Fresenius Medical Care AG & Co KGaA
XETRA:FME
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Earnings Call Analysis
Q4-2023 Analysis
Fresenius Medical Care AG & Co KGaA
The company is on a journey of transformation, adapting to the demands of value-based care, which represents the future of healthcare. They've acknowledged that this model, which prioritizes patient outcomes and cost efficiencies, is still maturing, requiring advancements in technology and scale. In their quest for clinical excellence, reducing hospitalizations for Chronic Kidney Disease (CKD) and End-Stage Renal Disease (ESRD) patients remains central. The company aims to grow medical costs under management by 20% and patient lives covered by 10% in 2024, with an expected increase in revenue from these programs to about $2 billion, also contributing positively to operating income. A key strategy includes increasing home dialysis treatment, which is seen as an optimal choice for patients due to its flexibility and quality of life improvement, aiming for a 25% penetration rate by 2027, up from the current 16%.
Innovation is another cornerstone of their strategic growth, with the introduction of high-volume hemodiafiltration (HDF) technology in the U.S. touted as a potential industry standard. This technique, known for its efficacy in international markets, offers a notable advantage over traditional methods, demonstrated by a 23% all-cause mortality reduction according to the CONVINCE study. The company's FDA-approved 5008X hemodialysis machine, integral to this new treatment, is expected to hit the U.S. market in a broad commercial launch planned for 2025. This represents a significant opportunity to improve patient care and open new revenue streams.
Financially, the company experienced a stable fourth quarter with 7% constant currency revenue growth and a reported increase in operating margin to 11%. Organic growth stemmed from pricing strategies in care delivery and increased volume and pricing in care enablement. Earnings benefited from FME25 savings and a settlement, though part of the margin improvement was due to non-recurring items such as the Tricare settlement. Despite facing a challenging comparable from the previous year, ongoing portfolio optimization including divestments and clinic consolidations have positioned the company for continued profitability and cost management.
Operational efficiencies and strategic financial decisions have led to a robust improvement in operating cash flow, up by 21% for the full year. The company has leveraged these gains, along with divestment proceeds, to significantly reduce debt by approximately €1 billion, consequently decreasing the leverage ratio from 3.4x to 3.2x. This disciplined approach toward capital allocation supports the goal of continued cash flow improvement and financial strengthening as they navigate through 2024 and beyond.
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Ladies and gentlemen, welcome to the report on the Fourth Quarter 2023 Conference Call. I'm Andrea, the Chorus Call operator. I would like to remind you that all participants will be in listen-only mode and the conference is being recorded. [Operator Instructions] The conference must not be recorded for publication or broadcast.
At this time, it's my pleasure to hand over to Dominik Heger, Head of Investor Relations. Please go ahead, sir.
Thank you, Andrea. Good afternoon or good morning depending on where you are. I would also like to welcome you to our earnings call for the fourth quarter 2023 for the fourth time at 2:00 p.m. As always, I need to start out the call by mentioning our cautionary language that is in our safe harbor statement as well as in our presentation and in all the materials that we have distributed earlier today.
For further details concerning risks and uncertainties, please refer to these documents and to our SEC filings. With the Q4 results, we traditionally share an update on our strategic plan. Therefore, we have more to cover than in the other quarters. Given that we only have the 60 minutes, we need to limit the number of questions again to 2 in order to give everyone the chance to ask questions. It would be great if we could make this work again.
With us today is Helen Giza, our CEO and Chair of the Management Board; and Martin Fischer, our CFO. Helen starts with an update on our execution against our strategic plan. Martin will provide a review of the fourth quarter and Helen will finish the prepared remarks with our outlook. Then we are happy to take your questions.
With that, Helen, the floor is yours.
Thank you, Dominik, and welcome, everyone. Thank you for joining our presentation today and for your continued interest in Fresenius Medical Care. I'll begin my prepared remarks on Slide 4.
A year ago, we laid out our strategic plan to turn around and transform Fresenius Medical Care. This plan included ambitious structural, operational and cultural changes. Thanks to the hard work and dedication of our teams around the world, we have successfully executed on our commitment of fundamental transformation, making progress against all facets of our plan. We have done what we said we would do. A lot of the change we have undertaken would not have been possible without the implementation of our new operating model at the start of 2023.
with our 2 distinct global segments, Care Delivery and Care Enablement, we are now operating with an end-to-end level of transparency and accountability that has not been in place previously. The new operating model enabled us to introduce new financial reporting with enhanced transparency. And throughout 2023, our commitment to our operational turnaround initiatives helped drive organic growth in both segments and improving operational performance. Our FME25 transformation program delivered savings ahead of schedule while ensuring our company becomes stronger and more resilient in the future. We have also undertaken a cultural transformation with greater emphasis on accountability.
To this extent, we made 2 important leadership changes on our management Board with Martin Fischer joining as CFO in October; and Craig Cordola, our new Head of Care Delivery joining in January of this year. I'm very excited about the new perspective that they bring to our company and the impact that they are already having.
