DaVita Inc

NYSE:DVA

Earnings Call Analysis

Sturdy Growth and Enhanced Processes Define Earnings

In 2023, we witnessed exceptional growth bolstered by strategic improvements, despite external challenges. Our steadfast service ethos led to a record 42,000 community service hours. Due to robust operational performance and efficacious initiatives, we observed a 20% rise in adjusted operating income, 28% in adjusted EPS, and stabilizing leverage ratios. Patient volume steadied, labor performance improved, and efficient revenue operations boosted collections. Revenue enhancements and cost optimizations foreshadowed a promising 2024 with a 10% and 9% guidance in adjusted operating income and EPS growth, respectively. The Integrated Kidney Care (IKC) unit forecasts a 25% upsurge in medical expense coverage with a 15% per-member cost decline and looks to profitability by 2026. With a resilient business model in place, we await 2024 with composed assurance and clarity.

Guidance Reflects Resilience and Growth Opportunities

Investors should find solace in the company's guidance, which projects a substantial surge in financial performance with an adjusted operating income growth of 10% and adjusted EPS (Earnings Per Share) growth of 9%. This optimism is hinged on expectations of a stable operating environment, returns from investments in the revenue cycle, and advancements within the Integrated Kidney Care (IKC) segment. The specified range for adjusted operating income is set between $1.825 billion to $1.975 billion for the year, marking a 9.6% year-over-year growth at the midpoint.

Substantial Specialized Segment Revenue

A notable highlight for the company is its SNP (Special Needs Plans) products within the value-based care framework, generating upward of $300 million and thus, fortifying the overall revenue stream.

Commercial Mix and Patient Treatment Revenues

With an emphasis on value and insurance benefits, the company reports a stable commercial patient mix, describing it as 'flattish'. This stability is ingrained into the revenue per treatment (RPT) guidance, allowing for a predictable revenue outcome for investors.

Operational Efficiency Through Center Consolidation

The company is strategically closing or merging about 50 centers, with plans to open 20 new ones, resulting in a net reduction of 30 centers. This approach aims to address inefficiencies and pivot towards optimizing fixed expenses like rent and medical director fees, thereby bettering overall operational efficacy.

Earnings Call Transcript 2023-Q4

[Operator]

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 Fourth Quarter 2023 Earnings Call. Today's conference is being recorded. If you have any objections, you may disconnect at this time. [Operator Instructions] Mr. Eliason, you may begin your conference.

[Nic Eliason, executive]

Thank you, and welcome to our fourth quarter conference call. We appreciate your continued interest in our company. I'm Nick 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 fourth 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.

[Javier Rodriguez, executive]

Thank you, Nick, and thank you all for joining the call today. As we reflect on the past year, our 2023 financial performance highlighted the resilience of our business and revealed some of the early benefits of our multiyear investment in strengthening our platform. .

External challenges over the past few years ultimately made us stronger and with continued investment in our teammates, systems and capabilities, we believe that we're well positioned for the years ahead. We began 2024 with great momentum and a reduction in the risk and uncertainties that characterize the recent years.

Today, I will cover our 2023 results and our 2024 guidance, provide an annual update on integrated Kidney Care and briefly continue our discussion on GLP-1 drugs.

First, however, I will begin the call, as we always do with the clinical highlights. More than 20 years we have strived to be a community first and a company second. This means that we're committed not only to providing outstanding care but also to give back. In 2023, our teammates logged over 42,000 hours of service to their communities, which marks our highest year ever and a step toward achieving our cumulative goal of 125,000 hours by 2025.

And some of our special teammates donated their personal time to advance our goal of raising awareness for kidney disease. We recently wrapped our 2023 health tour, a mobile health screening and kidney care education program supporting local communities across the country. Today, 15% of our U.S. population has kidney disease, which often goes undiagnosed and untreated until symptoms become severe. Our mobile health tour was designed to help identify risk factors that may lead to chronic kidney disease, including screening for obesity, diabetes, high blood pressure and family history of kidney disease.

For 2 months on the road, our bus traveled 17,000 miles to offer free screenings in 48 communities across 8 states. To power this tour, more than 300 of our teammates volunteered 1,200 hours in service to their local communities. This effort is a wonderful example of combining our dedication to service with our ongoing commitment to raising awareness for early detection and prevention of kidney disease.

