德維特 (DVA) 2021 Q4 法說會逐字稿

Good evening. My name is Michelle, and I will be your conference facilitator today. At this time, I would like to welcome everyone to the DaVita Fourth Quarter 2021 Earnings Call. (Operator Instructions) Today's call is being recorded. If anyone has any objections, you may disconnect at this time. Thank you, Mr. Gustafson, you may begin your conference.

晚上好。我叫 Michelle，今天我將擔任您的會議主持人。在這個時候，我想歡迎大家參加 DaVita 2021 年第四季度財報電話會議。 （操作員說明）今天的電話正在錄音。如果有人有任何異議，您可以此時斷開連接。謝謝你，Gustafson 先生，你可以開始你的會議了。

Thank you. And welcome, everyone, to our fourth quarter conference call. We appreciate your continued interest in the company. I'm Jim Gustafson, Vice President of Investor Relations. And joining me today are Javier Rodriguez, our CEO; and Joel Ackerman, our CFO. Please note that during this call, we may make forward-looking statements within the meaning of the federal securities laws. All of these statements are subject to known and unknown risks and uncertainties that could cause actual results to differ materially from those described in the forward-looking statements.

謝謝你。歡迎大家參加我們的第四季度電話會議。感謝您對公司的持續關注。我是投資者關係副總裁 Jim Gustafson。今天加入我的還有我們的首席執行官 Javier Rodriguez；和我們的首席財務官 Joel Ackerman。請注意，在本次電話會議期間，我們可能會做出聯邦證券法含義內的前瞻性陳述。所有這些陳述都受到已知和未知的風險和不確定性的影響，這些風險和不確定性可能導致實際結果與前瞻性陳述中描述的結果大不相同。

For further details concerning these risks and uncertainties, please refer to our fourth quarter earnings press release and our SEC filings, including our most recent annual report on Form 10-K and all subsequent quarterly reports on Form 10-Q and any subsequent filings we make with the SEC. Our forward-looking statements are based upon information currently available to us, and we do not intend and undertake no duty to update these statements, except as may be required by law. Additionally, we'd like to remind you that during this call, we will discuss some non-GAAP financial measures. A reconciliation of these non-GAAP measures to the more comparable GAAP financial measures is included in our earnings press release furnished to the SEC and available on our website. I will now turn the call over to Javier Rodriguez.

有關這些風險和不確定性的更多詳細信息，請參閱我們的第四季度收益新聞稿和我們提交給美國證券交易委員會的文件，包括我們最近的 10-K 表格年度報告和所有後續的 10-Q 表格季度報告以及我們提交的任何後續文件與美國證券交易委員會。我們的前瞻性陳述基於我們目前可獲得的信息，除法律要求外，我們不打算也不承擔更新這些陳述的義務。此外，我們想提醒您，在本次電話會議期間，我們將討論一些非公認會計原則的財務措施。這些非公認會計原則措施與更具可比性的公認會計原則財務措施的對賬包含在我們提供給美國證券交易委員會的收益新聞稿中，並可在我們的網站上查閱。我現在將把電話轉給哈維爾羅德里格斯。

Thank you, Jim, and thank you all for joining today's call to discuss our fourth quarter performance and our thoughts on 2022. Each quarter, for the last 2 years, I hope it's the last time that the pandemic is the start of my discussions with you, yet COVID continues to evolve and have a direct impact on our world, especially on our health care system. Similar to what's been seen in the general population, COVID infections within our patient population spiked significantly in late December through January.

謝謝你，吉姆，謝謝大家參加今天的電話會議，討論我們第四季度的表現和我們對 2022 年的想法。在過去的 2 年中，每個季度，我希望這是最後一次大流行是我與你，但 COVID 繼續發展並對我們的世界產生直接影響，尤其是對我們的醫療保健系統。與在普通人群中看到的情況類似，我們患者群體中的 COVID 感染在 12 月下旬至 1 月期間顯著飆升。

At a peak during the second week of January, the new case count was more than twice as high as the peak from last winter. Gratefully, the mortality rate to date with the latest surge has been lower than in prior surges. For the fourth quarter, we estimate that the incremental mortality due to COVID was approximately 1,100 compared to approximately 1,600 during the third quarter. Despite the challenges associated with COVID, I continue to be in awe at the resilience and dedication of our teammates across the DaVita Village. From our direct patient caregivers to our corporate teammates, all are unrelenting in their commitment to provide high-quality care, respond to a quickly changing environment and show incredible compassion and support for our patients.

在 1 月第二週的高峰期，新增病例數是去年冬季高峰期的兩倍多。值得慶幸的是，迄今為止，最近一次激增的死亡率低於之前的激增。對於第四季度，我們估計新冠病毒導致的新增死亡率約為 1,100 人，而第三季度約為 1,600 人。儘管與 COVID 相關的挑戰，我仍然對我們整個 DaVita 村的隊友的韌性和奉獻精神感到敬畏。從我們的直接患者護理人員到我們的公司團隊，所有人都在不懈地致力於提供高質量的護理，應對快速變化的環境，並對我們的患者表現出難以置信的同情和支持。

For the balance of my remarks, I will cover 5 topics: transplant; labor market; our supply chain; Integrated Kidney Care, IKC; and then I will wrap up with our fourth quarter results and our outlook.

為了平衡我的發言，我將討論 5 個主題：移植；勞動力市場；我們的供應鏈；綜合腎臟護理，IKC；然後我將總結我們的第四季度業績和展望。

First, transplant. At our Capital Markets Day presentation in November, I discussed our focus on innovation to improve the patient experience at every single stage along the patient's kidney care journey from delaying the progression of kidney disease to transplant and from acute hospital care to dialysis at home or in-center.

首先，移植。在 11 月的資本市場日演講中，我討論了我們對創新的關注，以改善患者腎臟護理過程中每個階段的患者體驗，從延緩腎臟疾病進展到移植，從急性醫院護理到在家或在醫院進行透析。 -中央。

Transplant is a preferred treatment option for most of our patients and during 2021, despite the challenges posed by the COVID pandemic, we celebrated that nearly 8,000 DaVita patients received a transplant, exceeding our pre-pandemic level. With that said, the transplant process is long and complicated with an average wait time of between 4 and 5 years for an organ. Staying active on the wait list for such a long time is difficult. As a result, patients sometimes miss their window for a transplant. We've been working to address some of these challenges through our industry-leading transplant smart education program and our partnership with the NKF to help more patients find living donors.

移植是我們大多數患者的首選治療選擇，在 2021 年期間，儘管 COVID 大流行帶來了挑戰，但我們慶祝近 8,000 名 DaVita 患者接受了移植，超過了大流行前的水平。話雖如此，移植過程漫長而復雜，器官的平均等待時間在 4 到 5 年之間。在等待名單上保持如此長時間的活躍是很困難的。因此，患者有時會錯過移植窗口。我們一直在努力通過我們行業領先的移植智能教育計劃以及與 NKF 的合作來應對其中的一些挑戰，以幫助更多患者找到活體捐贈者。

In early January, we announced the acquisition of MedSleuth, whose software enables closer partnerships and better coordination between transplant centers, nephrologists and kidney care providers, with all 3 working together to support our patient transplant journey. These efforts can also benefit another meaningful goal of ours, to improve health equity. Many process and outcome results in transplant are quite inequitable, different by race and ethnicity, economic means and insurance coverage. We believe it doesn't have to be this way. Removing barriers to access, making the process as easy as possible and providing strong care coordination and support through the transplant journey can all contribute to making transplants not just more available, but also more equitable for our patients.

1 月初，我們宣布收購 MedSleuth，其軟件使移植中心、腎病專家和腎臟護理提供者之間建立更緊密的合作夥伴關係和更好的協調，所有 3 人共同努力支持我們的患者移植之旅。這些努力也有利於我們另一個有意義的目標，即改善健康公平。移植的許多過程和結果結果是相當不公平的，因種族和民族、經濟手段和保險範圍而異。我們相信它不必是這樣的。消除獲取障礙，使過程盡可能簡單，並在移植過程中提供強有力的護理協調和支持，這些都有助於使移植不僅更容易獲得，而且對我們的患者更公平。

Now let me shift to an update on the labor markets. I've been fortunate enough to be part of DaVita Village for over 20 years and in all that time across my many roles, I've never experienced a labor market as challenging as we face today. To help deal with the challenge, we have provided incremental pay and benefits to help our frontline caregivers during COVID. We've also accelerated wage increases with a particular focus on our teammates in the clinic. As previously communicated, we expect higher-than-usual wage increases in 2022, which will put some additional pressure on our cost structure going forward. We believe this investment in our people will contribute to our ability to track and retain the talent needed to achieve our long-term objective. That said, the labor markets remain highly dynamic and will continue to be a swing factor for the year.

