mortality throughout the year of 2022, that has a negative impact on the full year-over-year as that -- the impact of that mortality annualizes.
Okay. And then you talked about the clinic closures in the third quarter. Can you tell us how many clinics are closed in the third quarter? And then how many do you expect to close for the full year this year? And any insight into how many you closed in 2023?
Sure, Justin. For the year, there's a little timing in there. So let's give a range between 130 and 150 for the year or so. And for next year, we're forecasting between 50 and 60. And again, those could bounce around depending on timing. And so just to remind you because I think we spoke of this last time, we put through several lenses. The first is to make sure we have the right patient access. Secondly, we look for the availability of home - and then lastly, we look at sort of the local market dynamics, the lens of the leases and those type of things. But it's a complicated process that we have to be really thoughtful to make sure that we're being responsible.
Justin the number was 44.
Okay. Good. And then does this have any impact on patient growth as well? Or do you feel like you retain pretty close to 100% of these patients when you close the center?
We don't retain 100%, but we retain the vast majority. So it shouldn't have much of an impact on volume.
Okay. And then last question before I jump back the leverage. So the - would you agree EBITDA next year somewhere in the $2 billion range ?
I don't want to get into the specifics. But I think if you're asking about leverage, where we round up to 3.9% this quarter. it is above our target range of 3 to 3.5x. And we are -- we would like to get the leverage down over the course of next year. Obviously, what happens to EBITDA year-over-year will be an important driver of that.
But to further that effort, we are certainly going to rethink how much of our free cash flow we're deploying to share buybacks and lean more heavily to debt pay down. So the revolver was down from 450 last quarter to a drag of $2.75 this quarter. And I think it's fair to say that our share buyback pace will come down over the next year and our leverage level should come down as well -- I'm sorry, our total leverage should come down as well.
Yes, Joe, I guess what I was trying to do is like the number you have in the press release is a little bit backward looking. -- if the EBITDA is coming in the OI coming down next year to 1.4, I'm assuming you get to like $22.1million EBITDA in total, right, with the D&A -- so that would leave you closer. I think you said in the release you were 8.8% net debt that would put you at close to 4.4% on kind of a forward look versus the backward look that you have in the release, one, is that the right number? And then two, maybe I appreciate the help and understanding debt-down over share repo. But if you could give us a little bit more color in terms of if you have $1 of free cash flow next year, maybe you could just tell us previously, it's been 100% towards share repo. Is it now 75-25 or at 4.4 times, are you doing any share repo so you get closer to 3.5%? Thanks.
Yes. So I'd start with a higher EBITDA number for next year. if you take, I think, in the middle of our range, you get somewhere a little north of $1.45 billion. I think it's 1.46% on OI, add back $700 million of depreciation and amortization, you'd get to an EBITDA number that's more in the 21% to 22% range.
And then in terms of how much of the free cash flow we deploy, I would think it would be a higher percentage to debt pay down than the kind of 75%, 25%. I don't want to give a specific number, but I think we're going to cut way back on share buyback.
Got it. That's helpful, guys. I appreciate it.
Thank you. Our next question comes from Pito Chickering with Deutsche Bank. Your line is open.
Hey, guys. Just a sort of a follow-up here. Looking just at the fourth quarter, implied OI, if I annualize that, it's pretty -- a lot lower than sort of the new ‘23. Just curious sort of what costs or sort of more of a onetime in nature in 4Q that we won't take as a run rate into 2023?
Sure. So let me try and build that bridge up of Q4 annualized to the 2023 guide. I think you wind up with about a $350 million gap that we would need to bridge. And here's how I do it. First, volume will be a headwind from Q4 to the full year, call that $100 million will be a tail will be a tailwind north of $200 million. I think important to realize there, again, RPT, we think, will run stronger next year, year-over-year than historically.\
One of the big drivers of that will be Medicare fee-for-service, where the final rule is not out we're expecting it imminently. We are anticipating that the final rule will be better than the preliminary rule. So that will help RPT and then just all the normal RPT increases, so call that north of $200 million. I would add in $150 million of cost savings, which is in the table that we called out in the press release -- and then there is a bit of negative seasonality on Q4 that's probably worth $50 million to $75 million.