Transitioning to our performance. Full year 2023 adjusted operating income, adjusted EPS and free cash flow all came in well above our guidance from the beginning of the year. As context, I think it's helpful to reflect back on our progress over the year. We began 2023 in an uncertain environment and shared the assumptions in our guidance that volume and labor challenges would continue throughout 2023.

We're simultaneously developing and executing on a number of initiatives focused on offsetting some of those financial headwinds we were facing. As the year progressed, we saw encouraging data points early in the year, which ultimately turned into consistent positive trends. These improved trends, combined with the strong operating performance and the positive impact on the initiatives we implemented, resulted in a 20% year-over-year growth in adjusted operating income, 28% growth in adjusted EPS, and a return of our leverage ratio back to the target range.

I'll share 3 points for additional color. First, on volume. We entered 2023 with a 2% growth headwind due to the annualization of excess mortality from prior year. Since then, successive COVID surges have been weaker in magnitude with lower mortality. At the same time, we were able to produce 4 consecutive quarters with year-over-year growth in new patient admits. Adding these factors together, 2023 saw increased patient census for the first time since COVID started, and volume that was approximately flat year-over-year, landing at the top of our guidance range.

Second, our labor performance in 2023 was better than 2022. We cut our reliance on contract labor more quickly than anticipated and improved staffing in our centers. On the other side of the ledger, teammate turnover has remained elevated in line with the strong health care labor markets. Looking forward, improved retention and training costs represent an opportunity for improvement in the years ahead.

Third, independent of these trends, we drove strong operating performance through our differentiated platform and capabilities. Most notably, we invested in our revenue operations to achieve sustainable improvements in our collections. This resulted in an additional $3.50 in revenue per treatment for the full year while reducing more than 12 days from our U.S. day sales outstanding. Adding to this, we executed against our cost-saving initiatives related to pharmaceutical spend and further consolidated our facility footprint.

Finally, we exceeded our annual profitability targets for Integrated Kidney Care, which I will cover more in detail in a moment.

To summarize, we entered 2024 with more visibility and confidence that we have had since the start of COVID in 2020. Our ability to invest in our people, process and systems, despite the operational and financial challenges of the last few years, has positioned us well for the years ahead.

On that note, let me transition to our value-based care business, which we will call Integrated Kidney Care or IKC. We have consistently urged our investors to assess this business on an annual basis rather than focusing on our quarterly results. Now is a good time to pause and reflect on our performance and outlook of IKC.

At a high level, we assess IKC performance based on 3 primary metrics: one, total medical expense and patients in our IKC programs, which represents growth; two, our clinical performance or effectiveness of reducing total medical costs; and three, per member per month spend on our model of care and G&A, which indicates cost management. I'll walk through each in a bit more detail.

First, total medical expense of patients in our IKC programs grew to $4.6 billion, reflecting approximately 30% growth year-over-year. This represents care for 58,000 patients as of year-end, a 38% increase from 2022.

Then our traditional value-based care programs, we continue to be disciplined, prioritizing profitable growth. For 2024, we expect growth in excess of 25% for total medical expense and covered lives.

Second, our model of care has proven effective in helping our patients lead healthier lives and reducing medical costs, reflecting in a net savings rate that is slightly ahead of our expectations. Largest driver is year-over-year reduction in hospitalizations, especially readmission rates. This relies on our collaboration efforts between our care teams and physician partners to prevent rising acuity and address the needs of our most complex and vulnerable patients.

And finally, our per member per month cost continue to trend down as a result of the program growth and improved fixed cost leverage. In 2023, our per member per month cost declined by 7%. We expect per member per month cost to further decline by approximately 15% in 2024.

The result of these efforts is that we outperformed our 2023 adjusted operating loss forecast, and we believe we remain on track to deliver breakeven or better performance by 2026. Beyond the core metrics, we can further break down our performance based on 3 primary components of our IKC business: special need plans, our value-based care portfolio focused primarily on Medicare Advantage patients, and the CKCC demonstration project for our Medicare fee-for-service patients.

Within that portfolio, after many years of investment and consistent year-over-year improvements in cost savings, our MA contracts and Special Need Plans have now reached profitability. Keep in mind that the third component, CKCC, represents approximately 50% of our value-based care census. We adjust the changes from CMS and further optimize our model of care, we expect this program to become profitable in 2026 time frame.

Before we get into 2024, I'll offer a quick comment on GLP-1. To be clear, none of our thinking has changed since our last earnings call. Shortly after our call, results for the select clinical trial were released. As expected, the trial confirms certain cardiovascular benefits in people with obesity and cardiovascular disease, including a 20% reduction in all-cause mortality.

