德維特 (DVA) 2018 Q4 法說會逐字稿

Thank you for standing by. My name is Colleen, and I will be your conference facilitator today. At this time, I would like to welcome everyone to DaVita Fourth Quarter 2018 Earnings Call. (Operator Instructions) Mr. Gustafson, you may begin your conference.

謝謝你的支持。我叫科琳，今天我將擔任你們的會議主持人。此時此刻，我謹歡迎大家參加 DaVita 2018 年第四季財報電話會議。（操作員指示）Gustafson 先生，您可以開始會議了。

Thank you, Colin, and welcome, everyone, to our fourth quarter conference call. We appreciate your continued interest in our company. I'm Jim Gustafson, Vice President of Investor Relations. And with me today in the room are Kent Thiry, our CEO; Joel Ackerman, our CFO; Javier Rodriguez, CEO of DaVita Kidney Care; Jim Hilger, our Chief Accounting Officer; and LeAnne Zumwalt, Group Vice President.

謝謝科林，歡迎大家參加我們的第四季電話會議。我們感謝您對我們公司的持續關注。我是吉姆‧古斯塔夫森，投資人關係副總裁。今天和我一起在房間裡的是我們的執行長肯特‧蒂裡 (Kent Thiry)；喬爾‧阿克曼，我們的財務長；哈維爾·羅德里格斯 (Javier Rodriguez)，DaVita Kidney Care 執行長； Jim Hilger，我們的會計長；和集團副總裁 LeAnne Zumwalt。

Please note that during this call, we may make forward-looking statements within the meaning of the federal securities laws. All of these statements are subject to known and unknown risks and uncertainties that could cause the actual results to differ materially from those described in the forward-looking statements. For further details concerning these risks and uncertainties, please refer to our fourth quarter earnings press release and our SEC filings, including our most recent annual report on Form 10-K and quarterly report on Form 10-Q. All forward-looking statements are based upon information currently available to us. And we do not intend and undertake no duty to update these statements.

請注意，在本次電話會議中，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，可能導致實際結果與前瞻性陳述中描述的結果有重大差異。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向 SEC 提交的文件，包括我們最新的 10-K 表年度報告和 10-Q 表季度報告。所有前瞻性陳述均基於我們目前掌握的資訊。我們不打算也不承擔更新這些聲明的義務。

Additionally, we like to remind you that during this call, we will discuss some non-GAAP financial measures. A reconciliation of these non-GAAP measures to the most comparable GAAP financial measures is included in our earnings press release submitted to the SEC and available on our website.

此外，我們想提醒您，在本次電話會議中，我們將討論一些非 GAAP 財務指標。這些非 GAAP 衡量標準與最具可比性的 GAAP 財務衡量標準的調整包含在我們提交給 SEC 的收益新聞稿中，並可在我們的網站上取得。

I'll now turn the call over to Kent Thiry, our Chief Executive Officer.

現在我將把電話轉給我們的執行長 Kent Thiry。

Thank you, Jim. As you probably already noted, we had solid fourth quarter results that were consistent with prior communications and, of course, JR and Joel will discuss those in greater detail a little bit downstream, but we're first and foremost a caregiving company and so as usual we will start by talking about a clinical highlight today, antibiotic stewardship.

謝謝你，吉姆。正如您可能已經注意到的那樣，我們第四季度的業績與先前的溝通一致，當然，JR 和喬爾將在下游更詳細地討論這些結果，但我們首先是一家護理公司，因此通常，我們首先討論今天的臨床亮點：抗生素管理。

As many of you know, dialysis patients are highly prone to infections. We have continued to get better at supporting evidence-based prescribing of antibiotics, which has a couple of benefits, including reducing harm to patients from excessive antibiotic use, and also preventing the emergence of antimicrobial resistance. This is something that all caregivers should be doing across American and global health care. And we're proud that we're getting better. In fact, in 2018, among patients with symptoms of bloodstream infections, we actually decreased IV antibiotic steroids by 12%, while maintaining all clinical quality.

眾所周知，透析患者非常容易受到感染。我們繼續更好地支持基於證據的抗生素處方，這有幾個好處，包括減少過度使用抗生素對患者的傷害，以及防止抗菌素抗藥性的出現。這是美國和全球醫療保健領域所有護理人員都應該做的事情。我們很自豪我們正在變得更好。事實上，2018 年，在出現血液感染症狀的患者中，我們實際上將靜脈注射抗生素類固醇減少了 12%，同時維持了所有臨床品質。

This is important not only in terms of what we did this year, but we continue to collect data to improve our ability to do even better in the future. Now a quick update on the DMG transaction. We're working closely with Optum to obtain FTC approval, which, of course, is necessary. The timing of the process was very negatively impacted by the government shutdown as it was for so many other transactions. And we cannot speak definitively the timing for all the reasons we haven't been able to do that up to this point, and all the same reasons that other companies involved in other transactions cannot, but everybody is working very diligently to move that ball forward.

這不僅對於我們今年所做的事情很重要，而且我們繼續收集數據以提高我們未來做得更好的能力。現在快速更新 DMG 交易。我們正在與 Optum 密切合作以獲得 FTC 的批准，這當然是必要的。與許多其他交易一樣，政府關閉對這一過程的時間安排產生了非常負面的影響。我們無法確切地說出具體時間，因為到目前為止我們還無法做到這一點，而且參與其他交易的其他公司也無法做到這一點，但每個人都在非常努力地推動這一進程。

In addition, some good news is that in 2019 the DMG financial performance will improve -- is expected to improve significantly. There are a number of very tangible reasons for this. One, for example, is significantly better Medicare Advantage rates than in prior years. Number two, the elimination of the health insurer fee is a dollar for dollar significant pickup. Number three, the dollar for dollar elimination of considerable consulting expenses incurred in 2018 that will be gone in 2019. And fourth, the number of operating improvements, investments that we made in prior years that are bearing fruit. So the net is that 2019 in DMG will be significantly better -- as expected, to be significantly better than 2018. Now over to Javier for a summary of our Kidney Care business.

此外，一些好消息是，2019年DMG的財務表現將會有所改善－預計將顯著改善。這有許多非常明顯的原因。例如，其中之一是醫療保險優惠率明顯高於前幾年。第二，取消醫療保險公司費用是一個顯著的提升。第三，以同樣的方式消除 2018 年發生的大量諮詢費用，這些費用將在 2019 年消失。第四，我們前幾年進行的營運改善和投資正在取得成果。因此，最終結果是，2019 年 DMG 將明顯優於預期，明顯優於 2018 年。現在請哈維爾總結一下我們的腎臟護理業務。

Thank you, Kent, and good morning, everyone. Today I'll cover two topics. First, I'll provide a recap of our financial performance. And second, I will discuss the legislation recently introduced in California. For the fourth quarter of 2018, our results are in line with our guidance. Adjusted operating income was $370 million for the quarter and $1.513 billion for the full year.

謝謝肯特，大家早安。今天我要講兩個主題。首先，我將回顧我們的財務表現。其次，我將討論加州最近推出的立法。2018 年第四季度，我們的業績符合我們的指引。該季度調整後營業收入為 3.7 億美元，全年調整後營業收入為 15.13 億美元。

Our 2018 operating cash flow from continuing operations also came in line with guidance at $1.48 billion. Related to cash flows, our 2018 CapEx spend came in better than our guidance, and we are guiding to a lower spend in 2019. There are several drivers of this declining CapEx spend, two of which are worth calling out as they should decrease the CapEx spend, new centers in the next couple of years.

我們 2018 年持續經營業務產生的營運現金流也符合指引，為 14.8 億美元。與現金流相關，我們 2018 年的資本支出支出優於我們的指導，我們指導 2019 年的支出較低。資本支出下降有幾個驅動因素，其中兩個值得指出，因為它們應該會減少未來幾年新中心的資本支出支出。

First, we continue to focus on driving the right modality for our patients. For many of them, dialyzing at home may be the best option. Now that we have a more secure supply on PD products, we anticipate more patients will be able to choose Home Dialysis. In fact, in 2018, we trained and educated over 13,000 new Home patients. As you know, Home growth has an incremental benefit of being more capital efficient.

首先，我們繼續專注於為患者提供正確的治療方式。對他們中的許多人來說，在家透析可能是最好的選擇。現在我們的腹膜透析產品供應更加安全，我們預計更多患者將能夠選擇居家透析。事實上，2018 年，我們培訓和教育了超過 13,000 名新的 Home 患者。如您所知，家庭成長具有提高資本效率的增量優勢。

Second, as we mentioned earlier this year, some recent data suggests that ESRD industry growth may be slowing. While we don't know whether this is a short-term impact of increased transplantation availability or whether there is a long-term implication in the immediate-term, we plan to build fewer centers to keep pace with patient demand.

其次，正如我們今年早些時候提到的，最近的一些數據表明 ESRD 行業成長可能正在放緩。雖然我們不知道這是否是移植可用性增加的短期影響，還是短期內的長期影響，但我們計劃建立更少的中心以滿足患者需求。

Next, as many of you know, Q4 includes open enrollment decisions for many of our patients. Overall, we observed stable results from open enrollment, which is consistent with our expectations. In the Individual markets in particular, we saw slightly higher re-enrollment than we experienced over the last couple of years. We believe that these results set us up to deliver on 2019 guidance we shared last month, which Joel will cover later.

接下來，正如你們許多人所知，第四季度包括對我們許多患者的公開入組決定。總體而言，我們觀察到公開招生的結果穩定，這與我們的預期一致。特別是在個人市場，我們看到重新註冊人數比過去幾年略高。我們相信，這些結果使我們能夠實現我們上個月分享的 2019 年指導方針，喬爾稍後將對此進行介紹。

Now let me transition to a legislative update in California. A member of the assembly has reintroduced effectively the same legislation as last year's SB 1156, which was vetoed by the Governor because of potential harm to patients.

現在讓我談談加州的立法更新。議會的一名成員實際上重新引入了與去年的 SB 1156 相同的立法，該立法因對患者的潛在傷害而被總督否決。

This new bill, AB 290, seeks to impose rate cuts on dialysis providers for their support of premium assistance charities and imposes restrictions on charitable premium assistance for patients with pre-existing conditions and end-stage renal disease. Our coalition of dialysis patients, physicians, and caregivers in California will, of course, fight to the fit -- defeat this ill-conceived bill.

這項新法案 AB 290 旨在對透析提供者對保費援助慈善機構的支持實行降費，並對患有既往疾病和終末期腎病的患者的慈善保費援助施加限制。當然，我們加州的透析患者、醫生和護理人員聯盟將全力以赴——擊敗這項考慮不周的法案。

Finally, let me finish by saying that we continue to build our integrated care capabilities, which are helping us care for patients in a more holistic way. Let me provide a couple of examples. First, we have developed a predictive model that incorporates lab data, dialysis, treatment data and claims data to determine which patients are at a highest risk of hospitalization over the following month. Second, we now have a team of nurse practitioners dedicated to addressing broad range of primary care needs on a more real-time basis for our patients.

最後，我想說的是，我們將繼續建立綜合護理能力，這有助於我們以更全面的方式照顧病人。讓我舉幾個例子。首先，我們開發了一個預測模型，該模型結合了實驗室數據、透析、治療數據和索賠數據，以確定哪些患者在接下來的一個月內住院風險最高。其次，我們現在擁有一支執業護理師團隊，致力於更即時地滿足患者的廣泛初級保健需求。

We believe that these capabilities will improve the quality of life of our patients, while reducing cost to the system, and, of course, we look forward to providing this coordinated care to many more patients in the future.