In the fourth quarter, we finalized our change in legal form and are now operating in a simplified governance structure with strengthened rights of our free float shareholders. We continued to execute against our portfolio optimization plan with several key assets divested by the end of the year and more underway and proceeds applied to deleveraging. And finally, our relentless focus on improving operating performance allowed us to upgrade our outlook for the first time in the company's history, and I'm very proud to say that we even exceeded our upgraded outlook. And we did a little bit more than we said we would do.
Turning to Slide 5. Beyond our achievements on the strategic front, I'd like to quickly recap our operational performance in 2023. We achieved revenue growth at the top end of our outlook range and organic growth in the year was mainly driven by favorable business development. As we still experience the annualization impact of excess mortality from the COVID pandemic, volume development in the U.S. is an important KPI that we have been watching closely, and I know the market is as well.
In 2023, we assumed a minus 1% to plus 1% growth in same market treatments in the U.S. and when adjusted for the exit of less profitable acute care contracts, we finished the year right at the center of that assumed range. This makes us optimistic for a positive growth development for 2024, which we have included with a careful assumption as the basis for our outlook for this year. As I mentioned, our earnings exceeded the top end of our upgraded outlook, thanks to business growth, realized FME25 savings ahead of plan and the Tricare settlement.
Contributing to the earnings growth were faster-than-expected labor productivity improvements in Care Delivery as well as positive impact from our pricing initiatives in Care Enablement. Regarding the portfolio optimization, the divestments closed in 2023 accounted for EUR 214 million of revenue and EUR 20 million of operating income. The strict commitment to our stringent financial policy resulted in significantly improved cash flow and an important decrease in our net leverage ratio. And we continue to make progress on our broader sustainability goals. Earlier this year, we submitted our commitment letter to the science-based targets initiative underlining our goal to achieve climate neutrality in our operations by 2040, in line with the Paris agreement.
Moving to Slide 6. Although we are going through a significant transformation, first and foremost, we remain a purpose-driven company focused on patient-centric care of the highest quality. Patient overall satisfaction with our services, measured by the Net Promoter Score of 72, was at an even higher level than in previous years. Our Global Quality Index is another important KPI in this regard. Throughout 2023, we saw sequential stability in our clinical performance at a high level.
Next, on Slide 7. In 2023, we delivered 5% revenue growth at constant currency and 4% organic growth. Organic growth in Care Delivery was driven by the expansion of our value-based care book of business in the United States and higher reimbursement. Organic revenue growth in Care Enablement was driven by both higher volumes and prices. As a reminder, organic growth does not include the Tricare settlement or the divestment proceeds.
Along with the solid top line growth, the successful execution of our turnaround initiatives translated into improved earnings, our operating income increased 15% in constant currency, and our group margin expanded 100 basis points to 8.9%. We are making important progress towards our 2025 group margin target, which is supported by our FME25 program, where we realized of EUR 346 million in savings through the end of 2023, well ahead of our plan.
The EUR 181 million Tricare settlement proceeds was another positive earnings driver for which we increased our outlook for the second time in 2023 and we realized meaningful labor productivity improvements in Care Delivery that we originally only expected to realize in 2024. It is terrific to have achieved so much already in 2023. And as such, we would expect a lower incremental degree of improvement in 2024. In Care Enablement, our successful pricing initiatives and earnings improvement were diluted by continued inflationary pressures and foreign currency transaction losses.
Turning to Slide 8. As you can imagine, I like this slide a lot as it confirms that we delivered against what we said we would and more. In 2023, we guided for low to mid-single-digit revenue growth, and we finished the year at the top of our outlook range with 5% revenue growth. While we started the year with an expected up to 9% earnings decline, we were able to upgrade our earnings outlook twice in 2023 and ultimately delivered operating income growth of 15%, exceeding our double upgraded range of 12% to 14%. This approach of a realistic outlook combined with successful execution is something I intend to continue.
Next, on Slide 9. To turn around our business performance, we need to reduce distraction and focus on our core and higher-margin businesses. Since we laid out our portfolio optimization plan at our Capital Markets Day last April, we have been moving at speed. We have announced and closed divestments of our clinic network and production sites in Argentina, our clinic network in Hungary and NCP, our cardiovascular clinic network in the United States. We have announced additional divestments that are subject to regulatory approval and are in the process of closing. These include our clinic network in Sub-Saharan Africa, Cura day hospital group in Australia and our clinic network in Turkey. We continue to work on a number of other divestments and of course, we'll keep you updated.
Turning to Slide 10. We strictly adhered to our disciplined financial policy in 2023. We improved our cash flow and we limited our capital expenditures. With our top priority to deleverage, we applied proceeds from divestments and the Tricare Settlement to reduce our debt. We reduced our leverage ratio from 3.4x to 3.2x. And in light of fully being on track for our deleveraging and as prescribed by our dividend policy, for 2023, the Supervisory Board and Management Board propose a dividend of EUR 1.19 per share. The 6% increase is in line with year-over-year adjusted net income growth. Martin will walk through our improved cash flow and strengthened financial position in more detail later in the presentation.