Next on the near-term horizon will be the FLOW study, which we anticipate will demonstrate efficacy on multiple endpoints, including slowing the progression of chronic kidney disease. As a reminder, such efficacy that may be demonstrated in the FLOW study is already incorporated into our GLP-1 base case, Flex, a net neutral impact to dialysis volume growth as adoption ramps up over the next decade.

Shifting to 2024. We're setting guidance for adjusted operating income growth of 10% and adjusted EPS growth of 9%, reflecting the midpoint of our respective guidance range for each metric. This incorporates our expectations of a more predictable operating environment, continued returns from our revenue cycle investment and further progress in IKC. This guidance demonstrates the resilience of our business and our ability, despite external challenges, to provide high-quality care while delivering strong financial results.

Let me touch on a few drivers of our forecast. First, 2024 adjusted operating income will benefit from the full year impact of positive development in 2023, including the annualization of revenue cycle improvement, our transition to Mircera and savings related to our center consolidation.

Second, as noted, we're demonstrating progress in our IKC business and continue to expect breakeven by 2026. And finally, adjusted earnings per share will benefit from our share repurchase program, offset by other factors below the OI line, including other losses, higher interest expense and higher effective tax rate.

As we turn the page to 2024, we have a great opportunity to drive operating advancements that further differentiate DaVita within kidney care.

I'll now turn it over to Joel to discuss our financial performance and outlook in more detail.

[Joel Ackerman, executive]

Thanks, Javier. In Q4, we delivered $415 million of adjusted operating income and $1.87 of adjusted earnings per share. Our strong performance for the quarter puts us just above the top end of our updated full year guidance range from the Q3 call. Our outperformance in the quarter relative to our expectations was primarily related to prior period development in our special needs programs in our IKC business, plus revenue per treatment growth from continued improvements in our revenue cycle management.

In the U.S. dialysis segment, fourth quarter treatments per day were flat versus the third quarter. As a reminder, mistreatment rates are seasonally higher in the winter months, which was offset by an improvement in our day of week mix relative to the third quarter.

Revenue per treatment was up approximately $6 quarter-over-quarter. About half of this was due to normal quarterly fluctuations. The remaining increase was driven equally by continued improvements in our revenue cycle management and typical fourth quarter seasonality related to higher acute mix and reimbursement for flu vaccines.

Adjusted patient care cost per treatment was up $13 sequentially, driven primarily by seasonality, including higher benefits expense and continued investment in our teammates. This sequential increase was higher than typical for Q4 but in line with our expectations described on our Q3 earnings call.

In our IKC business, adjusted operating results were down $39 million sequentially due primarily to timing of shared services revenue recognized in Q3 primarily from arrangements from 2022. Additionally, in Q4, we recognized incremental shared savings revenue of $55 million associated with Medicare Advantage value-based care arrangements for plan year 2023. This is earlier than we had previously anticipated recognizing revenue for 2023 arrangements and is the result of the clearing of several revenue recognition hurdles earlier than otherwise anticipated.

This revenue would have otherwise been recorded in 2024. As a result, we now anticipate that our recognition of shared savings revenue for our Medicare Advantage contracts in 2024 and beyond will generally align with the plan year in which they are earned. Although there will likely continue to be updates in our estimates during each planned year and beyond until final reconciliation.

This $55 million shared savings revenue recognized in 2023 has been excluded from our adjusted operating income as it represents earnings incremental to what would have been expected in 2023 absent the change.

International adjusted operating income was down $18 million quarter-over-quarter. The largest component of this sequential change was driven by an increase in bad debt reserves.

Transitioning to capital structure. During the fourth quarter, we repurchased 2.9 million shares and since the start of 2024, we repurchased an additional 1.5 million shares. We ended 2023 with 0 balance on our revolving credit facility and our leverage ratio declined slightly to 3.15x consolidated EBITDA, below the midpoint of our target leverage range. The strong free cash flow was partly the result of continued reduction of our U.S. dialysis DSOs, which ended the quarter at 54 days, down 3 days from last quarter and 12 days below the level at the end of 2022.

Turning now to detail on 2024 guidance. Our adjusted operating income guidance for the year is $1.825 billion to $1.975 billion, representing 9.6% year-over-year growth at the midpoint. This is above our long-term expectation of 3% to 7% growth in adjusted operating income, driven by higher revenue per treatment growth in typical as a result of our investments in our revenue cycle management and cost savings in our nonlabor patient care costs due to annualization of Mircera and footprint-related cost savings.

