Fresenius Medical Care AG
XMUN:FME
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Fresenius Medical Care AG
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Ladies and gentlemen, thank you for standing by. I'm Timo, your Chorus Call operator. Welcome and thank you for joining the Fresenius Medical Care Earnings Call on the First Quarter 2020 Results. [Operator Instructions] I would now like to turn the conference over to Dominik, Head of Investor Relations. Please go ahead, sir.
Thank you, Timo. We would like to welcome all of you in these very different time to the Fresenius Medical Care earnings call for the first quarter 2020. We hope you and your families are healthy and safe, and we appreciate you joining today. Now it is my pleasure, as always, 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, uncertainties, please refer to these documents as well as to our SEC filings. [Operator Instructions] With us today is in a virtual way, Rice Powell, our CEO and Chairman of the management Board. Rice will give you some more color on the challenges with COVID-19 and the business development in the first quarter. And of course, also with us in a similar virtual way is Helen Giza, our Chief Financial Officer, who will give you an update on the financials and the outlook. I will now hand over to Rice. The floor is yours.
Thank you, Dominik. Hello, everyone. It's great to have you with us today, especially under these trying circumstances. I very much appreciate your interest in Fresenius Medical Care. And let me echo Dominik's comment, I hope that you and your families are safe and extremely healthy. Before I begin my prepared remarks on the business development in the quarter, allow me to say thank you to the Fresenius Medical Care employees that are on this call. For months now, more than 120,000 employees of FMC have been working tirelessly to ensure that our patients receive their lifesaving dialysis treatments in a safe environment and with the same high degree of quality that they’ve become accustomed to. For the FMC employees on this call, thank you. Please pass my thanks on to all your people. You are health care heroes. We could not do this without you. As Dominik says, we are doing something very unique today. He's in Bad Homburg. Helen is in Chicago, and I'm in Boston. This is a new experience for us, and I think it's probably one that we will continue with for another quarter or 2. I'll begin my prepared remarks on Slide 4. In these unprecedented times, our business model has proven its resilience. Our first quarter results show that our business model is solid, and our outstanding performance continued. We delivered strong revenue growth of 9% with contributions from each region. Our earnings grew despite the impacts from COVID-19 pandemic. Excluding this negative impact, the first quarter results are at the top end of our target range for 2020. Our cash flow development in the first quarter was extremely strong. Helen will have more commentary for you on that in her prepared remarks. I'm happy to confirm our targets for 2020. We excluded the impacts from COVID-19 in this. We'll talk more about this, I'm sure, as the course of the day progresses. Moving to Slide 5. Our first absolute priority are our patients, providing the lifesaving, high-quality treatments in the safest environment commands our undivided attention. An example of creativity and excellent performance at Fresenius Medical Care in the first quarter goes to our government relations team in Washington, D.C. We saw very early on in March that people that needed vascular access surgery didn't know what to do. Was it elective? Should we put it off? Can we get it? Can we not? And this team went to work, had very detailed conversations with Health and Human Services and CMS, who were able to clear up a very troubling situation and have it very clearly communicated that dialysis patients need to have vascular access surgery, and it is essential. It is not elective. Just a way that our people have risen above the confusion and the issues in this delicate time. Our global medical office, I thank them greatly. We've taken wide-ranging measures across the Fresenius Medical Care enterprise, and we took these measures at a very early stage. We initiated our pandemic protocol. We took protective measures such as PPE or personal protective equipment, masks for our patients. And everybody obviously understands that we would do this in our clinics, but we went a step further, and we made these same conditions for our manufacturing facilities in order to make sure that we could protect the environment in which our products are made and we could continue supply to our patients and our customers. And despite countries locking their borders down and making moving products and goods difficult, we've been able to do so. Our manufacturing facilities have not had any disruptions, and our supply chain is functioning, and we're very thankful for that. Due to the pandemic, we had to absorb a sizably higher cost in the first quarter. This is fully reflected in our reported numbers. There is no benefit from the CARES Act included in the reported results for the first quarter. The benefits of the CARES Act were only initiated in April, and I'm sure we'll have more discussion on that as we go through Helen's presentation and the Q&A. In the U.S., Fresenius Medical Care is cooperating with other dialysis providers to create isolation clinics and dedicated shifts for COVID positive patients. A critical aim of this collaboration is to keep dialysis patients out of the hospital whenever possible. In these times, it is so incredibly important to free up the limited hospital resources to deal with the severe cases of COVID that are not necessarily dialysis-related. This is a way that we believe we are making a positive contribution to the health care situation in the U.S. in general. Moving on to Slide 6. In the first quarter, we provided more than 13 million treatments to more than 348,000 patients in more than 4,000 clinics worldwide. The slower growth of our clinical infrastructure, which you can see is at 1%, is the result of several things. Please recall in 2019, we did a dedicated restructuring that optimize our clinical infrastructure, specifically in the United States. We are growing our home business considerably. This requires fewer clinics to be built. And thirdly, in the Asia Pacific region, we had a legal interpretation that changed in one of our markets, which led us to make the decision that we would deconsolidate some 20-odd clinics that we had consolidated for a number of