Next, on Slide 11. We believe that value-based care is an important element in the future of health care. While value-based care is not entirely new, it is still in its early development stages as a business or risk model. It needs to continuously evolve from a technology and scale perspective. Also, revenue and profit recognition is often more retrospective than in our core business, which creates some volatility, in particular during the financial year. We continue to lead the industry with our capabilities for both CKD and ESRD patients. We focus on clinical excellence, which also includes reducing hospitalizations, being a key indicator here. And of course, as a dialysis company, we also have a clear focus on increasing optimal new starts for the dialysis treatment when patients progress to ESRD.
For 2024, we expect that medical costs under management will grow by 20% and patient lives covered by around 10%. From a revenue contribution, we assume around USD 2 billion with a positive operating income contribution. Home is an important treatment modality as it offers qualifying patients the opportunity for more flexibility in treatment and an improved quality of life. This is also visible in lower hospitalization days, which is supportive, in particular to costs in value-based care arrangements. Growth in home treatment is also an important opportunity for our business as it is asset light and requires significantly less labor hours. Although our home growth has recently slowed at around 16% penetration in the U.S., we remain optimistic in the opportunity for future growth given the wide benefited offers. With our new Care Delivery leadership, we will take a fresh look at the most optimal way to increase home treatments to get us closer to our aspirational goal of 25% by 2027.
Turning to Slide 12. We spent a lot of time talking about our strategic plan towards our 2025 targets. However, our thinking and planning does not stop there. As you will have seen from our press release earlier this month, we are on the verge of introducing a key innovation development in the United States with the potential to set a new standard of care for the industry. High-volume hemodiafiltration or high-volume HDF for short is a technology that is already transforming how dialysis is done in many of our international markets and would present an important opportunity for our patients and our business in the U.S. following the convinced study publication last year. Unlike conventional high-flex hemodialysis, which primarily employs diffusion to remove small molecules and fluid from the blood high-volume hemodiafiltration incorporates both diffusion and confection techniques to eliminate larger molecules and effectively manage fluid replacement through convection.
The CONVINCE study was a multinational research study that compared these 2 types of dialysis techniques. It was a 3-year trial performed at 61 dialysis centers in 8 European countries and included 1,360 patients. The results showed a 23% reduction in all-cause mortality in patients treated with high-volume HDF versus those treated with high-flux dialysis. In our own EMEA dialysis patient population, over half the treatments are already high-volume HDF, and we have been using this technique for a decade. Our 5008X hemodialysis machine received FDA clearance this month. It is the first machine capable of high-volume HDF to be approved in the United States. Along with our CorAL dialyzer, which is already registered in the U.S., the 5008X combines the latest device engineering and cutting-edge membrane technologies required to make high-volume HDF possible. This is a very exciting opportunity for the upcoming years as we plan a broad commercial launch in 2025.
In the U.S., there is currently an estimated installed base of around 160,000 in-center hemodialysis machines across all service providers that could be replaced to adopt this new standard of care.
I'll now hand over to Martin to provide an update on the fourth quarter.
Thank you, Helen, and welcome to everyone on the call. I will recap our fourth quarter performance beginning on Slide 14. The fourth quarter developed in line with our expectations. We continue to deliver solid organic growth, revenue growth and contributions from both operating segments. U.S.A. market treatment growth was broadly stable and in line with our assumptions for the year. When adjusted for the exit of less profitable acute contracts. These acute contracts exits demonstrate our continued focus on driving profitable growth. Earnings in the fourth quarter were supported by strong FME25 savings as well as proceeds from the Tricare settlement in the U.S. and improved pricing in Care Enablement.
In Care Delivery U.S., our value-based care business continued to expand. While this development was revenue supportive, we experienced a negative earnings contribution in the fourth quarter driven by CKCC retrospective trend adjustments. As Helen described earlier, we continued to make important progress on our portfolio optimization plan with the divestments of NCP and Argentina closing in the quarter.
Turning to Slide 15. In the fourth quarter, we delivered revenue growth of 7% at constant currency. Organic growth of 3% was mainly driven by price in Care Delivery and both volume and price in Care Enablement. The Tricare settlement and the closed portfolio optimization activities are not included in organic growth. During the fourth quarter, operating income on a guided basis improved by 18% and our group margin improved to 11%. Normalized for Tricare contribution, our margin in the fourth quarter normalized for Tricare settlement, our margin in the fourth quarter would have been 7.8%. Earnings development was supported by accelerated FME25 savings of EUR 114 million in the quarter as well as net proceeds from the Tricare settlement of EUR 181 million.
From an operational perspective, the fourth quarter developed in line with our expectations, as we had previously flat. Nothing fundamentally changed in our operating performance in the quarter as we continue to execute on our turnaround and transformative -- transformation initiatives. However, we did face much tougher comparables given one of favorable developments in the fourth quarter of 2022. As we already outlined in our Q3 earnings call, this included around EUR 40 million in NCP deconsolidation gains and around EUR 40 million in leadership bonus plan favorability given weaker company performance in 2022 and outperformance in 2023.