So if you were to add that all up, you get somewhere around 350. The one thing that wasn't on my list, I just want to highlight was labor relative to Q4 we could see 2023 as being relatively flat. Labor being flat in 2023 relative to Q4. And what you see there is higher wage rates offset by the lower training costs, which we see coming down in the back half of the year as well as contract labor coming down over time.
Okay. Got it. And then I know versus the other moving parts of the small one, but on the ITC guidance for 2023. I guess what what's changing your assumptions? Is it higher utilization that you're assuming? Is it lower reimbursement you're assuming? Is it increased investments? Kind of what's driving that change for ITC for 2023?
I'm sorry, Pito, I missed that. Could you repeat the question? I apologize.
Apologies. Looking at your 2023 guidance, previously, you're guiding to specifically on the ITC, you're guiding to tailwind now is a $25 million headwind or to flat headwind. So it's a swing here in ITC guidance for next year. Just curious exactly what's driving that? Is it more utilization -- is it -- it was the key driver of the delta/
Yes. Sorry about that. So if I look at 23 for IKC, I think there are really 2 factors at play here on the bridging it from 22 to 23. One is 22% is coming in a lot better than we expected. So you're comping to a to a much smaller loss. The second thing is we now expect growth in 2023 again. And as we've called out in the past, IC growth is a headwind in year 1 to OI.
So your - the overall result hasn't changed much. It's that 22 has gotten better and to some extent, some of the benefit we're seeing in '22 is going to get offset by the impact of growth in '23.
Is that growth coming from more MA contracts converting into...
There's a little mix of that, but the bulk of it is we are opening a lot more of the CKCC program. So we had 11 this year, and we're doing 11% more next year. There will be a little more MA, but the predictable large volume will be government.
Okay. Fair enough. And then, I guess, with all the moving parts, do you view the breakeven point for ICE getting better or worse from previous guidance?
I would say the business is performing better than we expected. But in the short term, growth has a negative impact on NOI.
Okay, great. Thanks so much.
Thank you.
Thank you . Our last question comes from Andrew Mok with UBS. Your line is open.
Hi. First, do you have the excess mortality number in the quarter that you can give to us? And then you noted that the annualization of excess mortality is a negative for next year. When you look at the patient population, are you seeing any evidence of reduced mortality rates for the current population such that when you finish annualizing this excess impact treatment should start to accelerate?
Yes. So excess mortality in the quarter was a little bit north of 1,000, call it, $1,100. In terms of are we seeing what we call the pull-forward effect it is very hard for us to tease out the difference between higher COVID mortality and lower mortality from pull forward. So the excess mortality number we give is effectively a blend or is a net of those two numbers. We still believe in the concept of the pull forward that some patients that our census is being positively impacted by lower mortality from the earlier excess mortality, but we're just not in a position to quantify it.
So I think it is fair to think of our excess mortality as a net number of the number of patients in the quarter who died as a result of COVID, offset by a lower mortality from the prior mortality that isn't occurring this quarter. I hope that's clear.
Okay. I think I understand. And then on the hurricane, you noted that you're able to get all the patients down in Florida access to dialysis throughout the hurricane impact. Can you quantify what impact that had on your P&L this quarter? And is there any lingering impact of the hurricane into the fourth quarter?
Yes, Andrew, there was no significant impact on the P&L and again, nothing in Q4 for that.
Okay. And then on the Medicare rate, I think you said you're already assuming better Medicare rates. Is that 100 basis points better? Can you give us some color on what you're assuming there?
Yes. That's a reasonable estimate. We've looked at what other sectors have seen in the delta between their prior and their final -- so we're thinking about 3.4%, I think, is a reasonable number.
Thank you. And we did have another question come through Justin Lake with Wolfe Research. Your line is open.
Can you hear me okay?
We can hear you fine, Justin.