To give you more detail, let me first cover the 3 main drivers of U.S. dialysis growth versus 2023. First, we expect treatment volume growth of 1% to 2%. This is the result of continued new patient admissions growth on par with pre-pandemic averages, partially offset by mortality that is expected to remain slightly higher than pre-COVID levels.

Second, we anticipate revenue per treatment growth of 2.5% to 3%. Approximately 2/3 of this growth is due to rate increases. The remaining 1/3 of the expected increase is primarily from annualization of the revenue cycle management improvements we saw in 2023.

Third, we expect adjusted patient care cost per treatment to increase 2.5% to 3%. We continue to expect wages to increase at rates above pre-COVID levels. Savings to offset this include leverage of fixed costs as treatment volume grows and annualization of cost savings initiatives in 2023, including our conversion to Mercera for anemia management and our center consolidation efforts.

Let me mention a couple of other items to help your thinking with U.S. dialysis. We expect adjusted depreciation and amortization to decline by approximately $10 million to $15 million, a marked change from historical increases of approximately $20 million annually. This is the delayed result of our consistent effort over many years to increase our capital efficiency.

As it relates to policy matters, we do not expect to spend the $50 million to $60 million related to ballot measures that would have been typical of past election years.

For IKC, our guidance assumes an adjusted operating income loss of approximately $50 million. This reflects our expectation of continued growth in total medical spend and covered lives within our IKC programs, improved shared savings performance and further fixed cost leverage, as outlined in Javier's earlier comments.

In our international business, we incorporated in our guidance continued growth in adjusted operating income of approximately $20 million year-over-year. Below the OI line, we expect losses of approximately $60 million, largely as a result of our share of the losses in Mozarc, our co-investment with Medtronic in kidney products. We expect interest expense of $100 million to $110 million per quarter in the first half of the year and $130 million to $140 million per quarter in the second half of the year. This increase is due to expiration of our 2% interest rate caps at midyear.

We expect an adjusted effective income tax rate of 24% to 26%. For free cash flow, we expect $900 million to $1.15 billion, approximately 125% of adjusted net income. Consistent with our long-term capital strategy, we expect to deploy the vast majority of our free cash flow towards either capital-efficient growth when such opportunities exist or otherwise return capital to shareholders through share repurchases. We anticipate ending the year within our long-term target leverage ratio range of 3 to 3.5x. That concludes my prepared remarks for today.

Operator, please open the call for Q&A.

[Operator]

[Operator Instructions] Justin Lake with Wolfe Research.

[Unknown Analyst]

This is [ Dean Rosales ] on for Justin. My question is on your Medicare risk businesses. Wondering what you're seeing there in terms of trend through 2023. And then specifically on special needs products, how many members do you have there exactly? And how much revenue is in those products? And could you speak to what you've seen in terms of costs year-to-date and then specifically Q4?

[Javier Rodriguez, executive]

Thanks, Dean. So what I'd highlight on the risk side of Medicare Advantage is, I think it's important to realize that the ESRD population is different than the broader MA population. And some of the trends you might be seeing with other payers, which we certainly watch very carefully don't necessarily apply to our population.

I'd highlight 3 things. First, the needs of these patients and the medical costs that they bear are very different than a population given the high acuity of these patients. So that's one.

Second, I would also note the reimbursement for this population runs differently, and it's a separate reimbursement rate that comes out in both the preliminary and the final rule. And third, that the coding changes that apply to the broader MA population do not apply to the ESRD population.

So with that, we're -- I think it's early for us to really have a full view on what 2023 is. That said, we're feeling pretty good about where our net savings came in, both on the SNP side and on the Medicare Advantage population within our value-based care.

In terms of just some of the cleanup, we have about 3,000 members in our SNP products. And in terms of revenue, it's somewhere north of $300 million.

[Operator]

Our next caller is Pito Chickering with Deutsche.

[Pito Chickering, analyst]

Looking at 2024 guidance, you're assuming a loss of $50 million in IKC. Can you refresh us what that was in 2023? And then in the script, I think you talked about 25% growth in revenues of IKC and a 15% reduction of PMPM. I would have noted it shifted from a loss to gain in 2024 of those metrics. So if you can sort of help bridge that.