Next, on Slide 16. From the left, you can see how we get to the starting point of our outlook basis, and then the quarterly margin contribution by segment, resulting in a margin increase from 9.8% to 11.1%. The EUR 127 million in special items on the fourth quarter, which you see on the right, comprised EUR 75 million in legacy portfolio optimization costs, primarily relating to the divestiture of Argentina and NCP. It also includes FME25 costs of EUR 52 million as well as EUR 17 million in costs associated with the legal form conversion.
With that, turning to Slide 17. Care delivery revenue increased by 8% on a constant currency basis, supported by a 2% organic development and EUR 191 million in topline Tricare proceeds. Operating income, development for Care Delivery faced a meaningful headwind from currency translation effects in the quarter. Operating income growth was largely supported by the EUR 181 million in additional operating income from Tricare. Normalized for the Tricare contribution on margin in the fourth quarter, we would have been at 10.3%. As I described earlier, we faced a tough fourth quarter comparable with NCP deconsolidation gains and bonus favorability benefiting 2022 performance. This negatively offset our business development in the quarter. In addition, the negative EBIT contribution from value-based care where in the fourth quarter -- was in the fourth quarter driven by retrospective CKCC Model trend adjustments.
FME25 savings were a strong tailwind in the quarter as we continue to drive clinical operational efficiencies. From the start of our U.S. clinic consolidation initiative at the beginning of the fourth quarter 2022, we closed net 72 clinics in line with the 50 to 100 we initially indicated. While labor costs were mainly offset by continued labor productivity initiatives, Care Delivery faced another inflationary cost increases for things such as medical supplies.
Turning to Slide 18. Care Enablement revenue in the fourth quarter grew 5% in constant currency, with 6% organic growth driven by higher product sales as well as higher average sales prices. Looking at the main buckets for operating income improvement within business growth, improved volumes and pricing were muted by a EUR 20 million in negative foreign currency transaction effects alone in the quarter. FME25 contributed with a strong savings of EUR 27 million. Inflation continued to be a headwind in the quarter, in particular, due to higher material prices.
Turning to Slide 19. We continue to deliver cash flow improvements through the fourth quarter and for the full year 2023, we realized an operating cash flow improvement of 21%. This was the result of positive change in certain working capital items and the Tricare settlement proceeds. Supported by our disciplined capital allocation policy, free cash flow conversion accelerated in line with operating cash flow. We have been very transparent about capital allocation priorities with deleveraging as one of our #1 priorities. In line with our commitment to deleverage, we used the Tricare settlement proceeds as well as the EUR 135 million in divestment proceeds to reduce our debt. Like net financial debt, our total debt, including these liabilities was meaningfully reduced by EUR 1 billion to around EUR 12 billion in 2023 and our leverage ratio decreased from 3.4x to 3.2x, putting us closer to the lower end of our self-imposed target range of 3 to 3.5x.
Looking ahead to '24, we are confident in our ability to continue to improve our cash flow and further strengthen our financial position. Our stringent approach to capital allocation remains a key priority and area of focus. With that, I hand it back over to Helen for our review of the outlook.
Thank you, Martin. On Slide 21, you can see our FME25 related savings and costs since the program's initiation. As I discussed earlier, our FME25 transformation has successfully delivered sustainable savings through 2023. We are fully on track to deliver our savings target of EUR 650 million by 2025. Looking ahead to 2024 specifically, we anticipate EUR 100 million to EUR 150 million in incremental sustainable savings from FME25 by year-end. We expect also EUR 100 million to EUR 150 million of onetime costs for the execution during 2024. This leaves us with EUR 150 million to EUR 200 million in incremental sustainable savings until the end of 2025 with investments of EUR 80 million to EUR 100 million in the same year.
Turning to Slide 22. We wanted to continue to be very transparent about the assumptions we are making in our annual outlook. In 2023, both our revenue and operating income were supported by the Tricare settlement and divestments that we have closed in the meantime. As these will not repeat in 2024, we are excluding them from our outlook base. We have been asked why the Tricare settlement is not being treated as a special item. I want to clarify that as the initial write-off and the constrained revenues and earnings were part of operational business and never classified as a special item in the past. This required us to leave it as an operational item.
To define our outlook, we have made certain assumptions. We are assuming positive U.S. same-market treatment growth of 0.5% to 2% over the course of the year. This excludes annualization effects from exited acute contracts. Based on this and the CE volume growth as well as positive support from pricing in both segments, we expect business growth contributions of EUR 400 million to EUR 500 million. The FME savings contribution -- FME25 savings contributions I mentioned on the previous slide. For headwinds, we assume an overall 3% merit increase for the group. Specifically with an overall CD labor cost increase of around 3% net. Net of labor productivity, we assume a EUR 150 million to EUR 200 million labor cost headwind for the group. We expect a headwind of EUR 100 million to EUR 150 million for other cost inflation in both Care Delivery and Care Enablement and we project around EUR 50 million currency transaction loss, also primarily from Care Enablement.