現在讓我談談勞動力市場的最新情況。 20 多年來，我有幸成為 DaVita Village 的一員，在那段時間裡，我擔任了許多職務，從未經歷過像我們今天所面臨的那樣充滿挑戰的勞動力市場。為了幫助應對挑戰，我們提供了增加的薪酬和福利，以幫助我們在 COVID 期間的一線護理人員。我們還加快了工資增長，特別關注診所的隊友。正如之前所傳達的，我們預計 2022 年的工資增長將高於往常，這將對我們未來的成本結構施加一些額外的壓力。我們相信，對員工的這種投資將有助於我們跟踪和留住實現長期目標所需的人才。儘管如此，勞動力市場仍然充滿活力，並將繼續成為今年的搖擺因素。

Over the years, in particular during the pandemic and natural disasters, we have navigated many supply chain challenges. To date, our supply chain has proven very resilient. Currently, we're working through a supply shortage primarily related to dialysate, which is a fluid solution used in hemodialysis to filter toxins and fluid from the blood. The shortage has rippled through the entire kidney care community and as a community, we have once again come together in support of our dialysis patients and thus far, have been able to provide uninterrupted life-sustaining care. We expect that these challenges related to dialysis will remain with us until the second quarter.

多年來，特別是在大流行和自然災害期間，我們克服了許多供應鏈挑戰。迄今為止，我們的供應鏈已被證明非常有彈性。目前，我們正在解決主要與透析液相關的供應短缺問題，透析液是一種用於血液透析的液體溶液，用於過濾血液中的毒素和液體。短缺已經波及整個腎臟護理社區，作為一個社區，我們再次團結起來支持我們的透析患者，到目前為止，我們已經能夠提供不間斷的維持生命的護理。我們預計這些與透析相關的挑戰將持續到第二季度。

Turning to IKC. We now have confirmation on the markets where we will partner with physicians under the federal government's new 5-year CKCC demonstration. These programs added approximately 12,000 ESKD patients and an additional 12,000 CKD patients across 11 value-based programs in different markets. We're engaging with our nephrologist partners to develop personalized care plans for each covered patient and identify opportunities to improve clinical outcomes and lower cost for each patient. Participating in these and other programs will more than double the number of patients we serve in value-based care arrangements.

轉向 IKC。我們現在已經確認我們將在聯邦政府新的 5 年 CKCC 示範下與醫生合作的市場。這些計劃在不同市場的 11 個基於價值的計劃中增加了大約 12,000 名 ESKD 患者和另外 12,000 名 CKD 患者。我們正在與我們的腎臟科醫生合作夥伴合作，為每位承保患者制定個性化護理計劃，並確定改善臨床結果和降低每位患者成本的機會。參與這些計劃和其他計劃將使我們在基於價值的護理安排中服務的患者人數增加一倍以上。

In light of our upfront cost of these programs and the lag of shared savings payment, as we discussed in November, we continue to expect that our operating loss in 2022 in our U.S. ancillary segment will increase by approximately $50 million, although this could increase or decrease depending on the number of new arrangements we enter into during the year. We believe that we are well positioned for the future and in particular, to deliver positive clinical and financial results in our IKC business over the long term.

鑑於我們在這些計劃的前期成本和共享儲蓄支付的滯後，正如我們在 11 月討論的那樣，我們繼續預計 2022 年我們在美國輔助部門的運營虧損將增加約 5000 萬美元，儘管這可能會增加或減少取決於我們在這一年中達成的新安排的數量。我們相信我們為未來做好了準備，特別是在我們的 IKC 業務中長期提供積極的臨床和財務結果。

Now let me finish with fourth quarter results and our updated outlook. Despite the negative impact of the Omicron surge, our fourth quarter results were slightly above the midpoint of our revised guidance. This resulted in a full year adjusted operating income increase of approximately 3% over 2020.

現在讓我結束第四季度的業績和我們更新的展望。儘管 Omicron 激增帶來了負面影響，但我們的第四季度業績仍略高於我們修訂後指引的中點。這導致全年調整後的營業收入比 2020 年增長約 3%。

Adjusted EPS from continuing operations grew by approximately 26% year-over-year, and we generated more than $1.1 billion of free cash flow, which we largely deployed to return capital to our shareholders. For 2022, we expect adjusted operating income guidance of $1.525 billion to $1.675 billion. The midpoint of this guidance range is $35 million below our expectations from Capital Markets Day last November, which is primarily driven by our updated views on COVID and labor costs.

來自持續經營的調整後每股收益同比增長約 26%，我們產生了超過 11 億美元的自由現金流，我們主要將其用於向股東返還資本。對於 2022 年，我們預計調整後的營業收入指引為 15.25 億美元至 16.75 億美元。該指導範圍的中點比我們對去年 11 月資本市場日的預期低 3500 萬美元，這主要是由於我們對 COVID 和勞動力成本的最新看法。

As we said previously, while 2022 will be a transition year due to some near-term investment and challenges that we're facing, we continue to believe that we're well positioned to perform across the kidney care continuum in the years to come. We still believe we can deliver the long-term compounded annual growth of adjusted operating income of 3% to 7% that we discussed at Capital Markets Day. With that, I will turn it over to Joel to discuss our financial performance and outlook in more detail.

正如我們之前所說，雖然由於我們面臨的一些近期投資和挑戰，2022 年將是一個過渡年，但我們仍然相信，我們有能力在未來幾年內全面開展腎臟護理工作。我們仍然相信我們可以實現我們在資本市場日討論的調整後營業收入 3% 至 7% 的長期復合年增長率。有了這個，我將把它交給喬爾來更詳細地討論我們的財務業績和前景。

Thanks, Javier. As Javier mentioned, our fourth quarter results were slightly above the midpoint of our revised guidance. Q4 results included a net COVID headwind of approximately $80 million, an increase relative to the quarterly impact that we experienced in the first 3 quarters of the year, primarily due to the impact of the incremental mortality from the Delta surge in Q3 and some temporary labor cost increases. For the year, we experienced a net COVID headwind of approximately $200 million.

謝謝，哈維爾。正如哈維爾所說，我們第四季度的業績略高於我們修訂後的指引的中點。第 4 季度的結果包括約 8000 萬美元的 COVID 淨逆風，相對於我們在今年前 3 個季度所經歷的季度影響有所增加，主要是由於第 3 季度 Delta 激增和一些臨時勞動力造成的死亡率增加的影響成本增加。這一年，我們經歷了大約 2 億美元的 COVID 淨逆風。

As Javier said, the incremental mortality due to COVID in the fourth quarter was approximately 1,100 compared to approximately 1,600 in Q3. While it's too early to accurately forecast incremental mortality in 2022, given the significant uptick in infections in January, we expect COVID-driven mortality in the first quarter to be at or above what we experienced in Q4.

正如哈維爾所說，第四季度因 COVID 導致的死亡率增加約為 1,100，而第三季度約為 1,600。雖然現在準確預測 2022 年的死亡率增加還為時過早，但鑑於 1 月份感染人數顯著上升，我們預計第一季度 COVID 驅動的死亡率將達到或高於我們在第四季度的經歷。

U.S. dialysis treatments per day were down 135 or 0.1% in Q4 compared to Q3. The primary headwind was the increase in mortality and higher missed treatments as a result of the ongoing COVID pandemic.

與第三季度相比，第四季度美國每天的透析治療量下降了 135 或 0.1%。主要的不利因素是持續的 COVID 大流行導致死亡率增加和錯過治療的情況增加。

U.S. dialysis patient care cost per treatment were up approximately $6 quarter-over-quarter, primarily due to the increased wage rates and health benefit expenses. Our Integrated Kidney Care business saw an increase in its operating loss in Q4, which is due primarily to positive prior period development in our special needs plans recognized in the third quarter and increased costs incurred in Q4, including preparation for new value-based care arrangements effective in 2022.