我們相信這些功能將改善患者的生活質量，同時降低系統成本，當然，我們期待將來為更多患者提供這種協調的護理。

So, in summary, overall, solid quarter, and we continue to focus on delivering high-quality care for our patients. Now on to Joel for financial details on our results.

因此，總而言之，總體而言，這個季度表現穩健，我們將繼續專注於為患者提供高品質的照護。現在請喬爾了解我們業績的財務細節。

Thanks, Javier. Let me walk you through some components of our U.S. Dialysis and Lab segment. First growth. Our treatment per day growth in Q4 was 3.1% and normalized non-acquired growth was 2.6% as we continue to see a decline in volume growth.

謝謝，哈維爾。讓我向您介紹我們美國透析和實驗室部門的一些組成部分。第一次成長。我們第四季的每日治療量成長為 3.1%，標準化非獲得性成長為 2.6%，因為我們繼續看到數量成長下降。

We continue to expect non-acquired growth to range between 2.5% and 3.5% in 2019. Next on revenue. Revenue per treatment was down $0.65 from Q3 to Q4. If you exclude the impact of calcimimetics, revenue was up a little more than $1 per treatment sequentially. To give some perspective on this for the full year, commercial RPT for the year was down approximately 1% as we shifted out-of-network business to in-network, which offset commercial rate increases that we've achieved across much of the portfolio.

我們繼續預期 2019 年非收購性成長將在 2.5% 至 3.5% 之間。接下來是收入。從第三季度到第四季度，每次治療的收入下降了 0.65 美元。如果排除擬鈣劑的影響，每次治療的收入比上一季增加略多於 1 美元。從全年的角度來看，隨著我們將網外業務轉移到網內業務，今年的商業 RPT 下降了約 1%，這抵消了我們在大部分投資組合中實現的商業費率成長。

For the year, commercial mix was down approximately 10 basis points from 10.5% in 2017 to 10.4% in 2018.

今年，商業組合下降約 10 個基點，從 2017 年的 10.5% 降至 2018 年的 10.4%。

We believe that our decline in mix was consistent with the demographic headwinds that we have previously outlined. Finally, on revenue. Our Strategic Initiative revenue was negatively impacted by our previously announced wind down of DaVita Rx. DaVita Rx revenue was down approximately $100 million quarter-over-quarter, and Q4 is reflective of the go-forward run rate.

我們相信，我們的組合下降與我們先前概述的人口不利因素是一致的。最後，關於收入。我們的策略計劃收入受到我們先前宣布的 DaVita Rx 停產的負面影響。DaVita Rx 營收季減約 1 億美元，第四季反映了前進的運行率。

On costs. Patient care Cost per treatment was up $1.26 quarter-over-quarter, primarily due to an increase in professional fees. Dialysis and Lab segment G&A was down quarter-over-quarter approximately $4 per treatment, $2 driven by a decrease in advocacy spend and the remainder due to normal quarterly spending fluctuations.

關於成本。患者護理 每次治療的成本環比上漲 1.26 美元，主要是由於專業費用的增加。透析和實驗室部門的一般管理費用較上季每項治療下降約 4 美元，其中 2 美元是由於宣傳支出減少所致，其餘則是由於正常的季度支出波動所致。

For International, we achieved a slightly positive adjusted operating profit for the quarter, excluding the FX impact of our joint venture in Asia. We expect positive operating income from International operations in 2019 excluding any FX impacts, which is incorporated in our enterprise guidance.

對於國際業務，排除亞洲合資企業的匯率影響，本季我們實現了小幅正調整營業利潤。我們預計 2019 年國際業務將實現正營業收入（排除任何外匯影響），這一點已納入我們的企業指引中。

For the fourth quarter, our effective tax rate on income attributable to DaVita from continuing operations was 24.3%, and for the year, it was 29.2%. The effective tax rate was unusually low for Q4 as a result of the positive quarterly true-ups for our federal, state and international accruals. It's unusual that all of these moved in the same direction in one quarter.

第四季度，歸屬於 DaVita 持續經營業務收入的有效稅率為 24.3%，全年為 29.2%。由於聯邦、州和國際應計項目的季度調整為正，第四季度的有效稅率異常低。所有這些在一個季度內都朝著同一個方向發展，這是不尋常的。

Now onto cash flow. Operating cash flow from continuing operations was $307 million for the quarter and $1.48 billion for the year, in line with our previous guidance. I will conclude by reiterating our 2019 guidance. We expect operating income to be between $1.54 billion and $1.64 billion. As a reminder, the first quarter has seasonally low operating income as the quarter is shorter with 76.6 treatment days, meaning lower treatment volumes and fewer treatments over which to absorb the fixed costs. Also, Q1 has higher seasonal payroll taxes.

現在談談現金流。本季持續經營業務產生的營運現金流為 3.07 億美元，全年為 14.8 億美元，與我們先前的指引一致。最後，我將重申我們的 2019 年指引。我們預計營業收入將在 15.4 億美元至 16.4 億美元之間。提醒一下，第一季的營業收入季節性較低，因為該季度的治療天數較短，為 76.6 天，這意味著治療量較低，可吸收固定成本的治療也較少。此外，第一季的季節性工資稅較高。

Our 2019 guidance includes the following expectations: 3% to 4% U.S. total treatment volume growth; 0% to 1% U.S. Revenue per treatment growth; and 0.5% to 1.5% U.S. Cost per treatment growth. We are initiating 2019 guidance for operating cash flow from continuing operations for the year to be $1.375 billion to $1.575 billion. In 2019, we expect $800 million to $840 million in CapEx from continuing operations.

我們的 2019 年指引包括以下預期： 美國總治療量成長 3% 至 4%；每次治療成長的美國收入為 0% 至 1%；美國每次治療成長的成本為 0.5% 至 1.5%。我們啟動 2019 年持續經營業務現金流量指引，目標為 13.75 億美元至 15.75 億美元。2019 年，我們預計持續營運的資本支出將達到 8 億至 8.4 億美元。

This range includes CapEx for self-developed real estate projects that are offset by proceeds from the subsequent sale-leaseback transactions. We expect approximately $100 million of proceeds from self-developed projects in 2019, leading to net spend of approximately $720 million at the midpoint.

該範圍包括自行開發的房地產項目的資本支出，這些支出被後續售後回租交易的收益所抵消。我們預計 2019 年自主開發項目的收益約為 1 億美元，中位數淨支出約為 7.2 億美元。

For comparison purposes, in 2018, our CapEx from continuing operations was $902 million. And we received proceeds from sale-leaseback transactions of $45 million for a net of $857 million.

出於比較目的，2018 年，我們來自持續營運的資本支出為 9.02 億美元。我們從售後回租交易中獲得的收益為 4,500 萬美元，淨收益為 8.57 億美元。

You can see the historical detail in Section 6 of our supplemental financial data in our earnings release. Finally, we expect our effective tax rate on income attributable to DaVita from continuing operations to be 28.5% to 29.5%.

您可以在我們的收益發布中的補充財務數據第 6 節中查看歷史詳細資訊。最後，我們預期 DaVita 持續經營收入的有效稅率為 28.5% 至 29.5%。

As always, our guidance captures the majority of probabilistic outcomes, although there are scenarios in which we could end up above or below the estimated -- the estimates provided. Now I'll turn it over to Kent for some closing remarks.

像往常一樣，我們的指導涵蓋了大部分機率結果，儘管在某些情況下我們最終可能會高於或低於估計值（所提供的估計值）。現在我將把它交給肯特做一些結束語。

I'd like to just make a few comments, four: Number one, please be reminded that the next few years Medicare year-over-year fee-for-service rate increases will be better than the almost 0 increases over the last few years. Second, the International business now has a foundation on which we can expect year-over-year OI contributions, rather than offsets. Number three, we continue to generate strong cash flows and they are in fact incrementally better than some of the prior years. And four, we are very well positioned to be a differentiated high value-added provider of integrated care for these needy and expensive patients. Operator, let's switch to Q&A, please.

我只想發表幾點意見，四：第一，請注意，未來幾年醫療保險服務費率的同比增幅將好於過去幾年幾乎為 0 的增幅。其次，國際業務現在已經有了一個基礎，我們可以在此基礎上期待同比的 OI 貢獻，而不是抵銷。第三，我們繼續產生強勁的現金流，而且實際上比前幾年更好。第四，我們完全有能力成為這些有需要且昂貴的患者的差異化高附加價值綜合護理提供者。接線員，請切換到問答環節。

(Operator Instructions) The first question comes from Kevin Fischbeck, Bank of America.

（操作員說明）第一個問題來自美國銀行的 Kevin Fischbeck。

Great, thanks. I guess we want to start off with DMG, as a question. I appreciate that you can't say exactly when it is going to close, but I didn't see your comments, we knew that you're still confident that it is going to close. Just wanted to make sure that from your perspective everything is still on track and it's just a matter of timing at this point?

萬分感謝。我想我們想從 DMG 開始，作為一個問題。我很感激你不能準確地說出它何時關閉，但我沒有看到你的評論，我們知道你仍然有信心它會關閉。只是想確保從您的角度來看，一切都仍在正軌上，這只是時間問題？

Yes.

是的。

Okay, great. And then I wanted to talk a little bit more about the slowdown in growth that you're seeing and expecting from a treatment perspective. I missed, I think you mentioned something about factors that may or may not be temporary. Can you talk a little bit about what those factors are? And if there's anything else, if you're thinking about or thinking about what organic growth should look like?

好的，太好了。然後我想更多地談談您從治療角度看到和期望的生長放緩。我錯過了，我想你提到了一些可能是暫時的，也可能不是暫時的因素。您能談談這些因素是什麼嗎？如果還有其他問題，您是否正在考慮或思考有機成長應該是什麼樣子？

Thanks Kevin, this is Javier. We started to see a bit of a slowdown on new starts in the back end of the year. And that's why when we provided guidance, you saw the number came down to 2.5 to 3.5 of non-acquired growth. Some of the factors that are still in play are what's happening upstream with other comorbid conditions and how that is impacting how many patients have ESRD. And another dynamic is, how many organs are going into the transplant pool as the number of organs has picked up due to the opioid crisis with many people being young and having healthy kidneys. So there is a lot interplay, many dynamics upstream and so we're trying to see if there is short-term or if they're going to be longer-term.

謝謝凱文，這是哈維爾。我們開始看到今年底新開工量放緩。這就是為什麼當我們提供指導時，您會看到非獲得性成長的數字降至 2.5 至 3.5。一些仍在發揮作用的因素包括上游其他合併症發生的情況，以及這如何影響 ESRD 患者的數量。另一個動態是，由於鴉片類藥物危機導致器官數量增加，許多人都很年輕且腎臟健康，因此有多少器官將進入移植池。因此，上游存在著許多相互作用、許多動態，因此我們試圖看看是否有短期影響或是否會是長期影響。

Okay. And from your perspective, the new starts that you're doing over the next year, is that going to position you for in-line industry growth, market share gains, market share losses, how are you thinking about that?

好的。從您的角度來看，您明年所做的新開始是否會讓您處於行業成長、市場佔有率增加、市場佔有率損失的位置，您對此有何看法？

I'm sorry. Are you asking how we're positioned within that growth? Is that the question?

對不起。您是否想問我們在這種成長中的定位如何？這是問題嗎？

Yes, so your guidance of 2.5% to 3.5%, does that mean that you expect to gain share or you're growing along with what you think the market will be relatively growing?