years. But with the government change and a different view of this, we decided it made sense to deconsolidate these clinics, but we have kept the product business. But those 3 items have contributed to the 1% growth in clinics. We consistently deliver a very high quality -- level of quality and services in our products and our dialysis for our patients worldwide. Turning to Slide 7, if you would. This is our quality indicators. I think you see stable performance in the first quarter. You can see we've made progress in the number of hospital days per year on a patient basis. We will see what Q2 brings. But at this point, we feel good about what we're able to deliver from our quality standpoint, and we like the sustained performance that we are contributing. Turning to Slide 8. Our business performance in the first quarter was very strong despite the pandemic. Revenue increased by 9% with solid organic growth of 3.8%. We delivered growth in both dialysis services and products. As already mentioned, despite the impact of the pandemic, we saw a positive operating performance with an increase in operating and net income. Helen, as she typically does, will take you through the details of that in her prepared remarks. Moving to Slide 9. All regions contributed to an overall organic growth rate of around 4%. The highest growth contribution in absolute terms came from North America with a 10% revenue increase. EMEA, Asia Pacific and Latin America came -- followed with a 4% growth. Now please, if we take a look at the next slide, we'll focus on Health Care Services. The COVID-19 pandemic did not affect revenues in our Health Care Services business in the first quarter. As you can see, we delivered strong growth, organic as well as same market. The increase was supported by acquisitions and an increase in dialysis days as well. In North America, same market growth continued with a 3% increase. As planned, and we've discussed, we did close a number of clinics as part of our 2019 cost optimization program. And obviously, that has a negative drag on the growth rate. In EMEA, we realized organic growth of 4%, and Asia Pacific's growth of 6% was supported by an increase in the core dialysis business as well as Care Coordination. Moving to Slide 9 -- 11, I'm sorry, and my last prepared slide. The products business delivered strong reported growth of 10%. To be taken into account is the acquisition effect from NxStage that helps here. In the light of the COVID-19 pandemic, the organic growth of 2% is a solid number. The strong organic growth in dialysis products in North America was not only driven by higher revenues from renal pharmaceuticals, renal disposables and home hemodialysis products but also by higher sales of products for acute care treatments in the intensive care units. At the same time, we saw a decrease in Asia Pacific, mainly due to lower sales of dialysis machines in China in particular. This is a consequence of the pandemic. Here, the higher sales of acute products cannot overcompensate for the lower sales of the dialysis equipment. Revenue from non-dialysis products increased significantly year-on-year, mainly due to the higher sales of Novalung machines, which can be used to treat COVID patients in the intensive care units, and this is from our Xenios acquisition of several years ago. At this point, I'll end my prepared remarks and gladly turn it over to you, Helen, please?
Thank you, Rice. Hi, everyone, and a warm welcome from Chicago. I hope you're all doing well wherever you may be dialed in from today as we embrace this new virtual world and ways of remote working. I would also like to echo Rice's comments and extend my own thanks to our employees who have worked tirelessly and selflessly these past few months to ensure our patients continue to receive uninterrupted dialysis care. I am so proud of our efforts and to be part of the FMC family. Rice has already outlined the very positive revenue development. I will focus my comments on giving you more flavor on the earnings side. I know we said it already, but I want to reinforce that we continue to deliver operating income growth despite the very challenging situation the world is in at the moment, and we are on track to deliver what we promised. In my first call with Fresenius Medical Care in February, which feels like a lifetime ago, I outlined a couple of priorities that are important to me. One you are already aware of, which is simplify. In the spirit of that and to leave more time for the Q&A today, I summarize the regional developments for you in one slide without losing any relevant details, and this is shown on Slide 13. In the bar chart on the left, you see the regional contributions and corresponding margins. The group operating income improved by more than EUR 30 million to EUR 648 million. This number includes a sizable negative impact from the COVID-19 pandemic that we absorbed in the first quarter. There is no positive contribution from the CARES Act or any other government support included in these results. The decline in operating income margin for the quarter of 60 basis points is mainly driven by the cost impact of COVID-19 where there was varying impact across all the regions. These higher costs in our operations are driven by an increased spend for personal protective equipment for staff as well as masks for patients, higher personnel expense due to additional shifts, over time, an emergency pay for our employees, along with child care expenses in the U.S. and by increased patient transportation requirements and more difficult distribution logistics for our products. In addition to the direct costs impacting our business, the fear of a worldwide recession and the corresponding capital market reactions resulted in unfavorable valuation impact on some of our investments. Our underlying business fundamentals are strong, and we are performing remarkably well. One of the main positive drivers in the quarter was the reduced cost of pharmaceuticals. We have been able to benefit from improved pricing on some pharmaceuticals as well as higher percentage of generic drugs. Additionally, we are continuing to optimize our Care Coordination portfolio. As part of this process, we divested in January some clinics in the cardiovascular space in North America and realized a positive contribution of EUR 24 million to the margin development. The 2019 prior year reduction of a contingent consideration liability related to Xenios was a known impact to reported performance in EMEA in the first quarter of this year. Some short key comments on our regional development. In North America, we