美國透析患者每次治療的護理成本環比增長約 6 美元，這主要是由於工資率和健康福利費用的增加。我們的綜合腎臟護理業務在第四季度的營業虧損有所增加，這主要是由於我們在第三季度確認的特殊需求計劃的前期積極發展以及第四季度產生的成本增加，包括為新的基於價值的護理安排做準備2022年生效。

Our adjusted effective tax rate attributable to DaVita was 16% for the fourth quarter and approximately 22% for the full year. The adjusted effective tax rate was lower quarter-over-quarter, primarily due to a favorable resolution of a state tax issue during Q4.

我們調整後的歸屬於 DaVita 的有效稅率在第四季度為 16%，全年約為 22%。調整後的有效稅率環比下降，主要是由於第四季度州稅收問題得到了有利的解決。

Finally, in 2021, we repurchased 13.9 million shares of our stock, reducing our shares outstanding by 11.5% during the year. We have repurchased to date an additional 1.4 million shares in 2022.

最後，在 2021 年，我們回購了 1,390 萬股我們的股票，年內流通股減少了 11.5%。迄今為止，我們已在 2022 年額外回購了 140 萬股股票。

Now looking ahead to 2022, our adjusted OI guidance is a range of $1.525 billion to $1.675 billion, and our adjusted EPS guidance is $7.50 to $8.50 per share. The midpoint of the OI guidance range is $35 million below the $1.635 billion that we discussed during our recent Capital Markets Day due to offsetting puts and takes. First, we have a tailwind from both higher final Medicare rate update as well as a partial extension of Medicare sequestration relief. However, this is more than offset by headwinds due to the recent COVID surge as well as incremental wage rate pressure.

現在展望 2022 年，我們調整後的 OI 指導範圍為 15.25 億美元至 16.75 億美元，調整後的每股收益指導為每股 7.50 美元至 8.50 美元。由於抵消了看跌期權，OI 指導範圍的中點比我們在最近的資本市場日討論的 16.35 億美元低 3500 萬美元。首先，我們從更高的最終醫療保險費率更新以及醫療保險隔離減免的部分擴展中獲得了順風。然而，由於最近的 COVID 激增以及工資率壓力的增加，這遠遠抵消了不利因素。

At the midpoint of our guidance range, we have incorporated the following assumptions related to COVID: excess patient mortality due to COVID of 6,000. This, along with our normal growth drivers, would result in a total treatment growth range of approximately 1.5% to 1%. A year-over-year improvement to COVID-driven costs such as PPE, which will be largely offset by the loss of revenue from Medicare sequestration relief beyond Q2 2022. As you would expect, the high and low end of our guidance incorporates a range of COVID scenarios for 2022. There are scenarios that could lead us to performance above or below this range. In addition to COVID, the expected headwinds I talked about on the Q3 earnings call and at our Capital Markets Day remain.

在我們指導範圍的中點，我們納入了以下與 COVID 相關的假設：因 COVID 導致的超額患者死亡率為 6,000。這與我們正常的增長驅動因素一起，將導致總治療增長范圍約為 1.5% 至 1%。 PPE 等由 COVID 驅動的成本同比有所改善，這將在很大程度上被 2022 年第二季度之後醫療保險隔離救濟的收入損失所抵消。如您所料，我們指導的高端和低端包含一個範圍2022 年的 COVID 情景。有些情景可能導致我們的表現高於或低於此範圍。除了 COVID，我在第三季度財報電話會議和資本市場日談到的預期逆風仍然存在。

As a reminder, we expect to incur expenses related to DaVita's portion of the industry effort to counter the expected ballot initiative in California. Our guidance assumes an incremental increase of between $100 million and $125 million in labor costs above a typical year's increase, which is $50 million higher than what we communicated at Capital Markets Day. Third, we anticipate a year-over-year incremental operating loss in the range of $50 million as we continue to invest to grow our IKC business; and fourth, we will also begin to depreciate our new clinical IT platform, which we expect to be approximately $35 million in 2022 and will begin in Q2.

提醒一下，我們預計將產生與 DaVita 為應對加利福尼亞州預期的投票倡議所做的行業努力相關的費用。我們的指導假設勞動力成本比典型年份的增幅增加 1 億至 1.25 億美元，這比我們在資本市場日傳達的信息高出 5000 萬美元。第三，隨著我們繼續投資發展我們的 IKC 業務，我們預計將出現 5000 萬美元的同比增量運營虧損；第四，我們還將開始折舊我們的新臨床 IT 平台，我們預計到 2022 年該平台的價值約為 3500 萬美元，並將於第二季度開始。

A few additional things to help you with our current thinking about 2022. We expect to offset a significant amount of these incremental costs with continuing MA penetration growth above historical levels and strong management of nonlabor patient care costs. We are forecasting our tax rate at 25% to 27% due to nondeductibility of ballot expense. Regarding seasonality, remember that Q1 had seasonally higher payroll taxes and seasonal impact of copayments and deductibles. The vast majority of our ballot related expenses will fall in Q3.

一些額外的事情可以幫助您了解我們目前對 2022 年的看法。我們希望通過 MA 滲透率持續增長超過歷史水平以及對非勞動患者護理成本的強有力管理來抵消這些增量成本的大部分。由於選票費用不可扣除，我們預測我們的稅率為 25% 至 27%。關於季節性，請記住，第一季度的工資稅季節性較高，共付額和免賠額的季節性影響。我們的絕大多數選票相關費用將在第三季度下降。

We have historically experienced higher G&A in Q4. Looking past 2022, we continue to expect compounded annual OI growth relative to 2021 of 3% to 7% and compounded annual adjusted EPS growth relative to 2021 of 8% to 14%. Finally, we expect free cash flow of $850 million to $1.1 billion in 2022. As we communicated at Capital Markets Day, we expect free cash flow to remain above adjusted net income with that difference contracting over time. Operator, please open the call for Q&A.

我們歷來在第四季度經歷了更高的 G&A。展望 2022 年之後，我們繼續預計相對於 2021 年的年均 OI 複合增長率為 3% 至 7%，相對於 2021 年的複合年調整後每股收益增長為 8% 至 14%。最後，我們預計 2022 年的自由現金流為 8.5 億美元至 11 億美元。正如我們在資本市場日所傳達的，我們預計自由現金流將保持在調整後的淨收入之上，並且隨著時間的推移，這種差異會縮小。接線員，請打開電話進行問答。

(Operator Instructions) Sarah James from Barclays.

（操作員說明）來自 Barclays 的 Sarah James。

Yes. So I wanted to get a sense, as we go through Omicron and we think about the waves that are coming ahead, there seems to be more mild outcomes like you mentioned today. And I'm wondering if that's contemplated when we think back to your Capital Markets Day, when you talked about the $160 million to $200 million in OI drag over the next 4 to 7 years from excess mortality, if that contemplates continuing more mild COVID trends as the years go on?

是的。所以我想了解一下，當我們通過 Omicron 並考慮即將到來的浪潮時，似乎會有像你今天提到的更溫和的結果。我想知道，當我們回想起您的資本市場日時，您是否考慮過這一點隨著歲月的流逝？

Well, I'll let Joel talk about the numbers in a second, but let me just start by saying the way we're talking about it internally in the company is that we are no longer going to speculate how this is going to behave because we have been so surprised over time. We all had such hope when the vaccines came out and then when the boosters came out. And of course, it has resulted in a milder hospitalization and mortality. But at the end of the day, I think we can all now accept that no one can speculate where this is going.

好吧，我會讓喬爾稍後談談這些數字，但讓我先說一下我們在公司內部談論它的方式是，我們不再猜測這將如何表現，因為隨著時間的推移，我們感到非常驚訝。當疫苗問世時，當加強劑問世時，我們都抱有這樣的希望。當然，它導致住院和死亡率降低。但歸根結底，我認為我們現在都可以接受沒有人能推測這會發生什麼。

Our hope is that it does become less impactful on our business and eventually, it's something that we can deal within the normal course of business, but that would not be a prudent thing to assume. So why don't you go ahead, Joel, and talk about what we've built into the number.

我們希望它確實對我們的業務影響較小，最終，這是我們可以在正常業務過程中處理的事情，但這並不是一個謹慎的假設。那麼，喬爾，您為什麼不繼續討論我們在數字中建立的內容。

Sure. Thanks, Sarah. So as I think about how COVID impact will play out going forward relative to a wave like Omicron or a wave like Delta, there are a whole bunch of impacts that COVID has across the P&L. And what we've said and remains to be true is that there are a lot of offsets in everything except the excess mortality. And the net impact that we expect from COVID will largely be the net impact of excess mortality. What you see with Omicron is, while, yes, it is a milder disease, because it was so much more transmissible, that it still led to a big wave of excess mortality. We saw that in Q4. We're continuing to see that in Q1. So as I think about different variants and how they might play out going forward. I think net-net, the question is what's the impact on excess mortality?