是的，所以你的指導是 2.5% 到 3.5%，這是否意味著你期望獲得份額，或者你正在隨著你認為市場的相對增長而增長？

Yes, in the last couple of years, actually not the last couple of years, maybe the last couple of decades we've outperformed in non-acquired growth. We believe that there is nothing in the data that would say that we would not do that. And so right now we're just looking more at the market dynamics overall.

是的，在過去幾年，實際上不是過去幾年，也許是過去幾十年，我們在非獲得性成長方面表現出色。我們相信，數據中沒有任何內容表明我們不會這樣做。所以現在我們只是更關注整體市場動態。

Okay. And then maybe last question for now. On the commercial mix, I think you said that your mix was down 10 basis points year-over-year, in line with kind of what you would expect in all demographic trends to kind of arguably slow, but I think your guidance assumes that actually mix will be relatively flat. So I'm not sure if the demographics point to a decline each year, how you're thinking about being flat in 2019?

好的。然後也許是現在的最後一個問題。關於商業組合，我認為您說過您的組合同比下降了 10 個基點，這與您對所有人口趨勢的預期一致，可能會放緩，但我認為您的指導假設實際上混合會相對平坦。所以我不確定人口統計數據是否表明每年都會下降，您如何看待 2019 年持平？

So Kevin, it's Joel here. The demographics are certainly a headwind, about 10 basis points a year. We see opportunities to offset the headwind through upstream education of patients as well as helping them with their insurance once they've come on dialysis. So we see opportunities to offset the headwind, but we do see the headwind persisting.

凱文，這是喬爾。人口統計無疑是一個逆風，每年大約上漲 10 個基點。我們看到了透過對患者進行上游教育以及在他們接受透析後幫助他們購買保險來抵消不利因素的機會。因此，我們看到了抵消逆風的機會，但我們確實看到逆風持續存在。

And our next question comes from Justin Lake, Wolfe Research.

我們的下一個問題來自沃爾夫研究中心的賈斯汀·萊克。

First let me follow up on Kevin's question around the deal close. I understand the government shutdown delayed everything, but the last thing you had talked about was expecting the deal to close in the first quarter. So with the government shutdown about 30 days, that would take us out to end of April. Is that still kind of where you would expect? Or do you feel like the first quarter, even extra government shutdown, things have changed?

首先讓我跟進凱文關於交易完成的問題。我知道政府關門推遲了一切，但你談到的最後一件事是預計交易將在第一季完成。因此，隨著政府關門約 30 天，我們將推遲到 4 月底。這仍然是您所期望的嗎？或者您覺得第一季度，甚至政府額外關閉，情況發生了變化？

So Justin it's Joel here. We're certainly still trying for Q1, that is a real possibility. But the government shutdown has certainly lowered the odds of that happening.

賈斯汀，這裡是喬爾。我們當然仍在努力爭取第一季度，這是一個真正的可能性。但政府關門無疑降低了這種情況發生的可能性。

Is there anything new besides the shutdown that would change that trajectory?

除了關閉之外，還有什麼新的事情可以改變這一軌跡嗎？

Justin, there's always a lot going on in one of these processes so to say, nothing new would suggest that nobody is doing any work, nobody is asking any questions. But Joel's answer still applies. We're working hard with a goal that he cited.

賈斯汀，在這些流程之一中總是會發生很多事情，所以可以說，沒有什麼新的東西表明沒有人在做任何工作，沒有人在問任何問題。但喬爾的回答仍然適用。我們正在努力實現他所提到的目標。

Okay. And then on the California legislation, just given this is the second time they're coming here and they've got a Governor that might be more likely to actually sign this legislation if it gets passed. Curious if you can help us put a range around the potential financial impact that we should think about for 2020, if this legislation does pass?

好的。然後是加州的立法，考慮到這是他們第二次來到這裡，而且他們有一位州長，如果這項立法獲得通過，他可能更有可能真正簽署這項立法。如果這項立法真的通過，您是否可以幫助我們列出我們應該考慮的 2020 年潛在財務影響範圍？

Yes, Justin, as you can imagine, the legislation moves and there are different ways to interpret, and, of course, you can never predict how it will play out, but to try and be constructive and give you a range, I think it would be useful to have somewhere in the $25 million to $40 million as a range.

是的，賈斯汀，正如你可以想像的那樣，立法會發生變化，並且有不同的解釋方式，當然，你永遠無法預測它會如何發展，但為了嘗試具有建設性並給你一個範圍，我認為它將2500 萬美元到4000 萬美元作為一個範圍會很有用。

Our next question comes from Steve Tanal, Goldman Sachs.

我們的下一個問題來自高盛的史蒂夫·塔納爾。

I guess, just on the slower normalized non-acquired treatment growth in the quarter at 2.6, is any of that attributable to pick up in Home Dialysis? Or is that capturing that?

我想，本季標準化非後天治療成長率較慢（2.6），這是否可以歸因於居家透析的成長？或者說這就是捕捉到的？

That is captured in there. The Home growth is in the 2.6%.

那是在那裡捕獲的。家庭成長率為 2.6%。

Got it. Okay. And, how are you thinking about Home Hemo, just the comments on sort of growing in the Home and making that more available. Is that -- with some of the newest sort of technologies in the market, are you guys planning for growth in that business or how should we think about that?

知道了。好的。而且，您如何看待家庭 Hemo，只是關於在家庭中成長並使其更容易獲得的評論。是不是——利用市場上一些最新的技術，你們是否正在計劃該業務的成長，或者我們應該如何考慮這個問題？

We've been leading in Home for as long as I can remember. And we will continue to do what's appropriate for the patient in the right modality for each patient. So we, of course, assess technologies. There is a lot of talk of innovation, but if you really look carefully there is a lot of smoke in that innovation, it really is a lot of the same, and people are just trying to talk up their products. We, of course, love it when there is something that is good for the patients, and we will pursue whatever is best for them.

從我記事起，我們就一直在主場領先。我們將繼續以正確的方式為每位患者做適合患者的事情。所以我們當然會評估技術。人們對創新有很多談論，但如果你仔細觀察，會發現創新中存在很多煙霧，它確實有很多相同之處，人們只是試圖談論他們的產品。當然，我們喜歡對患者有利的事情，我們會追求對他們最好的事情。

Okay, got it. Then just on the slower de novos can you give us a sense for what you're planning for '19? And how you are thinking about sort of the number of openings for longer term at this point?

好，知道了。那麼，在較慢的從頭開始，您能否讓我們了解您 19 年的計劃？目前您如何考慮長期職缺的數量？

Sure. So I'll preface the answer by highlighting the fact that there is a lag between the slowing of growth and the slowing of the de novos. De novos that are coming on now are decisions that were made in their leases that were signed a year or two ago. So with that said, we are looking at a significant slowdown in de novos in 2019, and we think that will continue going forward. I'll highlight that it's a function of two things. One it's a function of the slowing NAG, it's also a function of the growing Home. And as more and more patients are dialyzing at home, our need for the traditional in-center dialysis de novos comes down.

當然。因此，我將在回答前強調這樣一個事實：成長放緩和新經濟成長放緩之間存在著滯後性。現在出現的重新決定是在一兩年前簽署的租約中做出的決定。話雖如此，我們預計 2019 年的重新開發將顯著放緩，並且我們認為這種情況將繼續下去。我要強調的是，它是兩件事的函數。其一是 NAG 減速的函數，也是 Home 成長的函數。隨著越來越多的患者在家中進行透析，我們對傳統中心透析的需求下降。

Understood. Okay. Got it. And just lastly for me, just on the RPT side in calcimimetics, I think you had mentioned there was a $1 sort of headwind sequentially to calcimimetics and total added about $17. I think it was $18 in Q3 if I recall correctly?

明白了。好的。知道了。最後對我來說，在擬鈣劑的 RPT 方面，我想你已經提到過擬鈣劑有 1 美元的逆風，總共增加了約 17 美元。如果我沒記錯的話，我認為第三季的價格是 18 美元？

Yes, that's about right.

是的，差不多是這樣。

And our next question comes from Pito Chickering, Deutsche Bank.

我們的下一個問題來自德意志銀行的 Pito Chickering。

Two questions, first one on the Revenue per treatment. You talked about bringing more revenues from out of network to in network. We sort of estimate about 3.4% of revenues now out of network for your book of business, is that in a ballpark, can you talk about that?

有兩個問題，第一個問題是關於每次治療的收入。您談到將更多收入從網路外轉移到網路內。我們估計您的業務目前約有 3.4% 的收入來自網絡，這是一個大概的數字，您能談談嗎？

I think that question has been asked for many years, and I think we're not going to change our stance today to give more clarity on that. We try to be as useful as we could in January to provide some of the trends over the long haul, and Kent talked about sort of a 9-year trajectory of that number coming down. And I think that's as much as we can do right now.

我認為這個問題已經被問了很多年，而且我認為我們今天不會改變我們的立場來進一步澄清這一點。我們在一月份盡力提供一些長期趨勢，肯特談到了該數字的 9 年軌跡下降。我認為這就是我們現在能做的。

All right. Fair enough. And then on the weaker growth in the quarter, can you sort of talk about any impact from wildfires or weather? And then because it sort of -- it varied so much in the fourth quarter versus what we saw through the rest of the year, is there anyway of giving us any sort of monthly numbers just so we can get a better feel for sort of what was the core growth rate? And also what you guys exited January in?

好的。很公平。關於本季成長疲軟，您能談談野火或天氣的影響嗎？然後因為第四季度的情況與我們今年剩餘時間的情況相比變化很大，是否有辦法給我們任何類型的月度數據，以便我們可以更好地了解情況核心增長率是多少？你們一月退出時又是因為什麼？

Yes. So nothing to point out relating to wildfires or any sort of onetime stuff like that. In terms of monthly numbers, I don't think we're going to go to that level of granularity.

是的。因此，與野火或任何類似的一次性事件有關，沒有什麼可指出的。就每月數據而言，我認為我們不會達到那種粒度水平。

Okay, fair enough. And then last question from a leverage perspective, as the DMG business hopefully gets sold, I think about the next three years, what's the right leverage ratio we should be thinking about you guys running?

好吧，很公平。然後從槓桿角度來看最後一個問題，隨著 DMG 業務預計將出售，我想未來三年，我們應該考慮你們經營的正確槓桿率是多少？

No real change to our thinking around that, 3x to 3.5x is the range we expect to generally be in, although we have gone above that for a variety of reasons. Obviously, we're well above that right now. But I think the 3 to 3.5x is still the range to think about.

我們的想法並沒有真正改變，3 倍到 3.5 倍是我們通常預期的範圍，儘管出於各種原因我們已​​經超出了這個範圍。顯然，我們現在遠高於這個水準。但我認為 3 到 3.5 倍仍然是值得考慮的範圍。

Our next question comes from Patrick Feeley, Barclays.

我們的下一個問題來自巴克萊銀行的帕特里克·菲利。

You've mentioned in the past that as an industry you'd be looking to introduce some proactive legislation in California. Can you just provide some color on what that legislation might look to do?

您過去曾提到，作為一個行業，您希望在加州引入一些積極主動的立法。您能否就該立法可能的目的提供一些說明？

Patrick, of course, we are trying to make sure that we educate the legislators to understand all the dynamics that are going on in an ecosystem that is not something that they normally are discussing. And so in our legislation what we want to make sure is that whatever guardrails are needed, so that everybody understands that the right patients that have continuity of care are getting access to charitable premium assistance. And so it's clarity on that is what we're trying to do as opposed to the bill now, which goes beyond that.