realized growth on the top and bottom line despite the COVID-19 impact. This resulted in an improvement to the margin of 160 basis points. The most important drivers on the positive side we already mentioned, lower cost of pharmaceuticals, the divestiture of Care Coordination activities. But additionally, we saw continued improvement in our commercial mix contributing to the development, along with higher sales of acute products. On the negative side, an unfavorable effect from cost for COVID-19, which I outlined, and a reminder that we have not received any compensation under the CARES Act in Q1. The compensation will be in effect, and we will be talking about in Q2. As we have previously discussed with you, we are seeing lower ESCO savings than last year. And additionally, we had a lower contribution from pharmacy services. In EMEA, we already mentioned effect from Xenios in 2019 impacted the year-over-year growth the most. And we also have a COVID-19 cost impact here, but we benefited from positive contributions from acquisitions. The margin in Asia Pacific was affected by unfavorable foreign currency transaction effects by lower product sales, in particular for dialysis machines in China due to COVID-19, but they were partially offset by acute sales and by our continuous investments and ramp-up of our dialysis service business in the region. Latin America includes some economies with a deteriorating and challenging macroeconomic environment, which is becoming worse due to the COVID-19 pandemic. Here, we saw a margin decline, which is mainly due to unfavorable foreign currency impact. I will now move on to Slide 14. Our cash flow focus and deleverage targets are another key priority for me. The significant increase in our operating cash flow was largely driven by working capital improvement in the quarter. This was triggered by a couple of very actively managed cash that resulted in a positive effect from cash collections with lower DSO and improved timing of payments as well as changes in year-over-year inventory levels. The strong cash flow development resulted in operating cash flows of EUR 584 million or 13% of revenue. CapEx amounted to EUR 280 million and is in line with our planning for the first quarter. As a result of the strong operating cash flow, free cash flow improved significantly year-over-year to EUR 304 million. And just as a reminder, the free cash flow after investing activities in Q1 2019 included the acquisition of NxStage. And lastly, when you look at the leverage ratios on the bottom left of the page, including IFRS 16, the leverage ratio was broadly stable with 3.3x net debt to EBITDA. The ratings are unchanged. And as you can see, Fitch reconfirmed its rating with us in April. Let's turn to Slide 15. Here, you can see our targets for 2020, which remain unchanged and are confirmed. As previously guided, our 2020 targets exclude the impact of the COVID-19 pandemic and special items. Our current assessment of COVID-19 on our earnings is not so significant and is absorbed in our guidance range. Should the pandemic develop further, we will continue to review the impact on earnings and whether we utilize the use of special items. The net effect of the COVID-19 pandemic in the first quarter was not material in respect to the full year performance. Taking into account the committed support from the U.S. government, in particular via the CARES Act, we anticipate most of these costs will be covered. Based on the definition of these targets, which means excluding the negative effect from the COVID-19 pandemic, our first quarter results are clearly at the top end of our net income guidance in the first quarter. This makes us very comfortable in terms of our underlying business performance. With that, I close my prepared remarks and turn it back to Dominik Heger in Bad Homburg.
Thank you from Chicago. So thank you, Rice. Thank you, Helen, for your presentations. And I'm happy to turn it over to the Q&A, and we have 40 minutes left. That's great.
[Operator Instructions] The first question is from the line of Veronika Dubajova from Goldman Sachs.
I'll keep it to 2. My first one is on guidance, actually. Helen, I'd love to clarify the comment that you have just made in terms of saying that your current assessment of COVID is that it's not so significant and can be absorbed in your guidance range. Is this a comment inclusive or exclusive of the CARES Act funding? And kind of how are you thinking about how the incremental costs and the funding offset each other? That would be really helpful to understand on a full year basis. So that's my question number one. My question number two is on commercial mix in the U.S. I'd love to hear, one, where you are with respect to fourth quarter, if you've seen any change sequentially. And two, kind of bigger picture, if we do go through a period of higher unemployment in the U.S., what are your thoughts on what might happen with commercial mix and what that could mean for your business in the second half of the year or in 2021?
Helen, why don't you take number one, and I'll take number two, the 2 parts.
Yes. Thanks, Rice. Thanks, Veronika. I hope you're well. Yes, with regard to the guidance, we have estimated what the impact of these ongoing costs for corona, particularly as we incur the increased cost in the U.S. We do feel that, that guidance is inclusive of the CARES funding. We do expect to receive that and be -- attest to the fact that these costs are in keeping with the intent of the CARES Act, which is to reimburse providers to keep the clinic operational and keep the continuous care for dialysis patients. I think we have proved that we have done that over the last 2 months, and we have kept our patients out of the ICU and out of hospitals, and we have uninterrupted care in our clinics. So I think we feel very proud of that. But yes, our expectation is to benefit with the receipt from the CARES funding to cover the additional costs. Obviously, we're all reconciling how those costs are ongoing and how the government aid will help us with that. We know that we -- with the attestation, we have to reconcile it. So yes, on a full year basis, we still feel that we can absorb that within our guidance range. What I would say is we don't know how -- like everybody, we don't know how long and how deep this is going to last. If we are facing a second surge towards the back half of the year, I think we have to evaluate the impact on earnings for that. And I think the whole world is going to know more when we come back to the round of earnings for Q2. But right now, our assessment is pretty strong.