當然。謝謝，莎拉。因此，當我考慮相對於 Omicron 之類的浪潮或 Delta 之類的浪潮而言，COVID 的影響將如何發揮作用時，COVID 對損益表產生了很多影響。我們已經說過並且仍然正確的是，除了過高的死亡率之外，所有事物都有很多抵消。我們對 COVID 的預期淨影響將主要是死亡率過高的淨影響。你在 Omicron 看到的是，是的，它是一種較溫和的疾病，因為它的傳染性要強得多，它仍然會導致大量的超額死亡率。我們在第四季度看到了這一點。我們將在第一季度繼續看到這一點。因此，當我考慮不同的變體以及它們在未來可能會如何發揮作用時。我認為net-net，問題是對超額死亡率的影響是什麼？

Okay. And can you update us on your conversations with payers if -- when you're talking about future rates, you're building in inflationary factors for wages -- I don't know if it would be for ['24] contracts now?

好的。如果 - 當您談論未來利率時，您正在構建工資的通貨膨脹因素 - 我不知道現在是否適用於 ['24] 合同，您能否更新我們與付款人的對話？

Well, those conversations are playing out in real time, but the reality is that as you know, and we've talked about for some time, our contracts tend to be longer term in nature. And so the bulk of our contracts are not up for renegotiations. So we'll have to, of course, assess how inflation behaves over time when each and every one of those contracts comes up. And so right now, the, let's call it, in what was negotiated previous to seeing this ramp-up in inflation.

嗯，這些對話是實時進行的，但事實是，正如你所知，我們已經討論了一段時間，我們的合同往往是長期的。因此，我們的大部分合同都無法重新談判。因此，當然，當每一份合約出現時，我們必須評估通脹隨時間的變化情況。所以現在，讓我們稱之為，在看到通脹上升之前進行的談判。

And our next caller is Justin Lake from Wolfe Research.

我們的下一位來電者是 Wolfe Research 的 Justin Lake。

So I wanted to go through a few things in detail. First, Joel, you talked about the first quarter being similar to the fourth quarter in terms of the mortality headwind from an OI perspective. Can you walk us through, again -- and I might have this somewhere -- but the OI headwind by quarter, first quarter through fourth quarter in 2001 (sic) [2021]?

所以我想詳細介紹一些事情。首先，喬爾，從 OI 的角度來看，就死亡率逆風而言，第一季度與第四季度相似。您能否再次引導我們通過 - 我可能在某個地方有這個 - 但 OI 在 2001 年（原文如此）[2021] 的第一季度到第四季度的季度逆風？

The OI headwind by quarter, I'm going to do this off the top of my head. It was in the 30s each of the first 2 quarters, so mid-30s, 55 in Q3 and then 80 in Q4. And I'm getting thumbs up in the room, so I got it right.

四分之一的 OI 逆風，我將在我的頭頂上做這件事。前兩個季度都是 30 多歲，所以是 30 多歲，第三季度是 55 歲，第四季度是 80 歲。我在房間裡豎起大拇指，所以我做對了。

Okay. So then 80 is the number for Q1?

好的。那麼 80 是 Q1 的數字嗎？

No, no, Justin, let me clarify before you go. What I said in the script was that the excess mortality in Q1 was going to be at least as large as what we saw in Q4. So that's about the mortality. Remember, in terms of COVID impact, excess mortality has a cumulative effect. So adding another 1,100 deaths or more, you would add that to what we're seeing in the quarter. There are other dynamics, of course, but when you just focus on the excess mortality, which is the dominant dynamic, you'd expect that number to go up a bit.

不，不，賈斯汀，在你走之前讓我澄清一下。我在劇本中所說的是，第一季度的超額死亡率將至少與我們在第四季度看到的一樣大。所以這就是死亡率。請記住，就 COVID 影響而言，超額死亡率具有累積效應。因此，再增加 1,100 人或更多人死亡，您會將其添加到我們在本季度看到的情況中。當然，還有其他動態，但是當您只關注占主導地位的超額死亡率時，您會期望這個數字會上升一點。

Got it. So 50 to 80 might be 80 to 110, something like that, given its similar trajectory incrementally? Is that a way to think about it?

知道了。所以 50 到 80 可能是 80 到 110，類似的，考慮到其相似的軌跡增量？這是一種思考方式嗎？

That sounds a bit high. And I think that's really a function of 2 things. There was -- there were a significant number of missed treatments in Q4, which is a temporary negative impact of COVID, that would -- we would expect that to go down. And second, there were some nonrecurring labor components to the COVID impact in Q4 as well.

這聽起來有點高。我認為這實際上是兩件事的函數。第四季度有大量錯過的治療，這是 COVID 的暫時負面影響，我們預計這種情況會下降。其次，第四季度的 COVID 影響也有一些非經常性勞動力因素。

Got it. Is there -- I apologize if you said this, but is there a number like $200 million in 2021? Is there a number that you gave for 2022? Do you think that's embedded in guidance?

知道了。有沒有 - 如果你這麼說，我很抱歉，但是 2021 年有 2 億美元這樣的數字嗎？你有沒有給 2022 年的數字？您認為這包含在指導中嗎？

It's embedded in guidance. I think as we think about COVID impact, we've spent the last 7 quarters calling it out on a cumulative basis. As we get further and further away from the beginning of COVID, it gets harder and harder to estimate what the cumulative impact is. The baseline is -- we're so far removed from the baseline that it's hard to talk about the cumulative impact. So we're thinking about what the COVID that's baked into the numbers as effectively the new normal from which we're going to go forward. We'll continue to talk about the impact we see quarter-over-quarter, but I think we're going to move away from talking about it as a cumulative number.

它嵌入在指導中。我認為，當我們考慮 COVID 影響時，我們在過去 7 個季度中一直在累積地指出它。隨著我們離 COVID 的開始越來越遠，越來越難以估計累積的影響是什麼。基線是——我們離基線太遠了，很難談論累積影響。因此，我們正在考慮將哪些新冠病毒納入數字中，以及我們將繼續前進的新常態。我們將繼續討論我們看到的季度環比影響，但我認為我們將不再將其作為累積數字來討論。

Okay. And then you talked about Medicare Advantage penetration being an offset here. Can you tell us what that was at year-end? And where you are kind of after open enrollment if you don't mind?

好的。然後你談到 Medicare Advantage 的滲透在這裡是一種抵消。你能告訴我們年底那是什麼嗎？如果你不介意的話，在公開招生之後你在哪裡？

Yes. At the end of the year, which is the most recent number I have, Justin, we were at 42.3% on MA. And I think that's the latest one we want to disclose.

是的。今年年底，這是我掌握的最新數據，賈斯汀，我們在 MA 上的比率為 42.3%。我認為這是我們想要披露的最新消息。

Yes. If we think about it for the year, I would say we would expect growth to continue to be strong, but not as strong as we saw in '21.

是的。如果我們考慮今年的情況，我會說我們預計增長將繼續強勁，但不如我們在 21 年看到的那麼強勁。

Okay. Great. And then last question just on the dialysate issue. Can you tell us -- you talked about that, and I've -- there's been some discussion of this in the industry. Fresenius apparently has an issue. Can you confirm that? Like where the issue is coming from? And you said it will continue to at least the second quarter or you think for the second quarter? Is there any visibility on this improving?

好的。偉大的。然後是關於透析液問題的最後一個問題。你能告訴我們 - 你談到了這個，我已經 - 業內對此進行了一些討論。費森尤斯顯然有問題。你能證實嗎？比如問題出在哪裡？你說它至少會持續到第二季度，還是你認為第二季度？這種改善有什麼可見性嗎？

Well, yes, the community -- this is a national issue for all providers. So there has been a shortage in supply. You can trace it back, of course, to the chain supply issues across the country. And the distribution centers and the labor issues. So it's a cumulative of all of them. So there was labor transportation, everything all came together as it has happened in so many other places. What we did as a community is, of course, the first thing is to get the clinical leadership to make sure that we were doing safe dialysis, then we started to basically titrate so we would use less of the product.