派崔克，當然，我們正在努力確保我們教育立法者了解生態系統中正在發生的所有動態，這不是他們通常討論的內容。因此，在我們的立法中，我們要確保的是，無論需要什麼護欄，以便每個人都明白，獲得連續護理的合適患者正在獲得慈善高級援助。因此，明確這一點是我們正在努力做的事情，而不是現在的法案，後者超出了這個範圍。

Got it. And the other thing is, Kent, I've heard you speak recently about desire to get more involved with the pre-dialysis CKD population. Any color on what kind of investment you may look to make there? Why you think there's opportunity for DaVita? And just something that could better enable you to provide integrated care once patients are transitioning onto dialysis, and better address the cost of the patients outside the clinic? Just any color around that would be helpful.

知道了。另一件事是，Kent，我最近聽到您談到希望更多地參與透析前 CKD 人群。您可能會在那裡進行什麼樣的投資？為什麼你認為 DaVita 有機會？一旦患者過渡到透析，是否可以更好地讓您提供全面護理，並更好地解決患者在診所外的費用？只要周圍有任何顏色都會有幫助。

We will be able to add significant really impressive clinical and economic value if we're allowed to move upstream and help take care of people who have kidney disease, but have not yet experienced kidney failure. And by intervening with those patients in different ways, we'll be able to delay the onset of dialysis, in some cases prevent it, and not only delaying it, but also having people be healthier and have a healthier start to their dialysis. All of these improvements have big clinical and economic implications. But there's a bunch of regulatory work to be done as well as contracting work to get there and we're making some nice incremental progress, nothing to bake into any forecast yet, but we are working hard.

如果我們被允許向上游移動並幫助照顧患有腎臟疾病但尚未經歷腎衰竭的人，我們將能夠增加令人印象深刻的臨床和經濟價值。透過以不同的方式對這些患者進行幹預，我們將能夠推遲透析的開始，在某些情況下甚至可以預防透析，不僅可以推遲透析，還可以讓人們變得更健康，並有一個更健康的透析開始。所有這些改進都具有重大的臨床和經濟意義。但要實現這一目標，還有大量監管工作和承包工作要做，我們正在取得一些不錯的漸進進展，目前還沒有任何預測可以納入其中，但我們正在努力工作。

And our next question comes from John Ransom, Raymond James.

我們的下一個問題來自約翰·蘭塞姆、雷蒙·詹姆斯。

I went back and looked at some of the qualitative comments about commercial contracting, all of last year. And it seems like we ended up in a place and 2019 was a bit below at least what I was expecting. So was the thought that you would always end up here or did we get some kind of late-breaking news that caused the needle to move?

我回顧了去年全年關於商業承包的一些定性評論。看來我們最終的結果是 2019 年至少有點低於我的預期。那麼，是你總是會在這裡結束的想法還是我們得到了某種最新消息導致了指針的移動？

John, obviously, I don't know what's in your assumptions, but it came in line with what we were seeing. And of course, on any given time there's pluses and minuses that, for the year, it was in line with what we expected.

約翰，顯然，我不知道你的假設是什麼，但它與我們所看到的相符。當然，在任何特定時間都有優點和缺點，就今年而言，它符合我們的預期。

I was specifically talking about the five to six large contracts being redone and you're pleased with the increases. And I guess, I was thinking zero to one wouldn't be what you'd be shooting for, but that's what I was referring to. Okay, that's it for me.

我特別談到了五到六份大型合約正在重做，您對合約的增加感到滿意。我想，我認為從零到一不會是你想要的目標，但這就是我所指的。好吧，我就這樣了。

Our next question comes from Gary Taylor of JPMorgan.

我們的下一個問題來自摩根大通的加里泰勒。

Just a few quick ones. For 2019, is the expected advocacy spend still in the $30 million range?

就幾個快速的。2019 年，預期的宣傳支出是否仍在 3,000 萬美元的範圍內？

Gary, that is the additional spend from our regular advocacy spend.

加里，這是我們常規宣傳支出的額外支出。

Okay. As compared to like the $93 million extra last year, right?

好的。與去年多出的 9,300 萬美元相比，對嗎？

Correct.

正確的。

And then I just want to make sure I understood, in response to Justin's question on the California legislation equivalent of 1156. So you're saying if every CPA patient in California moved to the Medicare rate, it would be a $25 million to $40 million revenue and OI hit or there were some offsets between revenue and OI?

然後我只是想確保我理解了，以回答 Justin 關於相當於 1156 的加州立法的問題。那麼您是說，如果加州的每位 CPA 患者都轉為享受 Medicare 費率，那麼收入和 OI 將會受到 2500 萬至 4000 萬美元的影響，或者收入和 OI 之間會存在一些抵消？

I'm glad you're asking Gary, because basically we didn't provide much detail because there are so many assumptions that go into it around a lot of dynamics. And so what we're trying to do is just be useful and give you the top line, which is basically there is a range of $25 million to $40 million, but we're not going into the specific dynamics.

我很高興你問加里，因為基本上我們沒有提供太多細節，因為圍繞著許多動態有很多假設。因此，我們想做的只是提供有用的信息並為您提供收入，基本上範圍在 2500 萬美元到 4000 萬美元之間，但我們不會深入討論具體的動態。

And that would be every CPA patient going into Medicare rate?

那將是每個 CPA 患者進入 Medicare 費率？

Like I said, patients and the way the system will work is yet to be seen. So it's probably not good to assume anything, rather be constructive and give you the range of all of the dynamics going in there.

就像我說的，病人和系統的工作方式還有待觀察。因此，假設任何事情可能都不好，而應該具有建設性，並為您提供所有動態的範圍。

Okay. Last one is for CapEx, can you tell us, and I apologize if it is on that last page, but CapEx for new centers in 2018 and what you think that looks like for 2019 and '20? Or just you talked about fewer new center openings. I was trying to get a sense of the impact on annual CapEx spend?

好的。最後一個是資本支出，您能告訴我們嗎？如果它在最後一頁，我很抱歉，但是 2018 年新中心的資本支出以及您認為 2019 年和 20 年的情況如何？或者你剛才談到了新中心開放的數量減少。我試圖了解對年度資本支出的影響？

Gary, so we can't give you a specific number. There is a range built into that as we watch over the course of the year exactly how many de novos get built, where they get built, what the cost per de novo is, but it is safe to assume part of that significant decline from 2018 to '19 will be the result of fewer de novos getting billed. But let me jump in and just correct something I said before, there was a question about calcimimetics RPT and I think what I confirmed was a number of $17. Just to be clear, $17 was the number for the year. The number in Q4 was about $16 of RPT.

加里，所以我們不能給你一個具體的數字。當我們在一年中觀察到底有多少 de novo 建造、在哪裡建造、每個 de novo 的成本是多少時，其中存在一個範圍，但可以安全地假設 2018 年大幅下降的一部分到19 年，新的收費將減少。但讓我插話糾正我之前說過的話，有一個關於擬鈣劑 RPT 的問題，我想我確認的是 17 美元的數字。需要明確的是，17 美元是當年的數字。第四季的 RPT 數字約為 16 美元。

And our next question comes from Whit Mayo, UBS.

我們的下一個問題來自瑞銀集團的惠特·梅奧。

On the commercial book, how much of your contract or how much of your book is set to reset in 2019? I guess, I'm just trying to get a sense of what your expectation is for renewals in 2019 and what the expectation is for Revenue per treatment?

在商業書籍方面，您的合約或書籍的多少內容將在 2019 年重置？我想，我只是想了解一下您對 2019 年續約的預期以及每次治療收入的預期是多少？

We don't disclose how many contracts are up on any given year. And so can't give you that. What we guided to at JPM was that the commercial book would be down 1% to up 0.5%.

我們不會透露任何一年有多少合約到期。所以不能給你那個。我們在摩根大通的指引是商業帳簿將下跌 1% 至上漲 0.5%。

For 2019?

2019 年？

Correct.

正確的。

Okay. Looking at the deceleration in treatment growth, I know that we're all speculating and guessing on a lot of the contributing factors, whether it's better insurance management, transplants or whatever, but have you been able to size, maybe internally what you think some of these contributing headwinds are just to maybe help frame up for us how to get from point A to point B?

好的。看看治療成長的減速，我知道我們都在猜測和猜測很多影響因素，無論是更好的保險管理、移植還是其他什麼，但你是否能夠確定規模，也許是你內部認為的一些因素？這些不利因素可能只是為了幫助我們了解如何從A 點到達B 點？

Yes, we spent a lot of time on that. It's challenging because the data bounces around, then a lot of the data we're using comes on a really long lag. So how to assess kind of current numbers is more challenging than we like. So I don't think we can be particularly helpful in trying to break down how this -- how the deceleration comes about from the different components.

是的，我們在這上面花了很多時間。這是具有挑戰性的，因為數據會不斷變化，然後我們使用的許多數據都會出現很長的延遲。因此，如何評估目前的數字比我們想像的更具挑戰性。因此，我認為我們不能特別有助於嘗試分解不同組件如何產生減速。

I think we're all trying to do the same exercise. Looking at G&A in the fourth quarter, if we exclude the $30 million of advocacy cost in California, would have been around $180 million. And I know that there are quarter-to-quarter fluctuations, but it still stands up a little bit lower than I would have expected. And I guess, I'm just trying to think about the starting point into 2019, is this the new run rate? Just any color to put the G&A trends for this year into perspective?

我想我們都在嘗試做同樣的練習。看看第四季的一般行政費用，如果我們排除加州 3,000 萬美元的宣傳成本，則約為 1.8 億美元。我知道存在季度波動，但它仍然比我的預期低一點。我想，我只是想思考 2019 年的起點，這是新的運行率嗎？有什麼顏色可以透視今年的 G&A 趨勢嗎？

Yes. It does bounce around as you pointed out. I don't think there's anything major that we would call out for Q4 or in the year-over-year numbers. So roughly flattish would be a reasonable expectation for 2019. And just to be clear, that's on a per treatment basis.

是的。正如您所指出的，它確實會反彈。我認為第四季或年比數據中沒有什麼值得我們關注的重大內容。因此，對 2019 年的預期大致持平是合理的。需要明確的是，這是基於每次治療的。

On a per treatment. Maybe two other quick ones. I don't know if you've disclosed this metric before, but any idea how much of your total treatment mix is Medicare Advantage today, or may be another way to get a more responsive answer is like, I think CMS has sized the industry around 20% of total treatments. Any reason that you would be different one way or the other? And I guess, I'm trying to sort of gain some insight into 2021, and maybe where you think that mix can go over time?

每治療一次。也許還有另外兩個快的。我不知道您之前是否披露過這個指標，但如果您知道今天的總治療組合中有多少是Medicare Advantage，或者可能是獲得更具響應性的答案的另一種方式，我認為CMS 已經確定了行業規模約佔總治療量的20%。有什麼理由讓你在某一方面有所不同嗎？我想，我正試圖對 2021 年有一些了解，也許您認為隨著時間的推移，這種混合會走向何方？

Yes. We have not disclosed our MA mix, and we're not going to disclose our MA mix. But as you try and look out what happens into the future, it's difficult to predict, because as you could imagine, individuals will make their own decisions. But maybe one reasonable assumption could be that it's in line with the overall market, which is around 35%. But as you know, in individual decisions, there's going to be a consideration on co-pays and deductibles and out-of-pockets and coordination of care. They're going to try and see if the physicians are in their network, et cetera. So to try and guess that on a total population is hard. So we, of course, have done some modeling, and right now a reasonable assumption is it will be in line with the overall market.