And then I think you're shifting from a cash accounting to an accrual accounting. That seems like a pretty big shift for you guys. I guess, what's giving us comfort that, that accrual makes sense at this point?

[Javier Rodriguez, executive]

Yes. So a lot in there, Pito. Let me try and take this in the logical order. So first, on revenue accounting. What -- historically, we did not record revenue until we were comfortable that we could reasonably estimate what our share of the shared savings would be. And that was true for both our MA population and our Medicare fee-for-service population, the CKCC program.

The SNP product, we've always accounted for in, I'll use your words, in an accrual method. The change we're talking about is about the change in the timing of when we get comfortable with those estimates. And you asked why. It's really 3 things.

One is we've made some changes to the contractual language that gives us earlier clarity on attributed lives. So that's one. Second, we're getting our data earlier, which obviously helps us do some of the calculations earlier. And then third, just with the experience we've had, we've got better actuarial models. And putting those 3 things together, we're comfortable now that we can reasonably predict our share of the shared savings revenue which ultimately turns into revenue in the plan year. So that's on the change in the estimates.

In terms of you asked about 2023. So we're guiding to a loss of $50 million for 2024. Our non-GAAP number for 2023 is a loss of $94 million. The thing to realize about that $94 million is it includes the revenue from the value-based care products from plan year '23, which is the result of this estimate change that I mentioned as well as the revenue from that product line for 2022.

So I think the way to think about 2023 to make it a little bit more apples-to-apples with '24 would be to back out somewhere around $25 million, $25 million, maybe $30 million to make it a bit more apples-to-apples. And then what was your other question? There was a PMPM question in there.

[Pito Chickering, analyst]

So you're taking a loss of $94 million after you back out the $25 million to $30 million. I think you guided to in the script sort of growth on IKC of 25% and then a 15% reduction of PMPM in '24.

So I would assume that, that growth and those reductions would have resulted in a higher in operating -- conversion operating loss. So kind of how can we sort of take those growth metrics and those cost reduction metrics and still get to a $50 million loss?

[Javier Rodriguez, executive]

Yes. So a few things. First, just to clarify that as the change I referred to only is true of the Medicare Advantage business. The CKCC business is still new enough that we're not comfortable estimating the savings in the plan year. So that part hasn't changed.

In terms of your question. So the cost savings we're referring to is only related to our model of care in our G&A. It's not what you'd call the MLR in a health plan business. It's not that equivalent for us. Second, there are some -- there was a significant amount of positive period development in 2023, in particular in the SNP business that we're not forecasting to recur. So that would be another adjustment, which I think would help bridge the question of why aren't we getting to profitability next year or this year in '24.

[Pito Chickering, analyst]

And then on treatment growth, you're looking at the normalized growth in 4Q of 70 bps, you grew 50 bps in the third quarter. Is a key driver in fourth quarter new patients? Is it lower mortality? And also, when you close a center, those patients to win another center, is that organic growth at the new center as old as the one as your discontinued ops, even though the patients don't actually change the numbers?

[Javier Rodriguez, executive]

Yes. So no on the last one. If patient moves from one clinic to another, it doesn't show up as any sort of growth anywhere. It's still our patient.

In terms of the volume growth. I would point to Q4 over Q3 as effectively being flat, treatments per day were flat. And that's really a combination of a small census decline, which is not uncommon in Q4 offset by a better treatment mix day. So more Monday, Wednesday, Fridays, Fewer Tuesdays, Thursdays. So Q4 was really, I would call, a flat volume quarter-over-quarter.

[Operator]

[Operator Instructions] Kevin Fischbeck with Bank of America.

[Joanna Gajuk, analyst]

this is Joanna Gajuk filling in for Kevin today. Actually, first question is just a follow-up on the volume discussion and it sounds like flattish sequentially, but I guess year-over-year, up less than 1%. And your guidance for '24 assumes 1% to 2% volume growth. So kind of how do you build to that growth, especially to the higher end of 2%? What gives you confidence that, I guess, you could get to that volume growth for the year?

[Javier Rodriguez, executive]

Yes. Thanks, Joanna. So I'd start with the fact that the single biggest impact on volume year-over-year is census. And remember that census builds over the course of the year. So if you look at the '23 growth, which was effectively flat, that was burdened by the fact that the census declined over the course of 2022 and only started building in '23. So a lot of the 0 in 2023 is the annualization of of the negative impacts of 2022.