嗯，是的，社區——這是所有提供商的全國性問題。所以出現了供不應求的局面。當然，你可以追溯到全國的供應鏈問題。還有配送中心和勞工問題。所以它是所有這些的累積。所以有勞動力運輸，一切都聚集在一起，就像在許多其他地方發生的那樣。當然，我們作為一個社區所做的第一件事是讓臨床領導確保我們進行安全的透析，然後我們開始基本滴定，以便我們使用更少的產品。

And then we made sure that everybody understood what kind of inventory was at each location so that we would not have anyone stack -- or stock inventory. So the entire community did that. The visibility that we have right now is that, again, that will play out, and we will be back to normal sometime in Q2 is what we're being told. And so we will continue in the state we're all, if you will, in a much lower inventory level. Does that make -- did I answer your question, Justin?

然後我們確保每個人都了解每個位置的庫存類型，這樣我們就不會有任何人堆積——或庫存庫存。所以整個社區都這樣做了。我們現在所擁有的可見性是，這將再次發揮作用，我們將在第二季度的某個時候恢復正常，這就是我們被告知的情況。因此，如果您願意，我們將繼續處於我們所有人的狀態，庫存水平要低得多。這是否讓我回答了你的問題，賈斯汀？

Yes. I appreciate it.

是的。我很感激。

I don't know if it was entirely clear as to this whole notion of why we don't want to go back to the baseline because it's so far. So just to put a finger on something that we are all experiencing is travel and entertainment, which we -- of course, at one quarter over another, you could say we used to have a run rate. As the world actually changed, in travel and entertainment it's going to be completely different. Then we had benefits, which we told you we had a run rate, but the benefits have changed in the run rate. So that's why it starts to get a little harder to go to that. And as Joel said, we want to go now into sort of, let's call it, the new normal and go off of that. And so hopefully, that makes sense to you.

我不知道我們是否完全清楚為什麼我們不想回到基線，因為它到目前為止。因此，只需指出我們都在經歷的事情就是旅行和娛樂，我們 - 當然，在四分之一以上，你可以說我們曾經有一個運行率。隨著世界的實際變化，在旅行和娛樂方面將完全不同。然後我們有福利，我們告訴你我們有一個運行率，但是運行率的好處已經改變了。所以這就是為什麼它開始變得有點困難。正如喬爾所說，我們現在想進入某種，讓我們稱之為新常態，然後擺脫它。所以希望這對你有意義。

Pito Chickering from Deutsche Bank.

德意志銀行的 Pito Chickering。

Going down into the OI guidance for 2022, it's sort of down $35 million. Did I hear you right that there's an additional $50 million of labor costs versus the Analyst Day? And then you obviously have the more COVID excess mortality than you had expected, you now assume 6,000 excess mortality deaths in 2022. It seems like a lot of headwinds versus your guidance of going down $35 million. So I just wanted to understand what were the tailwinds versus your previous guidance?

根據 2022 年的 OI 指導，它減少了 3500 萬美元。我沒聽錯，與分析師日相比，人工成本增加了 5000 萬美元？然後，您的 COVID 超額死亡率顯然比您預期的要多，您現在假設 2022 年有 6,000 人超額死亡率死亡。與您減少 3500 萬美元的指導相比，這似乎是很多不利因素。所以我只是想了解與您之前的指導相比，順風是什麼？

Yes. Pito, I'd point to 2 tailwinds. One is the final Medicare fee-for-service rate came in at 1.9%, which was above our estimate. And the second is we got partial sequestration relief for the year, which is about $25 million. So those 2 offset those, and you wind up with a net $35 million decline.

是的。 Pito，我會指出 2 個順風。一是最終的醫療保險服務費率為 1.9%，高於我們的估計。第二個是我們今年獲得了部分封存減免，約為 2500 萬美元。所以這兩個抵消了那些，你最終淨減少了 3500 萬美元。

Okay. And on the excess mortality, I understand that it's impossible to forecast it at this point with the 1,100 for the first quarter. It's a little unclear sort of what the incidence rate is for new patients entering dialysis. So any chance you can give us sort of the color of how many patients you guys had at the end of the third quarter? How many do you have at the end of fourth quarter? And where that's tracking sort of at this point in the first quarter?

好的。關於超額死亡率，我知道目前無法預測第一季度的 1,100 人。進入透析的新患者的發病率有點不清楚。所以你有沒有機會告訴我們你們在第三季度末有多少病人？第四季度末你有多少？在第一季度的這一點上，這在哪裡進行跟踪？

I'm not sure I understand your question, Pito.

我不確定我是否理解你的問題，Pito。

Yes. So you've given us the excess mortality for death for the fourth quarter and the first quarter. And I guess, on the other side of the equation, you have (inaudible) of new patients entering into dialysis. So just curious if you can give us sort of what -- how many patients you had at the end of the third quarter, how many you had at the end of fourth quarter? Or where that is at this point today in the first quarter?

是的。所以你給了我們第四季度和第一季度的超額死亡死亡率。我猜，在等式的另一邊，你有（聽不清）新患者進入透析。所以只是好奇你能否給我們一些信息——第三季度末你有多少病人，第四季度末你有多少病人？或者今天第一季度的這個時候在哪裡？

Yes. So the patient count is relatively flat. In terms of the underlying drivers that drive the new to dialysis admits, we really haven't seen any changes there. It continues at the pattern that we saw pre-COVID. And there are really only 2 dynamics, if you were looking at treatment count or treatment volumes or treatments per day between Q3 and the end of the year. And that's, one, the continued excess mortality that we talked about; and the second is the dynamic of missed treatments. So the -- if you're asking about the pipeline of new to dialysis patients, that remains quite healthy.

是的。所以患者人數相對平穩。就推動透析新人承認的潛在驅動因素而言，我們確實沒有看到任何變化。它繼續我們在 COVID 之前看到的模式。如果您查看第三季度到年底之間每天的治療數量或治療量或治療，實際上只有兩種動態。這就是我們談到的持續超額死亡率；二是漏診動態。所以——如果你問的是新的透析患者的管道，那仍然很健康。

Okay. And then from a modeling perspective, as we think about first quarter sequential treatment versus the fourth quarter, we obviously had the excess mortality, sort of the time lag between the different quarters and then the lost treatments that we had during the fourth quarter due to patients that were in the hospitals. Should we be modeling first quarter down a little bit versus fourth quarter or relatively flat sequentially?

好的。然後從建模的角度來看，當我們考慮第一季度與第四季度的連續治療時，我們顯然有過高的死亡率，不同季度之間的時間滯後，然後是第四季度我們因治療而失去的治療那些在醫院裡的病人。我們應該將第一季度與第四季度相比略微下降還是按順序相對平穩？

It will depend a lot on mistreatment rates. I'd say for the -- actually, there's one other dynamic. We did make an acquisition in Q4, and that was almost 1,000 patients, about 750 patients. So that adds to the dynamic, and that will help Q1 as well. But I'd say for the course of the full year, we are -- based on the COVID numbers that we've built into our forecast, we're thinking of treatment volume growing somewhere between 0.5% and 1% for the year. Obviously, as COVID plays out, that number could vary.

這在很大程度上取決於虐待率。我會說 - 實際上，還有另一種動態。我們確實在第四季度進行了收購，那是近 1,000 名患者，大約 750 名患者。所以這增加了動態，這也將有助於第一季度。但我想說，在全年的過程中，我們 - 根據我們在預測中建立的 COVID 數字，我們認為今年的治療量將增長 0.5% 到 1% 之間。顯然，隨著 COVID 的出現，這個數字可能會有所不同。

Okay. And then on the IKC. I think at the Analyst Day, you guided to sort of $50 million to $75 million of incremental costs in 2022. In the script, I think you said $50 million. I wanted to see if the incremental costs for IKC -- have changed versus what you told us at the Analyst Day?

好的。然後在 IKC 上。我認為在分析師日，您指導在 2022 年增加 5000 萬至 7500 萬美元的成本。在腳本中，我認為您說的是 5000 萬美元。我想看看 IKC 的增量成本與您在分析師日告訴我們的相比是否發生了變化？

Yes. I think the number hasn't changed, Pito. So it is the $50 million, just to clarify, incremental $50 million.

是的。我認為數字沒有改變，皮托。所以這是 5000 萬美元，只是為了澄清，增加的 5000 萬美元。

Perfect. And then so one more question for IKC. Looking at the class of patients that you guys enrolled into the first quarter of 2021 in terms of how those losses were in the first quarter when you first got them versus the end of the fourth quarter of 2021. Any clarity on sort of how that class of patients or how those losses progress throughout the year?