To help with your modeling for 2024, we are assuming a tax rate of 27% to 29% and a net financial result of EUR 320 million to EUR 340 million. For corporate costs, we expect EUR 40 million to EUR 60 million all at constant rates and excluding special items. While GLP-1s are not relevant for the business development in 2024, I wanted to reconfirm that after having spent even more time and having modeled the different factors and corresponding effects in many different scenarios, with the data available, we continue to assume a balanced impact on the future patient growth.
Moving to the outlook on Slide 23. Based on the outlook base and assumptions I just described, we expect revenue to continue to grow by a low to mid-single-digit percent rate and operating income to grow by a mid- to high-teens percent rate in 2024. As always, these expected growth rates are in constant currency and exclude special items. While we do not provide quarterly outlook, from a phasing perspective, we do expect a low point in our operating income development in the first quarter. The first quarter is expected to provide only a high-teens percentage share of the 2024 operating income. We are also confirming our group margin target of 10% to 14% by 2025. As we only announced this target 10 months ago and are working through a significant transformation, I would like at least a couple more quarters of progress before we consider tightening our midterm outlook.
When I look back at everything we accomplished in 2023 and the foundation we laid I'm very optimistic about what we will be able to achieve this year and beyond. With that, I'll hand back to Dominik to begin the Q&A.
Thank you, Helen. Thank you for your presentation. Before I start the Q&A, I would like to remind everyone to please limit it to 2 questions. And with that, I hand over to Andrea to give you the instructions.
[Operator Instructions].
And the first question comes from Victoria from Berenberg.
So my first question is just on the -- if you could give us an indication of Q1 like-for-like growth. Just so we can get a sense of how you are coming to the 0.5% to 2% guidance for the year? And then the second question is just you guys have closed 72 clinics in 2023. What is the outlook for clinic closures in 2024? And how is it helping your utilization rates?
Thanks, Victoria. I'll take both of those. Regarding the volume question and maybe the sizing of how we see the guidance. Like the competition, I think we're encouraged by the market volume trends. We did see a tick-up in missed treatments in Q4 kind of weather and kind of flu and COVID effect in Q4, which really unfortunately impacted our respective volume. Why we've made tremendous strides in controlling our labor and improving our efficiencies in 2023. We still have some markets in some metro areas that are constrained and are impacting our growth. If growth truly is a top priority for our CD U.S. team. And I think with a different approach by a new leader, we are really encouraged by some of the early actions that are being taken there.
Obviously, some of that mistreatment flu in Q1. We didn't have a flu season last year, we have a mild one this year. So obviously, with Q1, we always expect that to be a bit lower, but that will ramp up over the year. And we're really optimistic by what we are seeing on the new patient start numbers. I'm sorry, the second question. The 72 clinics for 2023. When we put this plan out there, we size between 50 and 100. And perhaps, as you've come to expect from me, we've landed somewhere in the middle there. We don't have another ongoing major clinic closure plan. But obviously, as we are looking at our clinic portfolio and underperforming clinics, we will constantly keep a keen eye on those. But I think they will be in the small single digits, not a major program like we've seen in '23.
The next question comes from Richard Felton from Goldman Sachs.
Yes. So my first question is on the CE margin. So seems like transactional FX was a pretty big headwind to the business in FY '23, and it's going to be a headwind again in 2024. So my question is, do you still feel confident about achieving the 2025 margin bands for Care Enablement that you outlined at your CMD or has transactional FX moved against so much and that's going to be hard to achieve? And then my second question, I know you don't guide specifically on revenue per treatment for U.S. dialysis. But could you help us think about some of the key moving parts whether it's payer mix reimbursement or commercial negotiations as we think about revenue per treatment into 2024?
Martin, do you want to take the transaction piece and our confirmation of our CE margin bands? And then I'll take the revenue per treatment one.
Yes, sure. So thanks, Richard. On the transactional effect, you saw that we included another EUR 50 million in our '24 outlook. We also saw that this is coming down year-over-year. And yes, we are hedging against those topics. Topics we cannot hedge, others we do absolutely hedge, but there's uncertainties in things like Russia. We are confident that we will come into our margin band in 2025 and we are offsetting those transactional headwinds with our performance improvement and the transformation focus.
Thanks, Martin. And Richard, on our PT, I mean maybe just unpacking that a little bit. We obviously know we've seen from a PPS reimbursement rate at 2%, we are assuming moderate increases on the rest of the book of business. We are continuing to see an increasing Medicare Advantage book of business sitting at around 40% now, which is really encouraging. And our commercial mix has stayed quite sticky throughout. So we're sitting at around 11% on our commercial mix there. So I think the moving parts there, and we're seeing nice trends, quite consistent. I think you all know we're disappointed with the reimbursement rate on PPS. We continue to work that. And then in terms of major, no major contracts up for renewal, a couple of smaller regional ones towards the end of 2024. But I think we have a nice line of sight into that, our PT and it's developing quite nicely.
Next question comes from James from...