As we think about '24, I'd really break it down into 2 components. First is new to dialysis admissions and we've watched that build over the course of 2023. And we feel comfortable that, that growth rate is back to pre-COVID levels. Where -- the reason we don't get back to what you'd call a 2% number pre-COVID or that would be the high end of the range is mortality continues to run higher than it did pre-COVID. It is way down off its COVID peak but it's still running a bit higher than a typical pre-COVID year, remembering that mortality moved around in pre-COVID years, primarily as a result of the severity of the flu season.

So if you take a more normal new to dialysis admit outlook and then a slightly negative mortality outlook, that's how we get to the 1% to 2%.

[Joanna Gajuk, analyst]

And another follow-up on the guidance, I guess. You talked about your outlook for revenue per treatment. So specifically, can you talk about the build, I guess, for that? How much, I guess, is the commercial rate increases? And I guess last quarter, you mentioned there there's some larger contracts up for renewal. So any color in terms of these rate increases you're seeing there? And also inside that, your mix, commercial versus government? And then specifically MA, where you stand on the MA mix.

[Joel Ackerman, executive]

Let me grab that, Joanna. A couple of things because I think underlying those questions, there's usually -- is there something unusual in the payer dynamics, and let me go ahead and start by no, we are in a normal period. And of course, we're trying to make sure that rates reflect the inflationary pressures that we are receiving. .

To you direct question on what percent of that -- what part made out of the rate. Roughly 2/3 of the increase will be rate and 1/3 remaining. A good chunk of that is the annualization of the reimbursement operation improvements we saw in 2023 and the remaining is mix.

As you have seen, our mix is trending on MA slightly above the market. So our MA mix finished the quarter around 52%, and we expect that number to be a couple of points higher at the end of '24. So somewhere in the 54%, 55% range, depending on open enrollment.

[Joanna Gajuk, analyst]

And I guess on this commercial plan that you mentioned some larger plans up for renewal, any update there in terms of the rate increases you're seeing?

[Joel Ackerman, executive]

Commercial -- on the negotiations, we're not going to go into specifics. We continue to see that our commercial patients value their private insurance and commercial mix is flattish. So nothing to report on that. And of course, that's embedded in the guidance of the RPT that we gave you. .

[Operator]

A.J. Rice with UBS.

[Albert Rice, analyst]

I can't let you get through the call without asking one GLP-1 question. So in your prepared remarks, you're saying that for the FLOW study, you anticipate efficacy on multiple endpoints, including slowing CKD for digression. I think that's generally where the market is at.

I wondered, given your analysis that you've offered and seems to have really gotten traction in the financial community, are there anything -- is there anything that could come out of the FLOW study at least in the high probability range that would make you revisit? It seems like you've covered most of what you expect in your analysis, but I'm wondering is it something that makes you more optimistic, less optimistic about how this will all impact your business?

[Javier Rodriguez, executive]

Thanks for the question, A.J. And as you know, last quarter, we had sort of a dissertation on GLP-1 that's gotten a lot of conversation. At the end of the day, we, of course, wanted to make sure that our shareholders and others were really well versed on it. And I think that while there could be an unusual surprise because you never want to say that the chances are 0, highly, highly improbable that we didn't capture in our range, what is likely to play out.

And so that is -- that at the end of the day, we expect a net neutral impact on dialysis volume over the next decade. And we did a lot of [ probabilistic ] adjustments and weighted as to how many people would participate in all the normal math that we discussed. And we don't want to change our position a bit.

[Albert Rice, analyst]

Maybe if I could pivot and ask you about your assumptions around labor going into '24. I know there's the underlying what you're banking on for wages and benefits for your permanent workers. I believe you still should have a tailwind from contract labor, at least annualizing where you're ending the year. And then there's the whole issue of the California minimum wage for low wage health care workers. I know you said you wouldn't be spending for election spending, but I wonder what you're factoring in for that when you anticipate it to start to have an impact.

[Javier Rodriguez, executive]

Yes, A.J., thanks for that. So for labor for the year, so we called out 2.5% to 3% of patient care cost growth per treatment. I'd break that down. That's roughly half labor and half other stuff. On the labor side, we're thinking something around 5% for the year in that and California would be baked into that.

We called out a few months ago, something around $30 million to $40 million as the net impact of that once it's fully rolled out in a number of 20 to 25 for 24. We've been rolling it out a little bit quicker than we anticipated. So I would expect the number will probably be somewhere in that 25 to 30 range, and that's baked into our number.