Veronika, it's Rice. One thing I would add, it probably gives you a little bit of clarity. We saw the Q1 COVID expense at approximately around $40 million in Q1. So that probably gives you some help in that regard. Commercial mix, as it relates to sequential quarter, Q4 to Q1 improved. We are still seeing improvement in our commercial mix, and so we're pleased with that. Now unemployment is a big topic, and let me try to address it this way, what we know and what we don't know. What we know is that in '08 and '09 when we had the financial crisis, we didn't know what to expect in terms of commercial mix, and we didn't see a big shift there. So it was fairly stable through that period. A long time ago, different time. The way we think about this is it depends on who is unemployed. If these are people that are in the gig economy or they're not the type of people that are going to have company-sponsored plans, if they were going to come to us, they're going to come to us as a Medicare patient anyway. People that are working, that have health plans, many of those people are getting furloughed, and so their benefits are still intact. So that will have some impact as to what happens. And then lastly, obviously, if people are actually getting laid off, there's the option for COBRA, which you know about. So I think it's too early for us to prognosticate. We won't do that. But we know that there are different slices of unemployment. So we have to work that. We have to understand it and see where it goes. And keeping in mind that if we are seeing something go on that gives us a trend, then we'll report on it, we'll talk about it. We'll figure it out. But right now, I think it's simply too early for us to understand that. But that's how we're thinking about it, if you will, a couple of different levels.
That's very helpful. And if I can just clarify, Helen, that I understood your answer correctly. When you think about the guidance, including the additional COVID costs and including the CARES funding, you say it's effectively unchanged. Is that a fair interpretation of what you've just said?
That's correct, Veronika, as we see it right now. Yes.
Next question is from the line of Sebastian Walker with UBS.
I've got 2 as well, if I could. So the first one is just thinking about volumes. It'd be great to hear what you're hearing from your Chief Medical Office on how COVID may be impacting your patient volumes going forward. The second one was on the Products business. Can you maybe comment on how you see demand for both the dialyzer products but also the consumables used for acute kidney injury patients going forward?
Sure, Sebastian. I'll take these 2. Helen, chime in whenever you would like. When our medical office -- and we talk about where does this go, patients, volumes, treatments, what's coming, we go back to what do we know versus what do we not know. And we obviously know that looking today in Asia Pacific -- I have to do this globally. If you look at it in Asia Pacific, it would look like China has come through and beginning to stabilize. We're seeing a rebound of the virus in Hong Kong, and we don't know how big that rebound or what the duration will be. We're seeing some stability in France and Italy and Spain. You're seeing the positive count is sort of plateauing, but we're not seeing it come down particularly quickly. We know that it has migrated into parts of Eastern Europe, Russia, Romania, et cetera. So it's still tracking up. In the U.S., largest market, it does appear that we are seeing some tabling or tableau-ing, if you will. But what we are concerned about is simply the fact that how would that curve come down. It shot up very quickly. Now it's sort of plateaued. What happens? How long will it take for it to come down? That's really important to us because we get into the fall and influenza of the general kind is going to come back. So what happens with that mixture? So it's these unknowns that keep us from being able to try to predict or prognosticate where the volumes will end up. But we are looking at it, but we've just got to have more time and see where this goes. And relative to the Products business, we've not seen an impact on our disposable business. It's fairly -- as we haven't expected it to be. Obviously, the hemodialysis equipment is down, but we think that can come back at some point. We are seeing an upsurge in our acute business, but it's not enough to overcome everything. So we're going to see how this plays over time. The longer this pandemic continues, I think there could be more upside in the acute side of the house simply because we do know that roughly the COVID patients, non-dialysis-related, but about 20% of the COVID-19 patients end up with acute kidney injury, and they need to be treated. So the longer this goes, there may be more volume that we see in our ICU business.
The next question is from the line of Lisa Clive with Bernstein.
I'll start with North American Care Coordination, very robust growth at 9% organic. What is the main driver of that? Have you signed any integrated care contracts with private insurers or MA this quarter? Second question, Asia Pac, the deconsolidation of, I think, 22 clinics. Does that relate to a 2014 acquisition in the big markets that cannot be named? And then just lastly, very quickly, Cura in Australia, just was wondering how that business is doing. Have they had to stop or slow down their procedure volumes given the COVID situation?
Lisa, it's Rice. I'll take those, and Helen, please jump in when you like. So the biggest drivers in Care Coordination, it's -- really we've gotten the very best that we can get relative to reimbursement for vascular care. As you know, we were working very hard to get our site -- 11 sites move to ASCs. We got better reimbursement rates than we had anticipated getting. So that's been helpful and driven some of that. Our pharmacy has worked as we thought it had. So it's not that we've done anything new, if you will, at this point in the game as it relates to Q1. Different part of Asia Pacific, I will just tell you that these clinics that are deconsolidated are coming out of South Korea. There was a change there. It's a different view of the government. And so we felt it was most prudent that we would deconsolidate those, maintain the product business and go from there. And then Cura in Australia, there has been some impact, and Helen will jump in here and help me. I want to say that there was some impact in the month of March on elective procedures. The government did not want people doing that. It moved into April for a week or 2, I believe, and then went back -- it's going to click back. They're allowing it. But I may be off on the March comments, so I'm going to let Helen jump in. But beyond that, beyond electives being not allowed for a period of time, everything else is pretty much working as it needed to. Helen, am I wrong or -- on the months, did I get them wrong?