Two, if I may, please. Firstly, perhaps it would be great if you could just sort of comment on the margin improvement on an adjusted basis in 2023. And can you help me understand the impact from depreciation and amortization? Because it looks as a percentage of revenues, that was around a 50 basis points improvement as that was lower by around EUR 100 million, which seems to be about half the adjusted margin gains. So I was just kind of wondering if you expect further margin gains, some lower D&A in 2024 disposals and how that differs by segment. And then my second question is just on GLP-1. Just kind of curious what your thoughts are on what the industry impact could be from the Flow study, which I think is due in the first half.
Yes. Why don't I take the second one on GLPs, and I'll give Martin some time to pull what he can hear on depreciation question if we have something of that level of detail. So look, on GLP-1 I think as you heard in the closing comments there, we've got no new data. We continue to unpack all at different scenarios and analysis. We still keep coming back to this balanced overall or neutral and with this kind of a decade to kind of see the full effect. And I think we are seeing it exactly the same as the industry is seeing it.
We keep breaking it down into our 3 buckets of medical effectiveness, prescription rates and patient adherence. And obviously, the bigger part of that is the medical effectiveness where we do think that these drugs will slow the progression to ESRD but that will be counted by the cardiovascular protection where we should get more CKD patients coming in.
Obviously, there's unknowns on prescription rates while we think pricing and access will normalize over time, we still don't understand the side effect profile on this patient population. And we -- like with SGLT2s, have been on the market in a decade, we have a very slow or small uptick kind of uptake with it being around 8% there. For what we can see in our patient population, we have about 5% of our patients taking GLP-1s. But what we also see is a high drop-off rates of those patients taking GLP-1s as well. And then, of course, for patient adherence, we know these patients are taking -- with the comorbidities already taking a lot of other prescriptions. We're still not sure -- we don't think that there'll be a 100% adherence, which, obviously, for this where they have to take it for the rest of their lives, we'll kind of have to see how that plays.
All of that said, I mean, our story is still the same. We still see it balanced overall. With regard to the FLOW trial, obviously, there's no new data. We do expect it to be read out in half 1. We expect that to be maybe more towards the back end of half 1 but we're obviously waiting for that data like everybody else is. And in real time, we will unpack it and kind of compare it against the assumptions we've all made. But we continue to analyze it and push the boundaries on all those different assumptions.
Okay. So on the margin improvement, the biggest contributors that we see is labor efficiencies as we outlined and Helen mentioned before, that is predominantly driven by CD. In addition, we have also price, as you know, supporting our development in CD, and we have the supporting FME25 savings that are predominantly contributing to the margin expansion. When we look at CE, it is price and volume growth that is supporting the margin and similarly, we have also there in supporting the savings, especially that we drive in our, let's say, G&A area that also contribute. The depreciation topic is mainly a CD topic on the details of the depreciation and amortization topics, I would have to come back to you and I'll answer that.
So the next question comes from Hassan from Barclays.
I have a couple, please. So firstly, could you quantify the headwind in Q4 from the CKCC model retrospective changes? And to what extent is this still an attractive business? Will you consider some entity exits over the next couple of months? And secondly, Helen, when you set out your CE targets at your Capital Markets Day in April last year, contract repricing was a key lever that you laid out. Where are you on this plan? And how much of a tailwind will this represent to margins in 2024?
Thanks, Hassan. Why don't we take the CKCC piece into 2 parts. Let me have Martin speak to the headwind itself, and I'll pick up on the back end of that to speak about the attractiveness of the market and how we're looking at that. And I'll take the CE pricing question as well.
So on the CKCC topic for the quarter, we incurred about EUR 60 million loss or negative operating income in the quarter. And this is predominantly driven by changes in timing in actuarial assumptions that we took. And as with any of those topics, and the maturity of the business when you talk about insurance entities, those assumptions do change within quarters. And we look normally at the business on an annual or on a contractual and lifetime cycle. So those EUR 60 million is something that also when you consider the full year turns our full year CKCC into a EUR 10 million negative that you can assume after quarter 4.
Thanks. So in terms of the attractiveness, obviously, this isn't our first rodeo on being surprised with retroactive adjustments on the government programs. We feel that we had better line of sight into these. And of course, we were positive through Q3. And then when the retroactive adjustments came in, they had a big swing. For us, this is an important market for VBC and we get to get insight into both ESRD and CKD populations. But clearly, we have to get under these KCE or kidney care entities performance in more detail. There is a path coming up in the first part of this year where we can exit those underperforming KCEs, and we will obviously take a hard look at those.
Overall, we do see the value-based care book of business and that strategic driver as important for us and particularly in MA, and we are making significant progress there, which we like, and we have picked up some pretty significant new contracts but obviously, at the end of the day, we want to make sure that we get the positive contribution that we expect. So I think we'll continue to put more color on this, Hassan, as we go through the year, particularly as we evaluate the KCE entities. Obviously, on CE, we know that we were starting from a low -- sorry, switching to your second question. We know on CE, we were starting from a low base. And I think we made some really nice progress in '23 on pricing and overall efficiencies as we know, the inflationary impact and the transaction impact muted that. But we are sharpening our pencils and tightening what we're doing on pricing.