完美的。然後是 IKC 的另一個問題。看看你們在 2021 年第一季度登記的患者類別，看看第一季度與 2021 年第四季度末相比，這些損失在第一季度的情況如何。關於該類別如何的任何澄清患者或這些損失如何在全年進展？

Yes. Not yet, Pito. Remember, in the first year, we generally drive no revenue. So it will really be sometime in 2022, where we'll start to get -- see that playing through in the financials.

是的。還沒有，皮托。請記住，在第一年，我們通常沒有收入。所以它真的會在 2022 年的某個時候，我們將開始得到 - 看到它在財務方面發揮作用。

Okay. And then 2 more super quick ones here. What were your home treatments at the end of the fourth quarter? How should that progress through 2022?

好的。然後這裡還有 2 個超級快速的。第四季度末你的家庭治療是什麼？到 2022 年應該如何發展？

Yes. The home penetration rate was in the low 15% range. Home grew about 3% in the year versus in-center, which shrunk 2%. So our continued path to grow home and be a leader in that modality continues strong. We're not guiding specifically on that number for next year.

是的。家庭滲透率處於 15% 的低位。住宅在今年增長了約 3%，而中心則縮小了 2%。因此，我們在本土成長並成為該模式領導者的持續道路繼續強勁。我們沒有具體指導明年的這個數字。

Okay. And then to Justin's question on the dialysate supply shortage. Is there any inflationary cost pressures if you have to hit a spot market to get the dialysate required or are those under those contracts?

好的。然後是賈斯汀關於透析液供應短缺的問題。如果您必須進入現貨市場才能獲得所需的透析液，或者是否符合這些合同，是否存在任何通脹成本壓力？

Yes. Thanks, Pito. On the dialysate in particular, it is contracted. So no, the answer to that one.

是的。謝謝，皮托。特別是在透析液上，它會收縮。所以不，那個答案。

(Operator Instructions) Kevin Fischbeck from Bank of America.

（操作員說明）美國銀行的 Kevin Fischbeck。

All right. Great. I guess, not 100% clear to me what you guys are signaling about the 2023 outlook. I know still far out, but you gave us some comments last quarter about what 2023 would look like. And it seems like some of the headwinds here might persist into 2023 as far as maybe higher labor costs or mortality being a little bit higher from a starting point perspective, some of the tailwinds, like sequestration delay would not. But at the same time, you're also kind of saying your growth rate off of 2021 hasn't changed. In fact, 2021 is a little higher, which would point to a little bit higher 2023 number. I'm just trying to think directionally, how should we think about 2023 versus your prior comments?

好的。偉大的。我想，我不是 100% 清楚你們對 2023 年前景的看法。我知道還很遙遠，但你在上個季度給了我們一些關於 2023 年會是什麼樣子的評論。似乎這裡的一些不利因素可能會持續到 2023 年，因為從起點的角度來看，勞動力成本或死亡率可能會更高一些，而一些不利因素，比如隔離延遲則不會。但與此同時，你也有點說你從 2021 年開始的增長率沒有改變。事實上，2021 年要高一點，這將指向 2023 年的數字高一點。我只是想有方向地思考，與您之前的評論相比，我們應該如何看待 2023 年？

Yes. So I would say the following. First, your pointing out that labor and COVID remain big uncertainties through 2022 and potentially 2023 is spot on. That said, the uptick that we've talked about in 2023 at Capital Markets Day remains to be something -- remains something that we've got a lot of confidence in. And if I had to bucket them, I'd say the easier things that we can anticipate driving in '23 over '22, one would be the ballot initiative going away, right? We don't have those in odd years.

是的。所以我會說以下。首先，您指出到 2022 年勞動力和 COVID 仍然存在很大的不確定性，並且可能在 2023 年成為現實。話雖如此，我們在 2023 年資本市場日談到的上漲仍然是一些東西——仍然是我們非常有信心的東西。如果我不得不放棄它們，我會說更容易我們可以預期在 23 年超過 22 年駕駛的事情，一個是投票倡議會消失，對吧？我們在奇數年沒有這些。

Second would be IKC. We'll start seeing revenue in 2023 from the big cohort of patients that are being added in 2022. Third, are a number of cost initiatives that we have -- that we are implementing across the P&L. And so those are the, I'd say, the ones that we've got a lot of visibility on. The one we have less visibility on is the COVID unwind. We have -- we continue to believe that as COVID moves into the background in the future, that will be a tailwind for us. It will be a tailwind for us on certain cost items, but most importantly, it will be a tailwind for us on patient growth. So our views on those have not changed. And if I had to put a number on those, I think you could add those up and easily get to a $200 million opportunity that we're going after. And that would be over and above the normal growth we would expect in a typical year.

其次是 IKC。我們將在 2023 年開始從 2022 年增加的大量患者中看到收入。第三，是我們擁有的一些成本計劃——我們正在整個損益表中實施。因此，我想說的是，我們有很多知名度。我們不太了解的是 COVID 放鬆。我們有——我們仍然相信，隨著未來 COVID 進入後台，這對我們來說將是順風。這將是我們在某些成本項目上的順風，但最重要的是，這將是我們在患者增長方面的順風。所以我們對這些的看法沒有改變。如果我必須在這些上面加上一個數字，我認為你可以將這些加起來，輕鬆獲得我們正在追求的 2 億美元的機會。這將超過我們在典型年份中預期的正常增長。

But your current outlook for COVID mortality feels a little bit higher. So I would think that would kind of maybe delay kind of that reutilization of that $200 million, which might make how much you recapture in 2023 less than what you would have thought a few months ago?

但是，您目前對 COVID 死亡率的前景感覺要高一些。因此，我認為這可能會延遲對那 2 億美元的再利用，這可能會使您在 2023 年重新獲得的資金少於幾個月前的預期？

It will depend on the timing, and we don't profess to have a crystal ball about COVID. We wanted to be crystal clear about what we built into our forecast. Obviously, it could be better, it could be worse. Depending on how the timing plays out in 2022, there are different scenarios about what this number could look like in 2023.

這將取決於時間，我們並不聲稱對 COVID 有一個水晶球。我們希望清楚地了解我們在預測中構建的內容。顯然，它可能會更好，也可能會更糟。根據 2022 年的時間安排，這個數字在 2023 年可能會出現不同的情況。

Okay. That's fair enough. And then I guess in the quarter, it looks like you closed 30 centers, which I think is like as many as you've ever closed in a year like over the last decade plus that I've been covering DaVita. So I want to understand what was driving those closures in Q4 -- at least the year number's twice what you've ever done in a year before.

好的。這很公平。然後我想在本季度，看起來你關閉了 30 個中心，我認為這就像你在過去十年中關閉的一年一樣多，而且我一直在報導 DaVita。所以我想了解是什麼推動了第四季度的這些關閉——至少是你一年前做過的一年的兩倍。

Yes. Thanks for the question. It is a little higher than normal, although we always have some center closures and consolidations, et cetera. I think the best way to think of footprint is we have 3 lenses. The very first one is, of course, access to patients to ensure the patients are safe and have the right access; the second lens would be what is the mix of home and in-center and that changes over time; the third is utilization, which is -- we've had, of course, because of this excess mortality, we've had some utilization decrease; and then the last is sort of you think of the local market dynamics.

是的。謝謝你的問題。雖然我們總是有一些中心關閉和整合等，但它比正常情況要高一點。我認為考慮足蹟的最佳方式是我們有 3 個鏡頭。第一個當然是接觸患者，以確保患者安全並獲得正確的接觸；第二個鏡頭將是家庭和中心的混合，並且隨著時間的推移而變化；第三個是利用率，當然，由於死亡率過高，我們的利用率有所下降；最後一點是你對當地市場動態的看法。

And so we want to be really careful and we want to be very thoughtful. But if you were going to say, what's the net takeaway, is that we continue to think that we will build less de novos and more home centers over time.