是的。我們尚未揭露我們的 MA 組合，我們也不會透露我們的 MA 組合。但當你嘗試觀察未來會發生什麼時，你會發現很難預測，因為正如你可以想像的那樣，個人會做出自己的決定。但也許一個合理的假設是它與整體市場一致，即 35% 左右。但如您所知，在個人決定中，將會考慮共付額、免賠額、自付費用以及護理協調。他們將嘗試看看醫生是否在他們的網絡中，等等。因此，嘗試猜測總人口的情況是很困難的。當然，我們已經做了一些建模，現在一個合理的假設是它將與整體市場保持一致。

Okay. And just one last one. Joel, you said an increase in professional fees, any more color there?

好的。還有最後一張。喬爾，你說專業費用增加，還有色彩嗎？

Really nothing interesting there. Some legal stuff is probably the biggest component of that, but really just kind of normal fluctuations up and down.

那裡真的沒什麼好玩的。一些法律因素可能是其中最大的組成部分，但實際上只是正常的上下波動。

And that's in -- is your professional fees, is that flowing through G&A?

那就是──你的專業費用，是透過一般行政費用流轉的嗎？

No.

不。

It's in your -- it's in the cost number? Patient care?

它在你的——它在成本數字中嗎？病人照護？

Well, it's in both. I think my recollection, and I'll get an answer for you in a second is that most of the swing up is in the patient care side.

嗯，兩者都有。我想我的記憶是，大部分的上升是在病人照護方面，我很快就會得到答案。

Okay. So nothing in the ancillary segment that would be allocated?

好的。那麼輔助段中沒有任何內容可以分配嗎？

0

0

No.

不。

And our next question comes from Jeff Gates, Gates Capital.

我們的下一個問題來自蓋茲資本的傑夫蓋茲。

I'm looking at the U.S. Dialysis segment margin. And if I exclude the so-called incremental advocacy cost and if I exclude the calcimimetics revenue, and then if I move $25 million per quarter out of 2017 numbers, if I add it back because of removing the 401(k) benefit, I'm showing that underlying comparable U.S. Dialysis margin was actually up for the year. And I just wanted to confirm that, that math was approximately correct?

我正在研究美國透析業務的利潤率。如果我排除所謂的增量宣傳成本，如果我排除擬鈣劑收入，然後如果我每季從2017 年的數字中移出2500 萬美元，如果我因為取消401(k) 福利而將其加回來，我' m 顯示美國透析的基本可比利潤率今年實際上有所上升。我只是想確認一下，數學大約是正確的？

Yes. I'd suggest we kind of take this offline. I'd be happy to walk it through with you. I'm not 100% following your math. So why don't you reach out to Jim Gustafson and we'll follow-up on this.

是的。我建議我們將其離線。我很樂意和你一起經歷這一切。我沒有 100% 理解你的數學。那麼，您何不聯繫吉姆·古斯塔夫森（Jim Gustafson），我們將對此進行跟進。

And our next question comes from Justin Lake, Wolfe Research.

我們的下一個問題來自沃爾夫研究中心的賈斯汀·萊克。

I just got a few more here. Commercial price, so just trying to come at this in another way. You said 60% of the outlier rates have normalized over 9 years. Maybe you could tell us how much more normalization you're kind of assuming for 2019, kind of where we would end this year at?

我這裡剛多了一些。商業價格，所以只是嘗試以另一種方式來解決這個問題。您說過 9 年來 60% 的異常值已經正常化。也許您可以告訴我們您對 2019 年的正常化程度有何假設，今年的結束情況是什麼？

Justin, I think, talking about it year-by-year is just not reflective of reality, but -- which is why we gave you the long-term data. We pledged many years ago to work down the outlier part of the book in a constructive way. And in some cases that can be easy because you got a payer that's got some really high rates and similarly low rates. And so you move everything to the middle on sort of a net neutrality basis. In other cases, it is not so simple. But that's why we cited the historical data, so that people know that over a period of many years, it has not led to any material disruptions, although there have been good quarters and bad quarters, good years and bad years. And it's quite unpredictable. And so, once again, we give you the empirical data so you can see that it is relatively predictable over the long-term, but not over the short-term. So guessing and giving you a guess on a single year, we just think could be really a lot more noise than data. We do, however, commit to our belief that over the next 5, 6, 7 years, that this trend towards fewer outliers will continue. And there will be some bumps that are positive and some bumps that are negative along the way, but it shouldn't be anything fundamental.

賈斯汀，我認為，逐年談論它並不能反映現實，但是——這就是我們向您提供長期數據的原因。我們多年前就承諾以建設性的方式解決本書中異常的部分。在某些情況下，這可能很容易，因為付款人的利率非常高，但利率也很低。因此，您可以在網路中立的基礎上將所有內容移至中間。在其他情況下，事情就沒那麼簡單了。但這就是為什麼我們引用歷史數據，以便人們知道，多年來，儘管有好季度和壞季度、好年份和壞年份，但它並沒有導致任何實質破壞。這是相當不可預測的。因此，我們再次向您提供經驗數據，以便您可以看到，從長期來看，它是相對可預測的，但在短期內則不然。因此，猜測並給你一個對一年的猜測，我們只是認為噪音可能比數據多得多。然而，我們堅信，在未來 5 年、6 年、7 年中，這種異常值減少的趨勢將持續下去。在這個過程中，會有一些正面的障礙和一些負面的障礙，但這不應該是根本性的。

Right. I guess, I'm sure you can understand investors are trying to figure out the potential impact. And this year there was -- you have 0 kind of built-in for commercial rate growth give-or-take. So given you normally get increases in contracts as you said, we're just trying to figure out, like is this what we should consider a normal year over the next 5 to 6 that you talked about? Or is this a bigger year of these outlier rates moving to normal?

正確的。我想，我相信你能理解投資人正在試圖找出潛在的影響。今年，你有 0 種內建的商業利率成長讓步。因此，鑑於您通常會像您所說的那樣增加合同，我們只是想弄清楚，這是否是您提到的未來 5 到 6 年中我們應該考慮的正常年份？或者今年是這些離群率趨於正常的更大一年嗎？

Yes. I don't think we can say. We put a lot of work into giving the guidance for this year. We're going to put a lot of work into providing the 3-year outlook at our upcoming Capital Markets in 2019. But I just spontaneously trying to figure out whether or not the word "normal" applies to that particular number in the particular year of 2019. I don't think I want to say -- we don't want to say either yes or no to what exactly is normal. Hopefully, we really helped you understand that, clearly there are some offsets in '19 that are offsetting the fact that in a lot of our book we're getting nice rate increases. So that is going on. And we've done our best job of calibrating it for you. But I wouldn't want to characterize it as either normal or abnormal. If you look over the next, the last 8, 9 years, it's not an outlier, it's just a tough year.

是的。我想我們不能說。我們為今年的指導做了很多工作。我們將投入大量工作來為即將到來的 2019 年資本市場提供 3 年展望。但我只是自發性地想弄清楚「正常」這個詞是否適用於 2019 年特定年份的特定數字。我想我不想說——我們不想對正常的事情說「是」或「不是」。希望我們確實幫助您理解了這一點，顯然 19 年有一些抵消，抵消了我們書中的很多內容中我們得到了不錯的利率增長的事實。事情就是這樣。我們已盡力為您進行校準。但我不想將其描述為正常或異常。如果你回顧接下來的八、九年，你會發現這不是異常值，而是艱難的一年。

Okay. And then just switching over to volume. Obviously, you've got a ton of medical directors who are nephrologists, and I assume they are seeing upstream to create ESRD patients. And so I'm curious what they're telling you in terms of this slowdown in patient growth? Are they saying that people are sticking on -- are taking longer to -- they're able to prevent the kidneys from fully failing, so that's why it's slowing or are they seeing an actual slowdown in growth in pre-ESRD. I'd have assumed that would be something that you would be able to see coming from a pretty long distance?

好的。然後切換到音量。顯然，有很多腎臟病專家的醫療主管，我認為他們正在上游尋找 ESRD 患者。所以我很好奇他們在患者成長放緩方面告訴你什麼？他們是說人們堅持下去——需要更長的時間——他們能夠防止腎臟完全衰竭，所以這就是腎病進展放緩的原因，還是他們看到終末期腎病前期的生長實際上已經放緩。我以為你能從很遠的距離看到它？

It's a fair question. And as you know, there is a wide distribution of sophistication of the way that the practices are ran from very small practices to large practices. With the people that I'm talking to, Justin, they have not seen their CKD practice slowdown in any significant way. But one can never put too much stake in that because the reality is that many of these practices are not that sophisticated, that their practice is busy, and they don't segment as well as sort of a Fortune 500 would. But at the end of the day there's nothing that they're picking out.

這是一個公平的問題。如您所知，從非常小的實踐到大型實踐，實踐的複雜程度分佈廣泛。與我交談的人賈斯汀，他們沒有看到 CKD 實踐有任何顯著的放緩。但人們永遠不能對此投入太多賭注，因為現實情況是，其中許多實踐並不那麼複雜，他們的實踐很繁忙，而且他們不像財富 500 強那樣進行細分。但最終他們什麼也沒挑出來。

And Justin, it's worth throwing out a few numbers to help explain why JR's answer is the appropriate one. You just take a typical nephrology group and say there's 3 doctors, and say they've got 100 dialysis patients each, so it's 300. And then there is a 13% mortality rate, let's say. So that's 39 patients to replace the ones that passed away. And then you have 3% growth, and so you add another 9 patients on. So you're talking about 48 new patients per year spread across 3 doctors. When you have a 1% change in the organic population, you're talking about 2 patients difference over the course of an entire year. And so whether or not a group has 48 new patients or whatever number spread across 12 months or 50 or 46, that is not something a practice can notice because year by year they're going to have those fluctuations, not going to have anything to do with aggregate CKD incidents or advancement. And so that's why JR's answer that the practice wouldn't pick up on this unless it was way, way, way more than 1% for us in aggregate, and for you, we pay a lot of attention to 1% because there is some incremental EPS math attached to it. But it's highly, highly incremental and not discernible at the practice level with rare exceptions.

賈斯汀，值得拋出一些數字來幫助解釋為什麼 JR 的答案是合適的。你就拿一個典型的腎臟科小組來說，有 3 位醫生，每人有 100 位透析患者，所以就是 300 位。比如說，死亡率為 13%。總共有 39 名患者來取代去世的患者。然後增長了 3%，因此又增加了 9 名患者。所以你說的是每年 48 位新病人分佈在 3 位醫生身上。當有機人群發生 1% 的變化時，您指的是一整年中 2 名患者的差異。因此，無論一個群體是否有48 名新患者，或者在12 個月內是否有50 名或46 名新患者，這都不是實踐可以注意到的事情，因為年復一年，他們會出現這些波動，不會有任何變化。與總體 CKD 事件或進展有關。因此，這就是為什麼 JR 的回答是，除非對我們來說總計遠遠超過 1%，否則我們不會採取這種做法，而對您來說，我們非常關注 1%，因為有一些附加EPS 數學增量。但它是高度、高度漸進的，在實踐層面上是無法辨別的，除了極少數例外。

Okay. Just a few other numbers questions here. You mentioned International as getting to profitability. Can you give us any kind of trajectory there, maybe a margin kind of target over the next few years that we think -- you think would be a reasonable range to think about, where this business can operate?