And within '23, even though you only get to see the net effect, there was about EUR 100 million of pricing favorability actually, which equated to around 3% on average. And that will continue into 2024, where we're projecting a low to mid-single digit price increase for CE. Now the challenge there is we can't just go out and take 5% on every contract immediately. We have to wait for some of these -- whatever percentage it would be, we have to wait for these contracts to open up and we're obviously evaluating every contract on its own merits and understanding what kind of price we can take on it. So this will roll up or kind of ramp up over time as the contracts and tenders come up but we are committed and confident with the plans for the CE margins. And of course, we are working even harder to create tailwinds to offset the headwinds, which I think we did a nice job of in 2023. But obviously, as we've outlined, we do expect a step-up in margins for CE for 2024 and are committed to the margin band for 2025.
The next question comes from Lisa from Bernstein.
Just a few questions. One, can you comment on where your private mix sits today and how that's changed recently? And also, if you could comment about MA uptake as a percent of your total Medicare patients. And then last question is what would your U.S. growth been in Care Delivery, excluding the exit from the acute care contracts in the quarter.
Thanks, Lisa. I'll take 3 questions. The commercial mix is sitting at around 11%. We've seen that to be quite sticky, tiny little bits of improvement but really sitting around there. MA, we don't do it as a percentage of total Medicare. We do it as a total book of business and that's sitting around 40%. So again, we've seen some nice pickups there kind of along the way and improvement. I think U.S. treatment growth adjusted would have been flat. We had around -- the yes, around 50 basis points -- 50, 60 basis points of impact for the acute contract. So that would have taken us to flat on the organic treatment growth.
Next question comes from Veronika from Citi.
I hope you can hear me okay. 2 questions for me. First, please on same market treatment growth. And obviously, thank you for all the color you've given us in terms of the performance excluding acute care contracts. If I look at Q3 and Q4, you are still undergoing to be by sort of 50 to 70 basis points. Just curious how and why you think that's the case? And is the ambition to narrow that gap? Or are you happy with the type of growth that you're seeing at the moment on a kind of market flow basis? And then my second question, and I appreciate you might not enjoying answering this but I'm going to ask it anyhow. Obviously, if I compare your Baxter -- if I compare your products business to the Baxter products business.
Baxter have made a substantial amount of margin progress and margin improvement in the back half of 2023. You guys haven't done that. I know it's slightly out there, but what do you think are the key differences? Is it really just the FX that hindering you from showing as much progress and margin as they have? Or is there something else we need to be aware of?
It's hard to hear, but I think I got your questions, kind of crackling on the line. Same-market treatment growth compared to DaVita. Obviously, we've seen those results. Clearly, we had an underperformance in the Q4 compared to that and I think I'd break it down into 2 things. The market dynamic is strong. We are seeing strong new patient starts. I think we ended up being impacted in the quarter with the mistreatments, as I mentioned.
And I think we've got a bigger impact on that. Additionally, obviously, through 2023, we are still focused on the turnaround of our care delivery operations in the U.S. And while we have made significant progress, we do still have some constrained clinics and some labor challenges that we are working through.
Craig is on the team that are 1000% focused on this growth number was tearing apart our processes and approaching it in a different way. So I'm confident that we will get under this and fix the remaining operational challenges that we have to there. But I think where I'm encouraged is the overall market is there. We are working through [ unconstraining ] clinics in real time. We've already seen progress in January and February in market had been constrained for quite some time. We are fixing and fixed. So that's why I feel very confident about our volume outlook and closing that gap. As you rightly say, we have some adjustments for the acute -- I'm sorry, the acute contract. There'll be a small annualization for that in 2024. We also, I think, like-for-like, have closed when we look at the cumulative effect of closing clinics, we're sitting in about the same spot.
So we're optimistic about what -- we know what the work is that needs to be done, and we're optimistic about the results that we need to deliver here. Yes. The Baxter question. In the same way we compare ourselves all the time, of course, to the 2 different peers that you've mentioned. When we reviewed ourselves there, I think we had a -- we felt that we had a stronger beat in share and positioning and margin. So I don't know if we're comparing it like-for-like, as you mentioned there, Veronika. But we had good volume growth, and it could just be a transaction effect there, but our comparison was that we had a really strong quarter.
Next question comes from Hugo from BNP.
I have 2. First on Care Delivery International. We've seen price impact dropping from mid-teens to mid-single digit in Q4. Just wondering what the impact, what is the driver behind that? Is there any tender kicking in? Anything we should have in mind? And maybe a quick follow-up on that. If you can update us on the China VBPs and second question is on the growing contribution of value-based care, can you give a bit more quantitative details on the positive operating income contribution that you expect for 2024. I mean, the direction of travel is not really easy to model here given the 20% increase in cost under management, a 10% increase in patient but over 40% revenue growth. So if you can give us some details there, that would be much appreciated.