所以我們想要非常小心，我們想要非常周到。但是，如果您要說，淨外賣是什麼，我們繼續認為隨著時間的推移，我們將建立更少的從頭和更多的家庭中心。

Okay. But I guess -- I mean if the shift -- if you're talking about recapturing the COVID headwind, then your low volume this year would say that those sites should still stay open because they're going to recapture that [line over.] Is it really more of that shift to home is the biggest driver to that? Or is it (inaudible)

好的。但我想——我的意思是如果轉變——如果你在談論重新捕捉 COVID 逆風，那麼你今年的低銷量會說這些網站仍然應該保持開放，因為它們將重新奪回那個 [line over。 ] 搬家真的是最大的驅動力嗎？或者是（聽不清）

No, if you look at our utilization over time, we actually started to grow less pre-COVID than we had COVID. So the compounding of that actually has our footprint having less utilization than we've had historically. And so we're just -- and then you add the dynamic of home growing. And so that's what we're doing. We just want to make sure that we have the right modality in the right market. And so we continue to assess that at every market.

不，如果你看一下我們隨著時間的推移的利用率，我們實際上開始比 COVID 之前的增長更少。因此，這種情況的複合實際上使我們的足跡利用率低於歷史上的利用率。所以我們只是 - 然後你添加了家庭成長的動力。這就是我們正在做的事情。我們只是想確保我們在正確的市場中擁有正確的模式。因此，我們繼續在每個市場進行評估。

Okay. And then just maybe last question. The higher labor cost that you're building in now versus the previous guidance, are these underlying wage increases that kind of increased the base going forward? Or is there some component of that -- I think last time you talked about increased training and things like that. Is there some of that would go away? Or is this $50 million kind of added to the base going forward?

好的。然後也許是最後一個問題。與之前的指導相比，您現在建立的勞動力成本較高，這些潛在的工資增長是否會增加未來的基數？或者是否有其中的一些組成部分——我想你上次談到增加培訓之類的事情。有一些會消失嗎？或者這 5000 萬美元是否會在未來基礎上增加？

Yes. It's interesting. We were just talking about that because, of course, there has been a bit more turnover, and we're working on how to get training to be a bit more efficient and effective. But the bulk of the number will stick with us.

是的。這真有趣。我們只是在談論這個，因為當然，營業額增加了一些，我們正在研究如何讓訓練變得更有效率和效果。但大部分數字會留在我們身邊。

Gary Taylor from Cowen.

來自考恩的加里·泰勒。

A couple of small questions and then a larger one. The comment about the increase in commercial mix sequentially that's playing out. Is that still just the mortality impact, the primary driver there?

幾個小問題，然後是一個更大的問題。關於商業組合按順序增加的評論正在上演。這仍然只是死亡率的影響，是主要的驅動因素嗎？

Yes. And the consistent thing that the patients are really valuing choice of keeping their commercial insurance, it has really demonstrated through the pandemic, resilience and value of the patient wanting to keep their insurance and then the excess mortality coming, as you said, from a bigger number of Medicare patients.

是的。患者真正重視保留商業保險的選擇始終如一，這已經通過大流行、復原力和患者想要保留保險的價值以及隨後的超額死亡率來證明，正如你所說，來自更大的醫保患者人數。

And then the mention in the release about part of the revenue sequential growth was flu vaccine. I know that's a seasonal thing for you guys. Is that -- how material is that? And is there any larger pickup in that this year that's material in any way, just given (inaudible)

然後在發布中提到的部分收入環比增長是流感疫苗。我知道這對你們來說是季節性的。那是——那有多重要？今年是否有任何更大的回升，無論如何都是重要的，剛剛給出（聽不清）

Yes. It was immaterial -- sorry, I thought you were done, Gary. The number is immaterial and it's actually offset on the cost line item. So it's basically a service that we offer to our patients because it's good and convenient for them as opposed to thinking of it as an economic one.

是的。這無關緊要——對不起，我以為你已經完成了，加里。這個數字並不重要，它實際上在成本行項目上被抵消了。因此，這基本上是我們為患者提供的一項服務，因為它對他們來說既好又方便，而不是將其視為經濟服務。

Yes. Last question, I just want to get your view. I haven't heard you guys talk about the Supreme Court case on ERISA plans that have made changes to dialysis payments and benefit structure, I think the oral arguments are coming up on March 1 and presumably a ruling this summer. I think I understand your view would be that it's discriminatory practices, and I guess that's what the court is going to decide. But what do you think the implications are if the Sixth Circuit is overturned and the Ninth Circuit sort of upheld and it gives ERISA plans some leeway I guess, to pursue cost containment strategies for lack of a better word?

是的。最後一個問題，我只是想听聽你的看法。我還沒有聽到你們談論最高法院關於 ERISA 計劃的案件，該計劃已經改變了透析付款和福利結構，我認為口頭辯論將於 3 月 1 日提出，並且可能會在今年夏天作出裁決。我想我理解你的觀點是歧視性做法，我想這就是法院要決定的。但是你認為如果第六巡迴賽被推翻並且第九巡迴賽得到支持並且我猜它給 ERISA 計劃一些迴旋餘地，以追求成本控制策略，因為缺乏更好的詞，會產生什麼影響？

Yes. Thanks for the question. And I worry it's a complicated one if people haven't been tracking the details, so I'll probably just -- let me pull up a little and explain the case. And so at the heart of the issue is Medicare in the Secondary Payer Act, commonly referred to as MSPA, protect patients from direct and indirect discrimination. So that's really kind of the question. And so more narrowly, is there a distinction between dialysis patients or what's in the statute, which is ESRD patients.

是的。謝謝你的問題。我擔心如果人們沒有跟踪細節，這會很複雜，所以我可能會——讓我稍微拉一下，解釋一下這個案子。因此，問題的核心是第二支付者法案中的醫療保險，通常稱為 MSPA，保護患者免受直接和間接歧視。所以這真的是一個問題。更嚴格地說，透析患者或法規中的內容是否存在區別，即 ESRD 患者。

So that might sound like word splitting, but it's really at the heart of it. And so you say, how did we get here? Could you explain how we got here. And it's basically, as you know, there's small employer groups guided by third-party benefit design that limited benefits of dialysis patients and in essence, de facto pushed them to Medicare. And then that went into certain courts. And then as you said, the Sixth and the Ninth Circuit split ruling and then Supreme Court said they wanted to take it up.

所以這聽起來像是分詞，但它確實是它的核心。所以你說，我們是怎麼到這裡的？你能解釋一下我們是怎麼到這裡的嗎？正如你所知，基本上是由第三方福利設計指導的小型雇主團體限制了透析患者的福利，實際上將他們推向了醫療保險。然後進入某些法庭。然後正如你所說，第六巡迴法院和第九巡迴法院的裁決分開，然後最高法院說他們想接受它。

We won't speculate on the ruling, but you're basically asking, okay, what happens if you do lose. Of course, I put -- get my energy from winning. But if you ask me what happens if we do lose, there are several scenarios. As you know, the Supreme Court is highly nuanced. And so it could be a narrow loss, which may not have any impact, and they might provide a lot of clarity. And then you might say, okay, well, what happens if it's a broader loss? The first thing is you probably want to quantify it, and I don't think I can help you there because it is impossible to forecast what would plans do and how would they consider it in the light of the reputation risk and in the fact that there's all kinds of legal requirements under the ADA now.

我們不會推測裁決，但你基本上是在問，好吧，如果你輸了會發生什麼。當然，我說——從獲勝中獲取能量。但是如果你問我如果我們輸了會發生什麼，有幾種情況。如您所知，最高法院是非常細緻入微的。所以這可能是一個很小的損失，可能沒有任何影響，而且它們可能會提供很多清晰度。然後你可能會說，好吧，好吧，如果這是更廣泛的損失會發生什麼？第一件事是您可能想量化它，我認為我無法幫助您，因為無法預測計劃會做什麼以及他們將如何考慮聲譽風險以及事實上現在 ADA 下有各種法律要求。

And in addition, we have discrimination provision in the ACA. So it might be that we're arguing 1 pillar, but the other 2 pillars are so strong that it actually has no impact. But we don't know. We will continue to advocate hard and if we lose, we will continue to seek clarity in a legislative way. But the most important thing for us is that our patients are protected so that they have the right to get care just like in any other disease. And so we are going to be really, really focused on it and be aggressive both legally and legislatively because we believe that our patients deserve it. So I said a lot. So let me -- because it's such an important thing. So any follow-up questions?