No. I think the 2 were -- it was 2 weeks in early April. He may have struggled right at the end of March, but I think the first 2 weeks of April where the government had intervened and said no elective, but that turned around very, very quickly. And we don't expect that to have an impact. Again, maybe what I would add as well, Lisa, is we've obviously talked about the CARES Act. But right now, we have no favorable reimbursement impact built in for rest of world. And as you can imagine, we are in discussions with other governments and care providers to make sure that the additional costs or government interactions are not affecting us in a negative way.
The next question is with the line of Patrick Wood with Bank of America.
Perfect. Just 2 quick ones for me. The first one, how should we think about MA enrollment as we move through the latter part of this year and into next? And does the current environment change anything associated with that? And then the other one would be equally similar sort of topic, but how do we think that this might change the structural shift to home? Is this an accelerator for that trend? And how are we thinking about that internally?
Patrick, it's Rice. I feel like I should just give these to Helen because I'm doing all the talking, but I'll go ahead and have Helen jump in when she would like. On the Medicare Advantage enrollment, as we talked, open enrollment is coming in the fourth quarter. So I can’t tell you that we've really worked our way through what an impact may be or not. I think we're just going to have to play this out. And I keep saying it, but I mean it's the known and the unknown. So we'll get through Q2. We'll understand where this is going. We're going to have a pretty good idea, I hope, for our global medical team about, okay, what does Q3, Q4 look like in terms of the pandemic, and then we'll have to see where that is. I think it's just early for us at this point to have any more to contribute to trying to answer that question. And then on shift to home, I was asked this a couple of weeks ago. We are in a place where we are currently training 400, 500 people to go home. They've got to complete that training. We have to move them through the system. We're not really in a position that just because of COVID today, what has been sized and money spent to be able to move those people through the system that we can just decide to go double that right now because doubling that concerns me as to the quality of the training that they get. So we need to have this work at kind of the par value that we've looked at it for. I do think post-COVID and people learning and seeing what's going on in the pandemic, certainly, there may be more people that want to look at, can I do training at home, can I do my therapy at home? And we will react to that. But it's not like we can just flip a switch and say, "Hey, we're going to do 425 over the next 6 weeks. Let's just double that." I think there's a quality concern with that. And secondly, we've got a lot of our manpower going and doing things to attack COVID and helping out and moving around. We've had people come out of home training centers, nurses and be able to go help literally in ICUs and things like that. So we're maintaining the growth and the plan, but it's not a time to rush it right now. I think that would be ill advised.
The next question is from the line of Michael Jungling with Morgan Stanley.
Great. I had 2 questions. Firstly, on North America. Can you comment on a relative basis how the calcimimetic profits compare in Q1 of this year versus Q4 of 2019, some sort of relative comment on how the development has been? And then please, question 2 is on the CARES Act. Can you comment on the degree you want to accept the benefits from the CARES Act and what limitations that may place on your business flexibility? And as part of the CARES Act is sort of a 250 million benefit kind of similar proposed to what your main competitor proposed, is that a number that one could work with, with respect to what the CARES Act benefits could be in 2020?
Sure, Michael. Helen, do you want to take number one, please?
Yes. Sure. Yes, yes. Michael, hope you're well. So calcimimetics, as you know, we have not guided on the calcimimetics impact in last year or this year, either. What you do know is that we do see a benefit in Q1 of 2020 versus Q1 of 2019 because of the timing of the generic. So year-over-year for the quarter, you'd see a benefit. We won't disclose that. But as the year goes on, it will continue to be the headwind that we outlined when we did our guidance at the end of last year. Rice, are you going to take the CARES Act question?
Sure. So -- yes, I know, I'll comment. So Michael, on CARES Act, we had made a decision back in March on these additional expenses and our pandemic protocol and what we were going to do. Elder care, child care, emergency pay, et cetera, merchants pay for our drivers that go into people's homes to deliver home product. We had several discussions with executive management at HHS, and it was very clear to us that Medicare providers that were incurring excessive expense were trying to do the right things here in the midst of COVID. That was exactly what CARES was being developed to take care of. So I feel like we've done exactly what we needed to do. I think it's in the best interest of our patients, our employees and our shareholders if we take the availability of this. And the way we look at this is simply it's reimbursement for the extraordinary expenses that we've incurred, no more, no less. We will attest to the nature of the expenses and how we generated them, and that attestation is due to start, I think it's in early in July. So we're pretty comfortable that this process is understood. We've stayed close to the folks that are administering the CARES Act, which is HHS. And so we feel good about that. I will comment on the benefit relative to what the other guys tell you they got. I don't see a lot of value in walking you through that. Of course, the other piece of this, not related to CARES Act, is simply that the fact sequestration is going to be put on hold from May 1 through December 31. That'll have an impact for us, somewhere probably in the $50 million to $50 million range -- $50 million to $55 million. But I think that is where we kind of stand on this. We think it's prudent activity for us.