Could you please repeat your first question? We have some technical issues here.
We've got the China VBP question, but I didn't get -- we couldn't hear the first part of your question, Hugo.
No. The first one was on the price impact for Care Delivery International, which is about 5.5% in Q3 -- in Q4, sorry, while you were running at low double digit to mid-teens for the first 9 months. So just wondering what's driving that decline?
Okay. Let me see if we can snag that CDI price explanation while I'm filling in here. The China VBP, we did preempt that, and we also have moved to local manufacturing in China. While we expect the some impact from that, quite small. So we are thinking that the China VBP impact is about EUR 10 million to EUR 15 million and included in our outlook here. On the CDI, the price, I think that has to be an Argentina hyperinflation effect, where we exited in Q4. So I think that comes out of organic. So I think that's the technical adjustment there, it's just really Argentina.
On VBC, clearly, we're giving you a few more metrics than we have we're not disclosing the operating income contribution specifically for VBC for '24 other than we expect it to be positive. It's not an operating segment, so we wouldn't get into that level of detail by our disclosure.
Next question is from Oliver from ODDO.
The first one is also on VBC and the phasing of earnings. So historically, you commented on having an EBIT margin of around 1% for medical cost under management. We now see or basically, you plan to show up -- step up in the medical cost under management from the EUR 6 billion to EUR 8 billion in '24. So can you explain us about the phasing how does this -- how long does it take to realize some of irrespective profits. Do you expect the bulk of a delta to come in up from '25? Or do you see also a pro rata increase in the profits in '24? Second question is on the high-volume hemodiafiltration. Do you very [ conceptionally ] -- do you expect to be rewarded for this innovation by a higher price? Or do you really think that you use better technology to gain market share? That's from my side.
Martin, do you want to take the VBC question?
Yes. I mean, you're right, we are ramping up our cost under management from EUR 6 billion to EUR 8 billion. And yes, it will take some time until we generate savings out of that additional cost under management. So I would not figure in a big contribution into '24 , only a smaller one into '25. And I think we are rather positive and confident on our ability to manage that well.
Oliver, on the HDF, we're really excited about that. I mean obviously, this is a game changer for the industry to improve mortality by 23 months or -- sorry, 23%, which translates to about 18 months. That is massive. Obviously, we got really thrilled with the FDA approval, which came kind of a few weeks earlier than we anticipated. Obviously, right now, we are working through our go-to-market strategy, both from a product pricing but also a health economic perspective on what this means for the kind of the -- not just the products business but for the service business as well. So we are planning a full commercial launch in 2025.
As you can imagine, there's a lot of interest in this technology. It is significant innovation and maybe some of the first innovation we've had here in quite some time. So we are thrilled, excited, a game changer. Obviously, we will update -- I'm not going to disclose my commercial strategy and pricing strategy here, but we will update as we get closer to launch here.
Okay. Great. Very, very quick follow-up in this. So it does mean if you bring this technology into your value-based care agreements that there is kind of resettlement of the terms? Or does it bring more benefit to your side?
I think done right, this brings benefit to the entire industry, Oliver.
Thank you. I'm sorry about the coughing today, everybody.
We have one last question. Time for one last question. Marianne from Bank of America.
Just one question on your optimization plan of the portfolio. Maybe if you could remind us the type of assets you're looking to divest and how advanced are in the program. So if you feel there is much more to do here in 2024?
Thanks, Marianne. Happy to take that question. Obviously, when you starting to take a look at the portfolio a year or so ago, we put them into 2 buckets. It was -- those assets that were noncore to us and that we didn't feel we were the best owner of that asset, even though they're very nice assets. And obviously have some profitability associated with them. Then we had other assets mainly in Care Delivery International that were in market where they were unprofitable or the underlying structural reimbursement or profitability had changed all of the scale that we didn't feel that we could invest to grow or turn them around. So what you will have seen executed on in 2023 is a little bit of both. On the noncore, I mean, the bigger ones there, obviously, NCP and Cura.
But on the clinic exits in international, you will have heard the increasing long list of markets and countries that we are exiting. We are not done. There will be more to come. We can't put color on them until we have signed agreements. And then, of course, they close afterwards. So as we did in 2023, we will continue to provide color on those divestments went down. I think the overall sizing that we put out there, I mean, I know subject to exchange rates, as you think about Argentina and hyperinflation as an example. But as we think about the sizing that we put out there that still good, and we will provide progress as we go through 2024. But clearly, for us, as we're exiting these at speed, the focus and kind of the distraction effort is clear for us. And I think it gets us back focused on the core business and where we can grow and profitably grow there. So more to come, a lot still in the works, and we'll provide updates in future quarters. So thank you all.
So we did run out of time. I'm sorry for that. I apologize to those that are still in the queue. I'm sorry for that, thank you for listening in and for your great questions, which we appreciate a lot. And we'll see most of you hopefully soon, very soon tomorrow, I hope ideally. And looking forward to that. Thank you. Take care.
Yes. Thanks, everybody. Take care.
Thank you.
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