此外，我們在 ACA 中有歧視條款。因此，我們可能在爭論 1 個支柱，但其他 2 個支柱非常強大，實際上沒有任何影響。但我們不知道。我們將繼續努力倡導，如果我們輸了，我們將繼續以立法的方式尋求澄清。但對我們而言，最重要的是我們的患者受到保護，因此他們有權像對待任何其他疾病一樣獲得護理。因此，我們將真正、真正地專注於它，並在法律和立法上積極進取，因為我們相信我們的患者應得的。所以我說了很多。所以讓我 - 因為這是一件非常重要的事情。那麼有什麼後續問題嗎？

No, I think -- I mean, obviously, investors want -- are trying to think about how to quantify the possibility of a loss, and I'm struggling with that as well. And tend to agree it'd be a big step to think a lot of plans would significantly change behavior. So I think for now, I just appreciate what you laid out there.

不，我認為 - 我的意思是，顯然，投資者想要 - 正在嘗試考慮如何量化損失的可能性，我也在為此苦苦掙扎。並且傾向於同意認為許多計劃會顯著改變行為將是一大步。所以我想現在，我只是欣賞你在那里布置的東西。

Thank you.

謝謝你。

Lisa Clive from Bernstein.

來自伯恩斯坦的麗莎克萊夫。

Two questions. Just number one, could you give us the percentage of your patients -- of your Medicare eligible patients that are in MA now? I think the last number you gave us was around 41% around your Q3 results.

兩個問題。第一，你能告訴我們你的病人的百分比——你現在在 MA 的符合醫療保險條件的病人的百分比嗎？我認為您給我們的最後一個數字是您第三季度結果的 41% 左右。

And then number two, just on the labor costs, is it wage inflation mainly? Or is it also the staffing shortages? Or if you could just give us an idea of how that splits out?

然後第二個，就勞動力成本而言，主要是工資上漲嗎？還是人員短缺？或者如果你能給我們一個關於它是如何分裂的想法？

Yes. So quickly on the MA, it's a little north of 42% of our total Medicare patients are on MA. On the labor side, it's generally wage inflation that we're talking about.

是的。在 MA 上如此之快，它比我們所有醫療保險患者中的 42% 都稍微偏北一點。在勞動力方面，我們談論的通常是工資通脹。

Okay. So you don't have a lot of vacancies or needing to use agency staff, that sort of thing?

好的。所以你沒有很多空缺或需要使用代理人員之類的東西？

No, we do. But we're pretty good at that being kind of short term. So I think we're answering to be as helpful as possible as to you saying, is this a good stepping stone to go into the future. And the fact is that it is, even though we're struggling. One of the things that we do and when we have labor shortages is sometimes leadership, which is fixed salary, will step into the floor because we have a lot of our facility administrators that are nurses. That's not something we want to do for a long period of time. It's unsustainable, but that's very helpful when you're short-staffed. So there's a lot of dynamics, as you know, and interplay when you're looking at staffing. But I think if you're going to say what's the bulk of that number, it is inflationary in the wages.

不，我們有。但我們很擅長這種短期的。所以我認為我們的回答盡可能像你所說的那樣有幫助，這是進入未來的一個很好的墊腳石。事實是，即使我們在掙扎，也是如此。當我們遇到勞動力短缺時，我們會做的一件事是有時領導層，即固定工資，會介入，因為我們有很多設施管理員是護士。這不是我們長期想做的事情。這是不可持續的，但是當您人手不足時，這非常有幫助。因此，正如您所知，當您查看人員配備時，存在很多動態和相互作用。但我認為，如果你要說這個數字的大部分是什麼，那就是工資的通貨膨脹。

Okay. Great. And one last question, just on home dialysis. How has the growth rate changed, if at all, over the last year or 2? I guess there may be more interest in it, but are you also having more sort of bottlenecks around being able to train patients because of stretched staff? That would be helpful to understand how that's going.

好的。偉大的。最後一個問題，只是關於家庭透析。在過去的一年或兩年中，增長率如何變化（如果有的話）？我想可能會有更多的興趣，但你是否也因為工作人員緊張而在培訓患者方面遇到了更多的瓶頸？這將有助於了解情況如何。

Yes. I think COVID, of course, creates some air pockets as it relates to growth. And we've talked a lot about during the call, excess mortality. So if you were going to just step back and look at the mix overall in the last couple of years, we've basically gone from a little over 12% to 15% of our patients being in some kind of a home modality. So the modality was driving double-digit growth for quite some time and then COVID occurs. And so what happened during the year is we were between 2% and 3% growth during the year. But then again, our in-center shrunk. And so the modality is still thriving, people are still picking it. We continue to create the best home suite out there, surrounding patients with all kinds of things so that they can get on to the modality.

是的。當然，我認為 COVID 在與增長相關時會產生一些氣穴。我們在電話會議中談了很多關於死亡率過高的問題。因此，如果您打算退後一步，看看過去幾年的整體情況，我們基本上已經從略高於 12% 的患者增加到 15% 的患者處於某種家庭模式。因此，這種模式在相當長的一段時間內推動了兩位數的增長，然後 COVID 出現了。因此，這一年發生的事情是我們在這一年中增長了 2% 到 3%。但是話又說回來，我們的中心縮小了。因此，這種方式仍在蓬勃發展，人們仍在挑選它。我們繼續創造最好的家庭套房，用各種各樣的東西圍繞著病人，這樣他們就可以開始使用這種方式。

As it relates to training, of course, COVID has added some challenges and then also COVID has had some tailwinds in the sense that people say, gosh, if this happens again, maybe I want to dialyze at home. So it is not an easy answer, but hopefully, those trends give you a sense of the appetite for the modality.

當然，由於它與培訓有關，COVID 增加了一些挑戰，然後 COVID 也有一些順風，人們說，天哪，如果這種情況再次發生，也許我想在家透析。所以這不是一個簡單的答案，但希望這些趨勢能讓你對這種方式的胃口有所了解。

Pito Chickering from Deutsche Bank.

德意志銀行的 Pito Chickering。

Thank you for taking my last follow-up here. Just a really quick question here. And I understand it's impossible to model excess COVID mortality from COVID just because these waves are impossible to predict. But could you give us some sensitivities around operating income impact if excess mortality is 3,000 versus 6,000 you guys were assuming?

感謝您在這裡接受我的最後一次跟進。這裡只是一個非常快速的問題。而且我知道，僅僅因為這些波無法預測，就無法模擬 COVID 導致的過度 COVID 死亡率。但是，如果超額死亡率為 3,000 與你們假設的 6,000 相比，您能否給我們一些關於營業收入影響的敏感性？

I think the rough math on that would be about a $30 million Delta.

我認為粗略的計算將是大約 3000 萬美元的 Delta。

So basically...

所以基本上...

And that's for the year, and that uses a midyear convention.

那是今年的，使用年中會議。

Yes. So said differently, if you guys hadn't taken your excess COVID mortality up to 6,000, that probably would have been almost a delta between the guidance you provided at the Analyst Day versus today?

是的。換種說法，如果你們沒有將超額的 COVID 死亡率提高到 6,000，那可能幾乎是您在分析師日提供的指導與今天提供的指導之間的差值？

Yes. I think that math works, Pito.

是的。我認為數學有效，皮托。

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

在這個時候，我沒有再提出任何問題。

All right. Well, thank you, Michelle, and thank you all for your interest in our company. As you can see, like many other companies, the short term is a tough one with the macro landscape being quite complex and dynamic, in particular, in the labor markets. That said, hopefully, you hear from our voices that in the long term, we continue to build a differentiated capability and that we are very positive on how we are positioned to deliver integrated care for our patients, deliver world-class outcomes and bring savings to our payers.

好的。好吧，謝謝你，米歇爾，謝謝大家對我們公司的興趣。正如您所看到的，與許多其他公司一樣，短期是艱難的，宏觀環境非常複雜和充滿活力，尤其是在勞動力市場。也就是說，希望您能從我們的聲音中聽到，從長遠來看，我們將繼續建立差異化的能力，並且我們非常積極地定位於為我們的患者提供綜合護理、提供世界一流的結果並帶來節省給我們的付款人。

I would be just remiss if I don't finish by saying that this is all possible because the resilience, the passion and the dedication of the DaVita team that wakes up every single day to deliver life-sustaining therapy. So thank you for your time, and we'll talk again next quarter. Be well.

如果我最後不能說這一切都是可能的，那我就是失職了，因為每天醒來提供維持生命治療的 DaVita 團隊的韌性、熱情和奉獻精神。因此，感謝您抽出寶貴時間，我們將在下個季度再次討論。好好的。

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

謝謝你。今天的電話會議到此結束。此時您可以繼續斷開連接。