Great. And with respect to calcimimetics, can I just understand how calcimimetics compared to the fourth quarter of 2019? Did it take a substantial hit or a little bit of a hit? Just some sort of high level guidance, please, on that.
Yes. We did see...
I -- yes. Go ahead.
Go ahead. No, I was going to say, you know we won't disclose the number, but we did see a reduction in that from Q4 to Q1.
Next question is from Ed Ridley-Day with Redburn.
First of all, just on the acute care part of your business. We don't talk about this enough. Could you update us on what proportion of particularly your U.S. revenues in the product side are related to CRRT and acute care? That would be my first question. And secondly, a follow-up on the questions related to revenue per treatment in the U.S. Looking -- given the sort of puts and takes, revenue per treatment year-on-year was a little bit light of what I had. And I was wondering, was that primarily the impact of the clinic closures? Or were there other -- particularly given the positive update from Medicare and the slight improvement in mix, even with the calcimimetic negative, are there some other puts and takes that we should be aware of?
Helen, I thought I'd give you 1 and 2 and yes, please.
Yes. Yes. Sorry. The joys of remote working [indiscernible]. I'm sorry, Rice. I was going to say, on the acute care revenue, we don't disclose that level of detail in our North America segment. And on revenue per treatment, as you know when we gave guidance at the end of the year, we are not going to disclose the detail of our PT and PPT moving forward. But we do have a positive trend on revenue, which was up 2%. The -- so I don't know where you're getting a negative calculation from, but we could follow up along those lines.
No, no, no. It was -- obviously, it was positive, but I was just thinking it might have been slightly more positive, but no, that -- and just a quick follow-up as well on the timing of the support from the U.S. government. Rice, you highlighted that, obviously, it's being discussed. Just in terms of how that comes through, it would presumably be lagging, and therefore perhaps, just in terms of modeling, it should be more second half weighted.
No. I think there's been some fund flow. That started in April. So it's not like it's all pent-up and hasn't come in yet. So there's been some. I think there'll be some lag. We'll have to true that up. But I think it's not going to be back half of the year before we see that. I think we will see relief, reimbursement, if you will, in Q2. May not cover everything, obviously, but I think it will get started, and we'll be able to work our way through that process. The other thing, Ed, just real quick, 2 things I want to say. The acute business in the U.S. is predominantly NxStage business. We did not have an acute business in Fresenius pre that in the U.S. Rest of the world has had a very vibrant acute business, number one. Number two, just so you guys understand, we've gotten several emergency use authorizations from FDA that have allowed us to also bring in Xenios equipment so we could join the fight against COVID relative to doing ECMO membrane oxygenation for COVID patients in the ICU. And we're also getting some FMC, if you will, pre-NxStage European equipment like the multiFiltratePRO and the classic in, all in an effort to be able to help these institutions be able to treat these COVID patients when they end up in ICU, and they've got -- this is that 20% I was speaking of that develop acute kidney injury. So we're working very hard -- hand in glove with the U.S. government to try to be able to support as much of that as we can.
The next question is from Tom Jones with Berenberg.
I had 2 questions, actually, more about life after COVID-19, to be honest. The first was just on all the various models that are floating about, the kidney care first, chronic kidney care contracting model and the ETC model. Where are we with all that stuff? Is it just kind of on hold and probably likely to stay that way until after the election and we'll see where we are? Or is there any possibility there anything could happen sooner than that? And then the second question was just on -- I'm not asking for too much in the way of specifics, but the nature of your commercial contracting discussions at the moment. From memory, you had one of your larger commercial contracts coming up for renewal this year. Maybe you could just make some comments about how those discussions are going in the context of what might happen with MA numbers next year. The different insurers seem to be making different noises. Some of them seem to think this is a bit of an opportunity and that they can manage these patients well. Others seem to be like rabbits in the headlight and terrified of a potential wave of dialysis patients. So some color around how those discussions are going, what the framework is and potentially how that might influence your business going forward would be helpful.
Sure, Tom. I'll take both of those. I have to say my hats off to you. You're the only person to ask me about anything life after COVID. We haven't seen that far in advance. But here's what I would say. It's a really fair question. Everything in Washington today is COVID-focused with the folks that we deal with, CMS, HHS, FDA at the moment as well. There's been no official word coming out. My gut tells me that the voluntary models are very likely to be pushed out. It is just such a gargantuan effort that everybody has been undertaking to try to make sure they're doing everything they can in this COVID situation. We are still -- we're late with ESCO getting the [ lab ] -- I think its third quarter report from plan year 4. Just things like that. It is really everybody's focused on COVID. So when I have a better update for you, I'll let you know. But right now, we're just keeping our heads down and going forward. But I suspect pragmatically, it's going to end up getting pushed out. And on the contracting status, the very end of last year, the one big commercial contract we had to do this year got taken care of. So that was really done before COVID hit, if you will. And on the Medicare Advantage discussion, there are people all over the place. I think this is the way we view it. It's a rate negotiation. We are very comfortable with our capability and the outcomes that we are giving people, and many of these payers have history with us, and they know that we provide good outcomes and we can manage these patients in a tighter band than probably anyone else. So we're just going to have to see how it plays out over time. But I would confer to you that, yes, you do see very different perspectives, one Medicare Advantage provider or commercial versus the other. So it's a little bit of a smorgasbord, if you will, but we think we can work our way through that.