So I thought maybe we just throw in one more question on kind of cost going through 2023. And for instance, Andrew earlier brought up Micra you guys are going to be implementing that through the year. So just looking to see like, is there any potential right at the end of the tunnel as we go through the year. Freyser costs for the year. The benefit of that, you won't see it, but you'll be at a higher run rate on savings at the end of '23 than you were through was also thinking about the potential you talked about contract labor being higher than you expected and that's going to hopefully moderate through 2023. So just wondering if you could give us some numbers around that, for instance, is there -- within that cost cutting, how much is Macera in that cross-cutting number -- and how much do you think you could get out? How much will the total savings be that you could run rate in the 23%? And then maybe you could tell us what your contract labor costs are running in the third and fourth quarter. and how you expect those to run through 23, so we could think about an exit rate in three/
Yes. So first, I think you're thinking about things directionally correctly, that the front half of the year will be tougher than the back half of the year. And for -- I put it into 3 buckets. One is Q1 is always seasonally tough because of revenue per treatment. And that's just how we account for the nonpayment or the bad debt associated with deductibles and co-pays. Second is a combination of the savings from Mircera and some of the other initiatives building over the course of the year, combined with some of the pressures associated with contract labor and training declining over the course of the year. And then finally, IKC is a business that we have generally assumed will have a better Q4 than other quarters because of how revenue recognition works. We saw -- we're seeing less of that pattern in 2022.
We've seen more of the revenue that we expected to recognize in Q4 earlier in the year. But again, I think we're anticipating a better Q4 for ITC, although that's not something you could annualize. So those are the things in terms of how to quantify some of this stuff Contract labor for Q3 is running at about 30 -- a little bit north of $30 million for the quarter. We're looking at that to come down a bit in Q4 and Q1 and then really start declining starting Q2 of next year. although we're assuming it will remain elevated relative to our historical rate, which was almost insignificant. That's contract labor. In terms of quantifying the magnitude of the cost savings. So we've called out $150 million for next year at the middle of the range. Mircera is the biggest component of that. The the realignment of the footprint is number 2 and the G&A is number three. So we're not going to give specific numbers on those things, but I think that can help you get in the right ballpark on those three numbers.
Got it. Maybe on my Setra [ph] would be would the fourth quarter run rate kind of be double what the benefit that it covers the annualized, but is it going to be something that's kind of ratable for the year, so second fourth quarter exit is going to be a lot higher? -- than the full year along
It's hard to tell, Justin. This - remember, this is an operationally intensive effort. Ultimately, physicians do the prescribing not us, and it will be a question of how they're thinking about it, how long it takes them to integrate the information, how many will make the change and when. So I don't think we're ready to make a prediction on that.
Okay. And then last question for me is on revenue per treatment. So you talked about there were some kind of moving parts there that benefited revenue for treatment First, can you put a number around that in terms of how much dollars in revenue per treatment, you saw a benefit? Just trying to understand, one, how much that benefit is the quarter and two, was a reasonable run rate to think about going into the fourth quarter? And then lastly, maybe you could give us a number on that commercial treatment that commercial mix decline.
Yes. So I think you can think of the quarter as having benefited by $2 to $3 of normal fluctuation. We see that all the time. if you want a good exit run rate, I think $365 RPT is a reasonable exit run rate for Q4 and for the full year of 2022 off of which to build your '23 number. In terms of commercial mix, it was a few basis points down for the quarter. So really not significant. I think it was 10.4% last quarter and it rounds to 10.3% this quarter, but it was pretty small.
I apologize. At this time, we have no further questions. Mr. Rodriguez. I'll hand the call back to you.
Thank you, Aman. As you can see from all the conversation we have guidance is harder with the COVID uncertainty on volume and the labor dynamics that we have spoken of. We, of course, are working very hard to give you our best estimate and now are assuming that they will stay elevated for a period of time. Let me just close with a couple of comments. One is these are very challenging times for DaVita and they are challenging times for the broader kidney care community and all health care providers. But as I separate myself from this moment in time and I look further out, I can't help but to say, we are incredibly well positioned to differentiate and outperform given the experience of our team, the clarity of our strategy and the strength of our balance sheet. I appreciate your time today. Have a good day. Take care.
Thank you. That concludes today's conference. Thank you for participating. You may disconnect at this time.