好的。這裡還有一些其他數字問題。您提到國際公司正在實現獲利。您能否為我們提供任何類型的發展軌跡，也許是我們認為未來幾年的利潤率目標——您認為這是一個合理的範圍，可以考慮該業務可以在哪裡運作？

Yes, Justin, we're not going to -- we no longer going to call out specific guidance for international. We will continue to report on it every quarter. But given the magnitude in the context of the whole company, we don't think guiding on it as a specific number is something we're going to do.

是的，賈斯汀，我們不會 - 我們不會再為國際提供具體指導。我們將繼續每季對此進行報告。但考慮到整個公司的規模，我們認為我們不會將其作為具體數字來指導。

But we will add, just to try to be a little responsive without going into misleading detail that we've had 3 consecutive years of improving the EBITDA margin by 2% per year. So just to give you a sense of the incremental operating improvements and mix improvements. So things are moving in the right direction, we can say that right now.

但我們要補充一點，只是為了盡量做出回應，而不涉及誤導性的細節，我們已連續 3 年將 EBITDA 利潤率每年提高 2%。只是為了讓您了解增量操作改進和組合改進。所以事情正在朝著正確的方向發展，我們現在可以這麼說。

Okay, but no even target margin?

好吧，但是連目標利潤都沒有嗎？

I don't think that would be a good idea right now given the different country mix. It's heavily influenced by which countries grow the most, and sometimes you might have a lower-margin country, but in fact, it's got higher return on capital. And -- so I don't think it wouldn't yet be a useful number for you, Justin.

考慮到不同國家的組合，我認為現在這不是一個好主意。它很大程度上受到成長最快的國家的影響，有時可能有一個利潤率較低的國家，但事實上，它的資本回報率較高。而且——所以我認為這對你來說還不是一個有用的數字，賈斯汀。

Okay. And then two more here. The CapEx, it was asked before, where your CapEx can go? And Joel, you said CapEx could materially decline over some period of time, if your de novos moderate. Can you give us an idea of what kind of -- if you had to look today and obviously this takes years to kind of play out because of how far you have to plan them ahead. But two or three years from now, given the growth you're seeing in the business, what kind of CapEx moderation do you think can happen here from that net 7-and-change number that you're reporting for this year?

好的。然後這裡還有兩個。資本支出，之前有人問過，你的資本支出可以花在哪裡？喬爾，你說過，如果你的從頭溫和的話，資本支出可能會在一段時間內大幅下降。你能否給我們一個想法——如果你必須今天看看，顯然這需要數年時間才能實現，因為你必須提前計劃多遠。但兩三年後，考慮到您在業務中看到的成長，您認為從您今年報告的淨 7 和變化數字來看，這裡會發生什麼樣的資本支出調節？

It's hard to predict, Justin. We're just not in a position right now to give kind of multi-year guidance on this. It will depend on a bunch of things, including growth. And depending on what happens to the growth, whether this decline is temporary or not as well as what happens to home penetration and other things, there can be some real impact on that number. But we are not in a position to give longer-term guidance.

這很難預測，賈斯汀。我們現在無法就此提供多年指引。這將取決於許多因素，包括成長。根據成長情況，這種下降是否是暫時的，以及家庭滲透率和其他因素的情況，可能會對這個數字產生一些真正的影響。但我們無法提供長期指導。

No, I apologize. But I thought you said it was material. It could be a material decline if the growth continues and you continue moving towards Home, which it sounds like you're trying to, so I am just trying to get some order of magnitude. I understand if it were to re-accelerate you have to spend more money, but just at this growth rate in both of those factors where do you -- what would you call material?

不，我道歉。但我以為你說的是物質。如果增長繼續下去，並且你繼續向家邁進，這可能會是實質性的下降，這聽起來像是你正在嘗試的，所以我只是想得到一些數量級。我理解如果要重新加速，你就必須花更多的錢，但就這兩個因素的成長率而言，你認為什麼是物質？

Yes. I don't -- we're not in a position to quantify what exactly that would mean right now.

是的。我不知道——我們現在無法量化這到底意味著什麼。

Okay. Last one on Medicare Advantage. I know to which question it was helpful to say that you think you can get to an industry average over time in Medicare Advantage penetration. But obviously, the starting point is pretty important. And I just recollect you guys having said 10% to 15%. It was kind of the range of where you were today. Am I wrong in picking that number up?

好的。關於 Medicare Advantage 的最後一篇文章。我知道對哪個問題來說，您認為隨著時間的推移，您的 Medicare Advantage 滲透率可以達到行業平均水平，這對回答哪個問題會有所幫助。但顯然，出發點非常重要。我記得你們說過 10% 到 15%。這有點像你今天所處的範圍。我選擇這個號碼有錯嗎？

We're looking around the table Justin. No one remembers ever having shared that number, which is not to say it didn't happen, but there is just a bunch of blank stares across the table.

我們正在環視桌子周圍的賈斯汀。沒有人記得曾經分享過這個數字，這並不是說這件事沒有發生過，但桌子對面只有一堆茫然的目光。

Okay. Then I'll come at it in a different way. Obviously, we've talked about this being a potential meaningful positive and getting to 35%, 40% where the industry is going to be a few years from now, is obviously could be significant, but not understanding where the starting point is. There is no way to say whether that's even going to be a benefit or not, unless we understand the starting point. Is there anyway you can give us, even a round number, 10%, 20%, 30% of where you are today?

好的。然後我會以不同的方式來解決這個問題。顯然，我們已經討論過這是一個潛在的有意義的積極因素，幾年後該行業將達到 35%、40%，這顯然可能很重要，但不了解起點在哪裡。除非我們了解出發點，否則無法判斷這是否會帶來好處。不管怎樣，你能告訴我們你今天的情況的 10%、20%、30%嗎？哪怕是一個整數？

Justin, how about if we do this, because we weren't prepared to do that for today, but you're making a fair point, so this is obviously a multi-year issue. And we do expect our MA to grow in a nontrivial way. And it's going to be great for patients and we think great for the system, because it will also bring down total costs. But none of that is responsive to this specific starting point question. So if you just let us not make a spontaneous decision here, instead think about it and then maybe next quarter we'll provide that number.

賈斯汀，如果我們這樣做怎麼樣，因為我們今天還沒有準備這樣做，但你提出了一個公平的觀點，所以這顯然是一個多年的問題。我們確實希望我們的 MA 能夠以不平凡的方式成長。這對患者來說非常有利，我們認為對系統也非常有利，因為它也會降低總成本。但這些都沒有回答這個具體的起點問題。因此，如果您只是讓我們不要在這裡自發做出決定，而是考慮一下，那麼也許下個季度我們會提供該數字。

Our next question comes from John Ransom, Raymond James.

我們的下一個問題來自約翰·蘭塞姆、雷蒙·詹姆斯。

Let me just go back one more time on something. So you mentioned wanting to get more involved in pre-ESRD and it would involve some contracting. The commercial payers only being on the hook for 18 months and then Medicare being kind of slow. Are we talking probably the Medicare Advantage payers would be most receptive to some different type of contracting that would actually incentivize you to keep people from crashing into dialysis? Or is it -- or am I thinking about that wrong?

讓我再回顧一下某件事。所以你提到想要更多地參與終末期腎病前期，這將涉及一些合約。商業付款人只需要 18 個月的時間，然後醫療保險就有點慢了。我們是否在談論醫療保險優惠付款人可能最容易接受某種不同類型的合同，這些合同實際上會激勵您防止人們陷入透析？還是——或者我的想法是錯的？

No, you're thinking about it correctly. We're already doing that with some payers. And both they and we believe we're having quite an impact, clinically and economically. And so we would expect that to increase over time. However, right now there is not math associated with it that's exciting enough for you to bake it into any near-term forecast. Hopefully, as the future rolls on and we get better and better at it and have more data to prove how good we are at it, it will be more relevant to your model.

不，你的想法是正確的。我們已經與一些付款人這樣做了。他們和我們都相信我們在臨床和經濟上都產生了相當大的影響。因此，我們預計這一數字會隨著時間的推移而增加。然而，目前還沒有與之相關的數學足夠令人興奮，可以將其納入任何近期預測中。希望隨著未來的發展，我們在這方面做得越來越好，並有更多數據來證明我們在這方面有多擅長，它將與您的模型更加相關。

And is this part of the tuition from DMG or does this accelerate your learning curve on some of these risk-based type of contracts?

這是 DMG 學費的一部分嗎？或者這會加快您對某些基於風險的合約類型的學習曲線？

Yes, there was some very good learning in both directions, where DaVita Kidney Care was able to help DaVita Medical Group do better on kidney care patients, both dialysis and pre-dialysis. And similarly, DMG was able to help DaVita Kidney Care do better in managing down the total cost, and managing the economics of our dialysis patients. So it was a good mutual and continues to be a good mutual learning highway.

是的，在兩個方向上都有一些非常好的學習，DaVita Kidney Care 能夠幫助 DaVita Medical Group 在腎臟護理患者方面做得更好，包括透析和透析前。同樣，DMG 能夠幫助 DaVita Kidney Care 更好地管理總成本並管理透析患者的財務狀況。因此，這是一次良好的互助，並將繼續成為一條良好的互助學習高速公路。

The other question I had is, our D.C. folks think that CMMI might do some different payment structures for Home Dialysis. So two questions. One, are you hearing any of that? Number one. And then number two, let's just wave a wand for example and say, three years from now, you've got a set of 12% of your patients in Home, let's say it's 25%. How do you think about that at a high-level from a return on capital, a contribution to margin, total economics to the enterprise?

我的另一個問題是，我們華盛頓特區的人們認為 CMMI 可能會為家庭透析制定一些不同的支付結構。那麼兩個問題。一，你聽過這些嗎？第一。第二，舉個例子，讓我們揮動魔杖，說，三年後，您的家庭中有 12% 的患者，假設是 25%。您如何從資本報酬率、利潤率貢獻、企業總體經濟效益等方面來看待這個問題？

Yes, I'll take a stab at it. Number one, CMMI is looking at a bunch of kidney care stuff, including eliminating some of the obstacles to Home and PD growth. And we are supporters of that and we're in regular constructive conversations with them about the best way to do it. We have had a series of meetings. They have also talked with other people. And so we applaud a bunch of the stuff that they're looking at, and hope that they go ahead and put it in and think there's a good chance that they will. And then second, if you wave that wand, that is a good world in a couple of different ways. One, it just significantly reduces the capital intensity of our business. Number two, there are some patients in America who would be happier or healthier on Home that are not on it today because of local practice patterns, nephrology group preferences, et cetera. And we've been growing home steadily. Javier referred to the fact that we've been the leader for a long time in this and intend to remain the leader. But that doesn't mean that every single patient that should be on Home or might be happier on Home is on it now. And so implication #1 is that outside of capital intensity, excuse me, would be happier and in some cases healthier patients. Having said all that, right now when people walk around saying that Home is almost uniformly a better form of care for dialysis patients, it's factually incorrect. And so for a lot of patients, it leads to a better life. For a subset of patients, it leads to better clinical outcomes, but not for everyone. And what you tend to have is that the type of people who take the initiative and have the desire to dialyze at home are fundamentally different type of patients on average than those who stay in the center. So it's very, very difficult to do an apples-to-apples clinical comparison because of the type of population you have that is willing to take on the burden and responsibility and risk of dialyzing at home.