Okay. Perfect. And then just -- I just have one very quick follow-up on the previous question about home HD. I know you're not going to be keen to expedite home training at this current time, but maybe just as a kind of predictor of the future. What kind of level of patient inquiry have you seen during the COVID outbreak? Has it created a big spike in interest in home HD? Or is it people just focused on staying alive at the moment?
So I would say, and this is from my opinion, I don't think that I can give you a perfect answer, but I think people are much more in the mode of don't want to go out of the house if I don't have to, don't want to start something new. I think ultimately, we're going to see a lot more interest in home because as people begin to understand, doing it at home, I can self-isolate versus the clinic, et cetera. So I think that will come later. But I think right now, there's just a huge focus on people trying to stay healthy as they exist today more so than they're thinking through, do I want to jump and start training right this day? I think folks are trying to understand where this is all going to go because it's so vastly different from one part of the world to the next.
The next question is from Oliver Metzger with Commerzbank.
The first one is also on the compensation from the CARES Act. So the benefit comes in the second quarter. However, we do not know how long all the safety measures have to last. But can you give us any indication for how long the CARES Act benefit would cover your incremental costs? My second question is on the Non-Dialysis Products, so you have a very strong growth. You already mentioned Xenios. So could you elaborate on the contribution of this ECMO console from Xenios to this development? So was it a major contributor? I'm asking because I think Xenios business as comparatively small in mind. And yes, I would be really surprised by such a strong contribution.
Sure, Oliver. So again, it's a fair question on the CARES Act, and it's what we know versus what we don't know. So without knowing how long this is going to go on, we really haven't had discussion with the government about that. Everybody has their own opinion from the President all the way down to other people about how long this is going to go on. But the one thing we do know is the government has been extremely responsive. And so if we see there's a resurgence or this goes longer, then we would obviously engage and talk to them and see how it happens. I think the best way to think about this is, we think we know enough about Q2 and where it is that we'll be -- we'll update you when we get there. And then we're kind of looking at this quarter-to-quarter. I would say there's probably no more greater need for information than understanding anywhere in the world how long is this going to go, and we're trying to do that, but we're not there today. So there's a little bit that we'll have to take this as it comes. But there's also comfort in my mind having been on the phone for hours with people in the U.S. government how much they want this to be taken care of and worked on appropriately. And as Helen said earlier, we've got no assumption about the rest of the world, and is there going to be help there or relief. It's been talked about, but we just haven't done anything with it because we don't know where it is at this point. So that's out there as well. And the one thing that I would remind people of is Latin America is trailing even the U.S. in terms of the pickup of COVID and the rates beginning to climb in some of the markets in Latin America. So I just think we're going to have to work our way through this in that regard. Now on Xenios, it's a small factory. They're doing great things. People are working very hard to try to crank up as much product as we can. I would never do it just as medically to try and explain to you the value of that model. Let me just say it as simply as I can. What you're doing is you're getting oxygen pushed through the body. You're getting it into places that helps speed the recovery, if you will. And we can get you more information on that from the medical office, but we do believe and what we've seen in the work that's been done in Europe, and we had discussion with FDA on this, we do think the ability for us to be pushing oxygen through the membrane and getting more oxygen into the body is what is making the difference. But let me stop there before I get way out over my skis. And if you still have more question, we can get you some better answer once I have a chance to coordinate with our medical people who understand that much better than me, obviously.
Next question is from Hassan Al-Wakeel with Barclays.
I have a couple. So firstly, on the products business, are you starting to see any signs of normalization in acute machine sales in the month of April? And what was the magnitude of the decline on the HD side in Q1? And secondly, could you talk about the ESCO patient population and how increased COVID-related costs will be treated here, please?
Hassan, it's Rice. Sorry, I was writing really quickly. What I would say on the acute side of the house, no, it's not normalized in April. There is a huge need in Europe and the U.S., and I suspect it's going to end up being in Latin America as well because none of these markets are as far along as Asia Pacific is. So it has not normalized. I suspect that will continue for a while. Then when you look at HD, I don't think we can really -- that I'll size that for you. Obviously, as you know, just a couple of things to keep in mind. Asia Pacific, that region is a very product-heavy region. China is a large market. It's essentially a product market today. And so when your machines -- you're not selling them just because you can't even get into the hospital and have a sales call. Nobody wants to see you anyway. There is impact there. But I don't think I'll take it much beyond that. We do think there's a chance that this will come back. As we talk about capital equipment, you can miss a quarter or 2, and then pent-up demand comes to you. Again, it's really around what we know versus we don't know and how big is the rebound potentially going to be in Asia and what challenges will that present. And on the ESCO, our ESCO population is pretty consistent in terms of number of patients on ESCO. And I honestly don't know the detail on the interventions that we're making on them. But I don't think -- I have not heard that we've seen a big increase there in terms of ESCO patients that are COVID positive that we've got a big expense coming there. That would sort of fall in the same category, I think, is just the general population in terms of dynamics there.