The reason we're comfortable with the patient care cost being only 2.5% to 3%, given that half of it is labor, which is growing at 5% is we've got savings from the annualization of both Mircera -- the ship to Mircera as well as some of the clinic footprint actions we took. We've also got fixed cost leverage as we add volume without adding centers. And a lot of those other costs are fixed costs that don't grow with volume and are under long-term contracts. So we feel like despite a 5% wage pressure, we can get to that 2.5% to 3%.

[Operator]

Our next caller is Gary Taylor with TD Cowen.

[Unknown Analyst]

This is [ Ryan Linton ] on for Gary. I think Dean touched on it earlier, but maybe just to go back, how is the higher sort of Medicare Advantage trend we saw in the back half of the year impacting the accruals, I guess, not only for '23, but sort of your guidance for '24? And Joel, can you remind us when you anticipate to have the final reconciliation with your plan partners?

[Javier Rodriguez, executive]

Yes. So the final reconciliation will depend. It's plan by plan. It can often take 3 or 4 quarters, and that will be -- ultimately be baked into prior period development in the IKC business. In terms of the impact of some of the costs on the broader MA population in Q4. Again, we -- I think it's too early for us to say whether we think that's going to impact us. But again, I'd reiterate that our population is very different than the broader population.

In terms of 2024, we're keeping a careful eye on it to see how it plays out, and it's built into our range.

[Operator]

Our next caller is [ Lisa Klive ] with Bernstein.

[Unknown Analyst]

Just 2 questions for me. Number one, we're 18 months since the Marietta ruling, your commercial mix and pricing seems pretty stable. So just wanted to know if you have any thoughts on what that ruling has meant over the last few years and whether you're expecting any changes.

And then also just a clarification in terms of the fact that you don't need to spend on a ballot initiative and obviously, your wages are going up in California. So seems like a reasonable truce with the SEIU. Is this something that we should expect to continue? Or is it really just this election cycle? Or it would be obviously nice for you guys to be out of this 2-year cycle of fighting dollar initiatives.

[Javier Rodriguez, executive]

All right. Thank you, Lisa. So let's start with Marietta. As we have discussed in the past, we have not seen a lot of employer groups change benefits, which is absolutely great. It would be terrible for employers to not give their employees that have end-stage renal disease choice. That said, we continue to be very mindful and of course, work at the kidney community and disability groups because it is sort of a dangerous risk out there that we want to make sure has not taken advantage of.

And so the analogy I say in a town hall when someone asks me if I have -- why I have so much passion on it, it's like saying the door in your house, the lock is broken. And you said, yes, but no one's broken in or very little. And you say, well, you still want to fix

it. And so from our perspective, it's something that the Supreme Court said. It needed to be clarified and the champions and Congress and others believe it should be clarified. Now we just got to work the process. I also think, and we've discussed that our verification process admissions has helped in that we had an example of an employer group that actually did apply this. And when they found out that their employees didn't actually have a network, then they change their benefits again and basically reverted back to a network benefit.

So I think sometimes, people explore ideas without really understanding the full ramifications and in that case, it worked out well. And so we will continue to put a lot of energy on that.

Your second question was around the ballot. Of course, what we liked about it is that we were spending money on making sure that our patients and our teammates didn't suffer from what we call a very dangerous ballot process, but it takes a lot of money to educate the broader state on how to think about that. And so we are extremely happy that at the end of the day, instead of spending the money on that, our teammates get the benefit of that.

As it relates to is it just this election cycle. We talked about 2 election cycles and that, that would be a good time to hopefully iron out and revisit our relationship with labor.

[Operator]

And our next caller is Justin Lake with Wolfe Research.

[Unknown Analyst]

This is Dean on again for Justin. My question is on center closings. And I'm sorry if you've touched on it already, but how much more is there to do here? And could you speak or can you parse out the impact to the P&L from the center closing, right? So revenue versus cost savings from lower fixed costs and efficiencies.

[Javier Rodriguez, executive]

Yes. So I appreciate the question. We are thinking that the year will have roughly 50 centers, either closed or merged into other centers. And thinking about roughly in the ZIP code of 20 new centers, so net 30. As it relates to the P&L, I'm not sure I understood your question. Could you try it again? .

[Unknown Analyst]

More just the moving parts impact to the P&L. Just could you speak to how you guys -- one center closing.