是的，我會嘗試一下。第一，CMMI 正在研究一系列腎臟護理的內容，包括消除 Home 和 PD 成長的一些障礙。我們是這一點的支持者，我們定期與他們進行建設性對話，討論實現這一目標的最佳方式。我們舉行了一系列會議。他們也與其他人交談過。因此，我們對他們正在研究的許多東西表示讚賞，並希望他們繼續將其放入，並認為他們很有可能會這樣做。其次，如果你揮舞魔杖，從幾個不同的角度來看，這就是一個美好的世界。第一，它大大降低了我們業務的資本密集度。第二，在美國，有一些患者本來在 Home 上會更快樂或更健康，但由於當地的醫療模式、腎臟病學團體的偏好等原因，現在沒有在 Home 上。我們的家庭一直在穩步發展。哈維爾提到，我們長期以來一直是這方面的領導者，並且打算繼續保持領先地位。但這並不意味著每個應該在 Home 上或可能對 Home 更滿意的患者現在都在使用 Home。因此，暗示#1 是，除了資本密集度之外，請原諒，患者會更快樂，在某些情況下更健康。話雖如此，現在當人們到處說家庭幾乎都是透析患者更好的照護方式時，這實際上是錯誤的。因此，對於許多患者來說，它可以帶來更好的生活。對於一部分患者來說，它會帶來更好的臨床結果，但並非適合所有人。你往往會發現，那些主動採取行動並願意在家中進行透析的人與那些留在中心的人相比，是根本不同類型的患者。因此，由於願意承擔在家透析的負擔、責任和風險的人群類型，進行同類臨床比較是非常非常困難的。

And last one for me. Just at a very high level for home, how much of the relatively minor mix in your opinion is qualitative factors around physician practice patterns versus quantitive and clinical factors?

最後一張給我。就家庭而言，在非常高的水平上，您認為相對較小的組合中有多少是圍繞醫生實踐模式的定性因素，而不是定量和臨床因素？

Could you say the question again, please?

請你再說一次這個問題好嗎？

Probably not, but I'll try. So what we have been told is that some of the shortfall -- the growth has been kind of tiny, 20, 30 bps a year. What we've been told is that some of that is just physicians not being trained physicians, not being at the rhythm of thinking about Home and just the default answer is the clinic. And whereas others is, some patients don't belong at Home as you mentioned. So if you had to guess, if we normalize the physician practice patterns across the country and everybody was thinking about it like this is the first option let's send the patient home if we can. Where can the mix go to just with qualitative physician decision making versus some of the other factors around the payment structures and clinical obstacles?

可能不會，但我會嘗試。所以我們被告知的是，一些缺口——成長有點小，每年 20、30 個基點。我們被告知的是，其中一些只是醫生沒有接受過訓練，沒有達到思考「家」的節奏，而預設的答案就是診所。正如您所提到的，儘管其他患者是這樣，但有些患者不屬於家。因此，如果你不得不猜測，如果我們將全國範圍內的醫生執業模式標準化，並且每個人都在考慮這是第一個選擇，那麼如果可以的話，讓我們將患者送回家。與支付結構和臨床障礙相關的其他一些因素相比，定性醫師決策的組合可以走向何方？

John, this is Javier. I think when we look around and we see the most, let's call it, Home champions, the most dedicated physicians that have a good education program and are really trying to champion the right modality for the right patient, you get into a low 20-or-so mix, maybe you get it up to 25 if they are really, really good, but that's on the high-end. And as you look around the world, that's probably also a good number to use.

約翰，這是哈維爾。我認為，當我們環顧四周，看到最多的，讓我們稱之為家庭冠軍，最敬業的醫生，擁有良好的教育計劃，並真正努力為正確的患者提供正確的治療方式時，你就會進入低20-左右混合，如果它們真的非常好的話，也許你可以把它提高到 25，但這只是高端。當你環顧世界時，這可能也是一個很好的數字。

Our next question comes from Kevin Fischbeck, Bank of America.

我們的下一個問題來自美國銀行的 Kevin Fischbeck。

A few more for me. I guess I might have missed it, but did you say that the guidance for 2019 includes additional advocacy cost or is that included in the normal run rate spend?

給我多一些。我想我可能錯過了，但您是否說 2019 年的指導包括額外的宣傳成本，或者是否包含在正常的運行費用中？

No. It includes this $30 million, which is consistent with what we've said before. And think of it as 60-ish million less than the 90-something that we had in 2018. The point, I think, Javier was trying to make is that we've always had advocacy costs built into our cost structure. It went up significantly in 2018 as a result of the California stuff. So this 30 is kind of the remnant of that California piece that will roll through. There's other stuff that's always been in there, and that hasn't changed.

不。其中包括這3000萬美元，這和我們之前說的是一致的。與 2018 年 90 多歲的人數相比，這一數字減少了 60 多萬人。我認為，哈維爾試圖表達的觀點是，我們的成本結構中始終包含宣傳成本。由於加州的影響，2018 年這一數字顯著上升。所以這 30 是加州那篇即將推出的作品的殘餘。還有其他東西一直在那裡，沒有改變。

Okay, great. And then just on the Home Health commentary. Obviously, Home Health is something you guys have talked about from time to time and have been supportive of. But this is -- I don't know this feels a little bit more of a discussion than I'm used to hearing from you guys. Is there anything -- so obviously lower capital intensity is good, it's good for some subset of the patients, so that's good, probably better for commercial patients, so that's good. But is there anything that you have to worry about as you move to Home Hemo because one of the things that just structurally I would think that you and Fresenius have, there is some barrier to entry, and that you guys already have bricks-and-mortar across the country to the extent that we create and push towards a less capital-intensive model probably speaking? Does that create the potential for disruption or more competition, are you worried about it? So, a, am I off based on that concern? And b, is there any other -- is there any downside that you can think of it, if not that, that towards Home Hemo getting bigger?

好的，太好了。然後是家庭健康評論。顯然，家庭健康是你們不時會談論並支持的事情。但這是——我不知道這感覺比我習慣從你們那裡聽到的討論更多。有沒有什麼——很明顯，較低的資本密集度是好的，這對某些患者有好處，所以這很好，可能對商業患者更好，所以這很好。但是，當您轉向 Home Hemo 時，有什麼需要擔心的嗎？因為從結構上來說，我認為您和費森尤斯擁有的一件事是，存在一些進入壁壘，而且您已經擁有了實體——也許可以說，我們在全國範圍內創建並推動資本密集度較低的模式的程度如何？這是否會造成破壞或更多競爭的可能性，您擔心嗎？那麼，我是否因為這種擔憂而離開了？b，對於 Home Hemo 變得更大，是否還有其他您能想到的缺點（如果不是的話）？

Yes, so one of the most important things to remember is that our patients are big consumers of the entire healthcare system. And by definition, when your kidneys fail, you're fragile and you're quite sick. And so one of the things that's not discussed when discussing Home is that the peritoneal cavity, a, there are high infections. And two, that sometimes it doesn't last. And sometimes it's probably not the right word, but in most times it actually gives within two years or so. And so if you were to look at a patient of ours, they are, a, hospitalized -- Home patients that are hospitalized. And of course, DaVita and Fresenius serve in the acute setting. And then number two, is approximately 85% of patients that treat at Home will have to use an in-center at some point in their care. And so having the entire suite, meaning the hospital, the clinic and the Home service is a very important part of the value proposition for a patient, because they want the continuity of care, they want their doctor to go from the hospital, to the center, to the clinic, and then, of course, home. So is that responsive to your answer?

是的，所以要記住的最重要的事情之一是我們的患者是整個醫療保健系統的大消費者。根據定義，當您的腎臟衰竭時，您就會變得脆弱並且病得很重。因此，在討論「Home」時沒有討論的一件事是腹膜腔感染率很高。第二，有時它不會持久。有時這可能不是正確的詞，但在大多數情況下它實際上會在兩年左右的時間內給出。因此，如果你觀察我們的病人，他們是住院的家庭病人。當然，達維塔和費森尤斯在急性環境中發揮作用。第二，大約 85% 在家接受治療的患者在護理過程中的某個時刻必須使用中心治療。因此，擁有整個套件，意味著醫院、診所和家庭服務，對病人來說是價值主張中非常重要的一部分，因為他們想要護理的連續性，他們希望他們的醫生從醫院到醫院中心，到診所，然後當然是回家。那麼這對你的答案有反應嗎？

Yes the presence of bricks-and-mortar is always going to have an important role, even if home hemo becomes a bit bigger than what it is now. All right. And then the other question I want to understand a little bit more about the sale-leaseback dynamic. Are you signaling that you plan on owning your sites as a percentage going forward through these sale-leasebacks? Or is this more just a method of financing that disruption and that you wouldn't expect to be leasing a higher percentage of the sale-lease going forward?

是的，實體店的存在總是會發揮重要作用，即使家庭血液變得比現在更大。好的。然後另一個問題是我想更多地了解售後回租的動態。您是否表示您計劃透過這些售後回租來擁有自己的網站？或者這只是一種為這種破壞提供融資的方法，而您不希望未來租賃更高比例的銷售租賃？

So Kevin, there's no real change in the amount of real estate we're planning on owning, which is extremely low. What the dynamic here is that we have found rather than having someone else build the center for us and us leasing it, it is more cost-effective for us both in terms of the capital and the ultimate lease expense for us to build the center and then sell the already constructed center. So the impact on our cash flow is that we are -- we have an increase in CapEx as a result of this, which flows through the normal CapEx line. There's a net benefit, which doesn't flow through the CapEx line, but is effectively economically an offset to our CapEx when we sell the center. So no real change in how the ultimate ownership of the center, but it does create a little noise on our cash flow that we wanted to really clarify. And that's why we've added over the last few quarters how this plays out in Table 6, what the net kind of bring back against the CapEx is. We understand it's a little bit confusing, but we thought it was important to lay it out to make sure everyone has the clearest view of what the real CapEx and cash flow of the business is.

凱文，我們計劃擁有的房地產數量沒有真正的變化，這個數量非常低。這裡的動態是，我們發現，與讓別人為我們建造中心並由我們租賃它相比，無論是在資本還是最終租賃費用方面，我們建造中心和租賃它對我們來說都更具成本效益。然後出售已經建成的中心。因此，對我們現金流量的影響是，我們的資本支出因此增加，流經正常的資本支出線。這是一個淨收益，它不會流經資本支出線，但在我們出售該中心時，它在經濟上有效地抵消了我們的資本支出。因此，中心的最終所有權並沒有發生真正的變化，但它確實對我們的現金流產生了一些噪音，我們想要真正澄清這一點。這就是為什麼我們在過去幾季在表 6 中加入了這種情況的表現，即針對資本支出的淨回報是什麼。我們知道這有點令人困惑，但我們認為將其列出來確保每個人都能最清楚地了解業務的真實資本支出和現金流量是很重要的。

Our next question comes from Whit Mayo, UBS.

我們的下一個問題來自瑞銀集團的惠特·梅奧。

Just a couple of quick ones, there are some numbers kind of moving around versus my notes. So just want to make sure I've got the correct headwinds and tailwinds written down. On the tailwind side for this year, I've got DaVita Rx losses reversing to be a $25 million tailwind. I think Joel you cited now a net 60-million-ish tailwind in California on advocacy, and then may be a $35 million pick up on Medicare rates. Are those the big buckets or those the right numbers, are we missing anything?

只是幾個快速的，有一些數字在我的筆記中移動。所以只是想確保我寫下了正確的逆風和順風。今年的有利因素是，DaVita Rx 的虧損扭轉為 2500 萬美元。我認為喬爾現在提到了加州在宣傳方面淨帶來 6000 萬左右的順風車，然後醫療保險費率可能會增加 3500 萬美元。這些是大桶還是正確的數字，我們是否遺漏了什麼？

I think the sizes are about right. The Medicare is actually a headwind. I'm getting puzzled.