And a follow-up, were that to change, would you expect a change in the benchmark potentially?
Well, that would result in us having some conversations with the government. And at this point, given that everybody is focused on COVID and we are well behind on getting that third quarter report for plan year 4, I suppose it's possible we could have that discussion. But at this point, there's been nothing going on that I'm aware of.
The next question is from David Adlington with JPMorgan.
Most of have been asked already, but one technical one and one follow-up on Novalung. So just on the $40 million additional costs in the first quarter, will you be able to kind of go back and kind of recall that back under the CARES Act? And if so, do you expect to recognize that in the second quarter? And then secondly, just on Novalung. I'm just wondering what interest you're getting in coming from health care authorities across the world and what sort of capacity could you ramp up to because I suspect there's quite a lot of demand out there for the moment for that.
David, I'd take the first question.
Please, sorry.
Sorry. Sorry, Rice. Yes, David, on the $40 million, just to clarify and just make sure everybody on the call understands this. The $40 million is EAT basis. It does cover a broad range of things, not just U.S. costs. There are costs incurred elsewhere. Also, we know all of the costs incurred are not eligible for the CARES Act as well. And then there's also this investment impact, which has more to do with the market kind of economy, if you like, that we expect to reverse as the year goes on. So anything that is eligible in direct cost in the U.S., we would expect to be reimbursed. And I would say, between a half to 2/3 of the costs incurred in Q1 falls into that category and will then get reversed in Q2 when we get the benefits from the CARES Act.
Yes. David, on Novalung, from a capacity standpoint, what I would tell you is we're ramping as quickly as we can. Think about this, you've got a piece of equipment, the console, as we call it, then you've got disposables, you actually got the membrane that you do the oxygenation with. So all of those components are being worked on, trying to be ramped up. Yes, there are a number of those pieces of equipment in the supplies that were in Asia Pacific. Big market in Europe because it's been there. People understand the product, et cetera. And the U.S. really came through some Herculean efforts that our people made to get FDA aware that we have some equipment. We want you to use it. We're trying to ramp up as quick as we can. And when FDA understood it from talking with our medical people, they were very interested. It's a great problem to have, but we're moving as fast as we can. But your instincts are good. This is not a factor where this stuff is being produced. It's anywhere of the size and scope of dialyzer factories or our main machine factory in Schweinfurt. So we're just going to have to continue to push to get our capacities up.
The next question is from the line of Falko Friedrichs with Deutsche Bank.
I would have one quick question left. So you talked about the creation of these isolated clinics for COVID-19 patients. How occupied are these clinics currently? And is everything functioning smoothly so far?
Falko, that's a really, really good question. The clinics are functioning well. They are all being used. They're maxed, if you will. And it is an incredible effort that we have people going into these COVID positive clinics every day delivering the care that they are. My hats are off to the entire industry, but particularly my team in North America that pushed hard to do this as a industry team and get this done. Bill Valle was instrumental in that, our CEO here in North America. So it has been probably one of the most significant things that we've done in order to make sure that we're trying to keep everybody as safe and well treated as we can.
And we have a follow-up question from Veronika Dubajova with Goldman Sachs.
I just have one, please. Rice, just curious to get your thoughts. We've seen a pretty high incidence of acute kidney injury among the COVID-19 patients who aren't getting hospitalized. Are you seeing these folks arriving in your clinic now that they've recovered? And do you think this is something that could be permanent and drive some incremental volume growth for you guys over the next couple of quarters?
Yes. Veronika, not at this point. As I understand this, and this is back to the 20% of the general COVID positive population, these folks have to be in the ICU, and we are treating them there. We do any number of different or any number of derivations of dialysis. It can be slow flow, a whole bunch of different things as physicians believe it's best for that individual patient. I would say right now, these patients aren't well enough to be considered to be coming out of an AKI situation in the ICU and then end up in the clinic. It's not to say that may ultimately end up happening, but I think we've got to see a real change in the severity, if you will, Veronika, of what we are understanding and what our nurses are seeing when they're going into these hospitals to work in the ICU to try to help. Particularly in New York, we've had over 500 nurses just volunteer from all over the country to go to the hottest spots possible and treat patients because they thought it's what they want to do. I don't think they're capable of coming out of AKI and the ICU and continuing that right now. So we need a little more time on that. And if I'm completely off base, I will check with Frank Maddux, and we'll come back to you. But I think this is the right answer at the moment.
There are no further questions at this time. I hand back to Dominik for closing comments.
Okay. Perfect. So thank you, everyone. We always make it in time. 3 minutes over is close to perfect. Thank you so much for the discipline and your interest that you had so many questions. And with that, I think the 3 of us say thank you very much, stay safe, and goodbye.
Thanks, everyone. Stay healthy.
Bye-bye, everyone. Stay safe.
Ladies and gentlemen, the conference has now concluded, and you may disconnect your telephone. Thank you for joining, and have a pleasant day. Goodbye.