[Javier Rodriguez, executive]

A good healthy way to think about it is you will have a little volume loss on patient choice. But when you strip all of that, these centers tend to be inefficient. And so what you do is you consolidate the management and the leadership. And then you have some savings on fixed expense in particular, rent and medical director fees. And so at the end of the day, that's where the savings come from, inefficient center with some fixed expenses that get eliminated. .

[Operator]

Pito Chickering with Deutsche.

[Pito Chickering, analyst]

If you could just -- follow ups here. To Joanna's question, what was the commercial mix in the quarter? And what are you seeing for 2024?

[Javier Rodriguez, executive]

Commercial mix for the quarter was 10.9%, and we expect it to stay flattish.

[Pito Chickering, analyst]

And then free cash flow conversion was very strong in '23 guidance is about 54% in '24. Is there anything changing within cash flow conversion? Or is this simply the DSOs that you got, what, 12 days in '23 which won't repeat in '24.

[Joel Ackerman, executive]

Yes. You've got it right. '23 was a really impressive decline in DSOs. '24, the free cash flow conversion remains well above net income, and that's really driven by 2 things. One is just structurally our CapEx is lower than our depreciation and amortization. And second is share-based comp, stock-based comp. And those 2 things should persist, and that's why, call it, 125% of net income that we're driving in free cash flow for this year, we would expect to persist for some time.

[Pito Chickering, analyst]

Like any updates on AB 290?

[Javier Rodriguez, executive]

There is a little update. There is some activity on it. But at the end of the day, maybe the best way to summarize it is that the judge hasn't had a final ruling but gave some color. And in that color, basically both parties won some points and both parties lost some points. And so therefore, the odds of an appeal are quite high when there is a final ruling.

And so the next question is probably if you were to say what will be the financial impact we had guided to in the past, something in the $25 million to $40 million range. And as less people are on the AKF, I think that number is likely to be lower, more like a $0 million to $25 million would be a good range.

[Pito Chickering, analyst]

And then last question, I'm going to ask the center closure question differently. What was center in liquidation at the end of -- I guess, in the fourth quarter of '23. And what do you assume that goes in fourth quarter of '24?

[Joel Ackerman, executive]

I'm sorry, Pito, did you say capacity utilization?

[Pito Chickering, analyst]

Yes. I mean just thinking about a combination of centers closing and patients coming back and there's overall center legalization. Where do you exit the year in '23? And where do you think that can get to by the end of '24?

[Joel Ackerman, executive]

Yes. So we're exiting the year at about 58%. And I would expect picking up a point, maybe a little bit more over the course of the year.

[Javier Rodriguez, executive]

And just as a point of reference. Like if you want to go back, pre-COVID, I'm going to go back several years in the 2016 or so range, we would be in the 65-or-so percent range. And then just so you see the impact of all of this California conversation that we've had, California because how difficult the operating environment is, is roughly in the 70% range because people aren't opening centers. So all these very expensive propositions and poor conduct have had an impact and the people do not want to open centers there.

[Pito Chickering, analyst]

And then just out of curiosity, if over a multiyear period to get back to 65% kind of, is this worth like 300 bps of G&A leverage here and kind of if you can size up that for me, that would be wonderful.

[Javier Rodriguez, executive]

Yes. So the leverage you'd see would be in our patient care costs, it's not in the G&A because there's a fixed cost associated with the clinic that's in the patient care cost. So you'd see it there. I think the best I can do to help you with that math would be to think about our patient care cost per treatment number, right? So running at $255 2023. That is roughly 2/3 variable, 1/3 fixed.

So if you imagine us growing that volume without building as many centers and just to be clear, we would have to build some centers because even though capacity utilization is low, the capacity may not be exactly where in the country you need it to be. So depending on what assumption you make there, recognizing that -- 1/3 of that PCC per treatment is fixed, I think that will give you everything you need to do to do the math on what it could be worth.

[Operator]

And at this time, I'm showing no further questions.

[Javier Rodriguez, executive]

Okay. Thank you, Michelle, and thank you all for your interest in DaVita. Just in summary, we had a strong close to the year and that, combined with our [ gunshot ] 2024, we are now back on a path to recuperate our pre-pandemic financial trajectory. We will continue to work hard to deliver strong results, innovate and most importantly, provide a great clinical care for our patients. Thank you all for joining the call. Be well. .

[Operator]

Thank you. This concludes today's conference call. You may go ahead and disconnect at this time.