我認為尺寸差不多。醫療保險其實是一個逆風。我越來越困惑了

I guess I was thinking more just on the rate update?

我想我更多地考慮的是費率更新？

Oh, on the rate update, yes, I thought you were talking about the Medicare bad debt issue with positive revenue.

哦，關於費率更新，是的，我以為您正在談論具有正收入的醫療保險壞帳問題。

Yes, okay. Is that in the ballpark, $35 million just net incremental tailwind from the rate update?

是的，好的。3500 萬美元只是利率更新帶來的淨增量順風車，這是否符合預期？

That's about right.

差不多是這樣吧。

Okay. And then on the headwinds, as you mentioned, you've got a $36 million headwind from the Medicare bad debt recoveries and then maybe a $17 million reversal from DaVita Health Solutions. Any other major headwinds and are those the right numbers?

好的。然後就逆風而言，正如您所提到的，醫療保險壞帳回收帶來了 3600 萬美元的逆風，然後 DaVita Health Solutions 可能帶來了 1700 萬美元的逆轉。還有其他主要阻力嗎？這些數字正確嗎？

Those are about right. DHS, I wouldn't call it a reversal in an accounting standpoint, it's -- it was pocketed last year

這些都是對的。國土安全部，從會計角度來看，我不會稱之為逆轉，它是－－去年被收入囊中的

Lack of a tailwind.

缺乏順風。

Yes, it's the lack of -- yes.

是的，這是缺乏——是的。

Yes, okay, okay, and so that implies...

是的，好吧，好吧，這意味著......

The one other thing I would point to was the retirement cost that we had in Q3. The number was roughly $25 million -- $23 million precisely, add that to the tailwind category.

我要指出的另一件事是我們在第三季的退休成本。這個數字大約是 2500 萬美元——準確地說是 2300 萬美元，加上順風車類別。

Yes, got it. Okay. And then one last one, just the calcimimetics landscape is like fairly fluid right now, some drugs coming on/off the market. Just what's the expectation for 2019 and I'll get off next?

是的，明白了。好的。最後一點，擬鈣劑的前景現在相當不穩定，一些藥物上市/退出市場。2019年的期望是什麼，接下來我會下車嗎？

Yes. So I think, you're exactly right, it is a very fluid situation. It is one of the largest components of the swing in our $100 million of OI guidance, given the different ways it could play out. But roughly speaking, kind of if you think about the middle of the range, it's not a big change year-over-year. But again, a lot of variability in terms of how it plays out.

是的。所以我認為，你是完全正確的，這是一個非常不穩定的情況。考慮到它可能以不同的方式發揮作用，它是我們 1 億美元的 OI 指導中波動最大的組成部分之一。但粗略地說，如果你考慮範圍的中間，那麼同比變化並不是很大。但同樣，它的發揮方式也存在著很大的可變性。

So what would be the scenarios that would play out that would get you towards the low end versus the high end. Is there any way to share what would have to happen with calcimimetics to be within that range?

那麼，什麼情況會導致你走向低端而不是高端。有什麼方法可以分享擬鈣劑在這個範圍內會發生什麼嗎？

The couple of dynamics that you have to consider are, one, prescription patterns. In there you have, does oral come down? Or go up? Or do physicians prefer IV or oral? So there is a mix in there. In addition, then you have to consider whether more generics come in the market. So if it's one player versus five players and what happens to pricing. And so then, of course, you have a calculation on ASP that has got a lag, and has got a six month lag in that. So those are the dynamics in play.

您必須考慮的兩個動態因素是：第一，處方模式。你那裡有，口頭下來嗎？還是上去？或是醫生喜歡靜脈注射還是口服？所以裡面有一個混合。此外，你還必須考慮市場上是否有更多仿製藥上市。那麼，如果是一名玩家對五名玩家，定價會發生什麼變化。當然，您對 ASP 的計算存在滯後，並且存在六個月的滯後。這些就是發揮作用的動力。

One last one just on ASP. Can you comment how ASP has trended the last 6 to 12 months? And what that implies for the next 6 months. And I promise I'm off now.

最後一篇是關於 ASP 的。您能否評論一下過去 6 至 12 個月 ASP 的趨勢？這對未來 6 個月意味著什麼。我保證我現在就走了。

ASP has trended down. And then as it relates to prediction, you can't have one, because of all the things I just went through.

ASP 呈下降趨勢。然後，當它與預測相關時，你不可能有一個，因為我剛剛經歷了所有的事情。

And the next question comes from Gary Taylor, JPMorgan.

下一個問題來自摩根大通的加里泰勒。

See what happens when you move your call to the morning, nobody knows how to get off the phone. Everybody is double dipping. I just had a quick one. I just want to go back to while I had you kind of this question about slower growth in the industry. Looking at the U.S. RDF data and maybe there's a good reason why it's not good or comprehensive, but if you look at prevalent population growth before 2000, it was in the 5s. From 2010, it was in the 4s. Since 2010, it's been in the 3s, it's a couple of years lag, but it looks like it's poised to drop into the 2s. So when you look at kind of that bigger picture of the industry maturing, you're saying you're seeing something that looks more step function-ish than sort of that long decline we've seen over the last 30 years?

看看當你把電話轉移到早上會發生什麼，沒有人知道如何掛斷電話。每個人都在雙重浸淫。我剛剛喝了一杯。我只想回顧一下我向你們提出的有關行業成長放緩的問題。看看美國的 RDF 數據，也許它不夠好或不全面是有充分理由的，但如果你看看 2000 年之前的普遍人口成長率，你會發現它是在 5 左右。從2010年開始，一直是4s。自 2010 年以來，它一直處於 3 年代，雖然滯後了幾年，但看起來即將跌至 2 年代。所以，當你從更大的角度看待這個行業的成熟時，你是說你看到的東西看起來更像是階躍函數，而不是我們在過去 30 年看到的長期衰退？

No. I would say the opposite probably, is that the data is quite clear that nothing dramatic happens quickly. And yet the trend is the trend. And we're not predicting any significant change in either direction off the trend. But recognize that there is an awful lot of dynamism underneath that number. On the one hand treatment for diabetes and hypertension, some of the primary causes of kidney failure are getting better. So you could argue that, that would lead to a reduction in dialysis patients. On the other hand, the African-American and Hispanic populations are growing significantly in America, and they are far more likely to have kidney disease and kidney failure so that pushes exactly the opposite direction. And I could cite two or three or fur other variables. So under the surface of that long-term trend, which we think may very well continue without any significant discontinuity up or down. But underneath that are a lot of basic fundamental forces in American health care and American demographics. And so it's very difficult to get too confident, because if any of those underlying trends change, that would in fact create some sort of discontinuity in the trend. It just hasn't for the past 25 years.

不。我想說的可能恰恰相反，數據非常清楚，沒有什麼戲劇性的事情會很快發生。但趨勢就是趨勢。我們預期趨勢中的任何一個方向都不會有任何重大變化。但要認識到，這個數字背後蘊藏著巨大的活力。一方面治療糖尿病和高血壓，一些導致腎衰竭的主要原因正在改善。所以你可能會說，這會導致透析患者的減少。另一方面，美國的非裔美國人和西班牙裔人口正在顯著增長，他們患腎病和腎衰竭的可能性要大得多，因此，情況恰恰相反。我可以引用兩個或三個或其他變數。因此，在長期趨勢的表面之下，我們認為這種趨勢很可能會持續下去，不會有任何明顯的上下不連續。但背後是美國醫療保健和美國人口統計中的許多基本力量。因此，很難變得過於自信，因為如果這些潛在趨勢中的任何一個發生變化，實際上都會在趨勢中造成某種不連續性。只是過去 25 年來一直沒有這樣。

Got you. Yes, I just thought the opioids transplant commentary was perhaps suggesting you thought you were seeing something more onerous or steeper. So I appreciate the clarification.

明白你了。是的，我只是認為阿片類藥物移植評論可能暗示你認為你看到了更繁重或更陡峭的東西。所以我很感謝你的澄清。

Let's stay on that for one second. Because that is a perfect example of a new discontinuity, but we would also predict probably a relatively temporary one and that we would say that five years from now the incidence of opioid abuse and people getting to the point where their kidneys fail because of a lack of treatment is going to be reduced dramatically because already the leading indicators for that things like prescription patterns, prescription limitations, prescription oversight, clinic availability to help these people, all of that is fundamentally changing throughout America, and is quite well-funded in many cases. So that's a classic example of a new thing that has had a negative impact in some ways -- on us in the short term, but will probably on a relative basis become an incrementally positive one over the next 5, 6, 7, 8 years. But it's once again very difficult to quantify and calibrate because it has do with fundamental demographic issues and fundamental health care system issues.

讓我們在此停留一秒鐘。因為這是一個新的不連續性的完美例子，但我們也預測可能是一個相對暫時的不連續性，我們會說五年後阿片類藥物濫用的發生率以及人們會因為缺乏阿片類藥物而導致腎臟衰竭治療的費用將大幅減少，因為處方模式、處方限制、處方監督、幫助這些人的診所可用性等方面的領先指標已經在整個美國發生了根本性的變化，並且在許多國家都得到了充足的資金案例。這是一個新事物的典型例子，它在短期內對我們產生了某些方面的負面影響，但在未來 5、6、7、8 年裡，相對而言可能會逐漸變得積極。 。但它再次非常難以量化和校準，因為它與基本的人口問題和基本的醫療保健系統問題有關。

Our next question comes from Pito Chickering, Deutsche Bank.

我們的下一個問題來自德意志銀行的 Pito Chickering。

Thanks for taking extra questions here. So I want to take another crack at the organic treatment growth you guys are -- what you guys have guided to versus what we did in the fourth quarter, the 2.6 in the fourth quarter, guidance of 2.5 to 3.5 for 2019. So new point of guidance is implying an upside versus what you're reporting and effectively calling fourth quarter as with the bottom with the range this can be. Can you give us any additional color in terms of sort of why this has improved to the midpoint of your guidance for '19?

感謝您在這裡提出額外問題。因此，我想對你們的有機治療成長進行另一次嘗試——你們所指導的與我們在第四季度所做的相比，第四季度為 2.6，2019 年指導為 2.5 至 3.5。因此，新的指導點意味著與您所報告的情況相比有上行空間，並有效地將第四季度稱為該範圍的底部。您能給我們任何額外的資訊來解釋為什麼這已經改善到您 19 年指導的中點嗎？

I'll take a crack at that. Although I don't think I got much to add. The number does bounce around a bit. And we tend to look at things, somethings purely on a quarterly basis, other with a little bit of a blending over time. So I'd say we're not -- we're blending the Q4 data point with some prior data and our go-forward model, so we come up with something that's in that 2.5 to 3.5 range.

我會嘗試一下。雖然我不認為我有太多可以補充的。這個數字確實有點反彈。我們傾向於看一些事情，有些事情純粹是按季度進行，有些則隨著時間的推移進行一些混合。所以我想說我們不是——我們將第四季度的數據點與一些先前的數據和我們的前進模型混合在一起，所以我們得出了 2.5 到 3.5 範圍內的數據。

And speakers we show no further questions at this time.

對於發言人，我們目前沒有提出任何進一步的問題。

All right. Thank you all very much for your interest in DaVita. We look forward to talking to you, again, next quarter.

好的。非常感謝大家對 DaVita 的興趣。我們期待下個季度再次與您交談。

Thank you, speakers. And that concludes today's conference. Thank you all for joining. You may disconnect at this time.

謝謝各位發言者。今天的會議到此結束。感謝大家的加入。此時您可以斷開連線。