Q2 2026 DaVita Inc Earnings Call
Speaker #1: on mute to prevent any background noise. After the speakers' remarks, there will be a question-and-answer period. If you would like to ask a question during this time, simply press star then the number 1 on your telephone keypad.
Speaker #1: question, press star then the number 2. Thank you. Mr. Eliason, you may begin your conference.
Speaker #2: our second quarter conference call. We appreciate your continued interest in our company. I'm Nich Eliason, Group Vice President of Investor Relations and joining me today are Javier Rodriguez, our CEO, and Joel Ackerman, our CFO.
Speaker #2: 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.
Speaker #2: 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 second quarter earnings press release and our SEC filings, including our most recent annual report on Form 10-K, all subsequent quarterly reports on Form 10-Q, and other subsequent filings that we may make with the SEC.
Speaker #2: Our forward-looking statements are based on information currently available to us, and we do not intend and undertake no duty to update these statements except as may be required by law.
Speaker #2: Additionally, we'd like to remind you that during this call we will discuss some non-GAAP financial measures. A reconciliation of these non-GAAP measures to the most comparable GAAP financial measures is included in our earnings press release furnished to the SEC and available on our website.
Speaker #2: I will now turn the call over to Javier Rodriguez.
Speaker #3: Thank you, Nick. Good afternoon, everyone, and thank you for joining the call today. It's been a busy and exciting summer. One exception is that I have to wait another four years to root for Mexico to win the World Cup.
Speaker #3: Our strategies are coming together thanks to the amazing work of our teammates and caregivers. Their effort has led to another positive quarter for our patient outcomes and financial results.
Speaker #3: On today's call, in addition to our second quarter performance, I will focus on recent innovation in the dialysis industry. Specifically, the clearance of metal molecules and the steps we're taking to Moving on to more important elevate the standard of care for our patients.
Speaker #3: I'll also share our perspective on the recent ESRD proposed rule in close with our guidance for the remaining of the year. But first, as always, I will begin with the clinical highlight.
Speaker #3: Today, I'd like to reflect on the successful transition of phosphate binders into the Medicare dialysis bundle. With advanced notice from CMS, this process began more than two years ago with a goal of expanding access to a wide range of therapies for a broader group of patients.
Speaker #3: And that goal has been achieved. With DAVITA's broad formulary, our physician partners now have greater flexibility to prescribe the therapy that's best suited for each patient's needs.
Speaker #3: This has reduced by more than 50% the number of patients relying on less effective over-the-counter options, such as TUMS, and instead now are benefiting from clinically preferred therapies.
Speaker #3: That means more patients are receiving treatments that better manage phosphate levels and help reduce the risk of cardiovascular complications and bone fractures. It's a powerful example of how the right policy combined with strong clinical execution can expand access to better care and improve long-term patient health.
Speaker #3: Transitioning to the second quarter performance, our results were broadly in line with our expectations. Beneath this headline, I will highlight two primary dynamics. First, year-over-year volume growth continued to accelerate, slightly faster than expected, driven by continued improvements in mortality.
Speaker #3: Second, compared to the first quarter, revenue per treatment declined as we expected, reflecting lower commercial mix from declining ACA enrollment and lower sequential revenue contribution from phosphate binders.
Speaker #3: Joel will provide more detail on these dynamics and other moving pieces within the quarter. Turning to policy, in late June, as its customary, CMS released a proposed rule for 2027 prospective payment system for ESRD.
Speaker #3: The proposal includes an update to Medicare-based rates and the addition of phosphate binders to the bundle dialysis payment beginning next year. Starting with the base rate, the proposed payment update is more complex than in prior years, with methodology changes in various to DAPA-related dynamics.
Speaker #3: The net result is a rate increase that once again tracks below the cost trends for the industry. We're providing feedback during the rulemaking process and remain hopeful the final rule will better reflect the cost of delivering high-quality care.
Speaker #3: On phosphate binders, we continue to support CMS's approach to moving these medications into the dialysis bundle. In addition to the clinical benefits, the policy is lowering projected government spending.
Speaker #3: Since the initial transition of these medications, CMS has reduced their estimate for phosphate binder spend by nearly $500 million. We also support concluding the to DAPA period after two years.
Speaker #3: And while the proposed post to DAPA rate adjustment is appropriate, our ultimate financial impact for 2027 will depend on the bundle update within the final rule later this year.
Speaker #3: Let me turn to metal molecule clearance and the recent results from the mother clinical trial. As a reminder, the primary objective of dialysis is to remove harmful toxins from the body.
Speaker #3: Newer therapies can remove a broader range of these toxins known as metal molecules. The goal is to reduce inflammation, cardiovascular complications, and mortality while enhancing the patient's quality of life.
Speaker #3: Achieving these outcomes is a key building block in our expectation of returning the treatment volume growth of at least 2% by 2029. Two approaches which have been used for many years internationally and are now emerging in the United States.
Speaker #3: Hemodial filtration, or HDF, which utilizes a specialized dialysis machine and expanded hemodialysis, or expanded HD, which is performed with an advanced dialyzer. I will cover three things: what the study showed, why it matters, and what it means for DAVITA going forward.
Speaker #3: First, the mother trial compared these two dialysis therapies head-to-head and demonstrated that expanded HD, using medium cutoff dialyzer, is non-inferior to HDF on a composite endpoint of all cost mortality and major cardiovascular events.
Speaker #3: Why does this matter? First and foremost, it is a great news for our patient. It gives physicians another evidence-based option for metal molecule clearance, allowing them to tailor treatment to the need of individual patients.
Speaker #3: Expanded HD also offers meaningful operational advantages because it can be delivered on our existing dialysis machines, making it faster to expand access without significant capital investment.
Speaker #3: This brings us to our path forward. We continue to support both HDF and expanded HD and believe physicians should have the flexibility to choose the right therapy for each patient.
Speaker #3: That said, the recent FDA approval of the new expanded HD dialyzer from NEPRO represents an important milestone that should materially improve both market supply and economics.
Speaker #3: To capture this clinical opportunity, we have secured supply to these expanded HD dialyzers which are fully compatible with our existing machines and provide highly effective clearance of metal molecules.
Speaker #3: As a result, we expect to begin deploying expanded HD broadly across our network in the coming quarters. This will allow us to expand access quickly and deliver this option to our patients and physicians' partners.
Speaker #3: As we move forward, we'll continue evaluating how both approaches perform across different care settings and patient populations in the real world practice. I'll wrap up my prepared remarks with our financial outlook for the remaining of the year.
Speaker #3: With the benefit of another quarter, three trends are coming into better focus. First, continued momentum in volume growth. Second, greater confidence in our estimate of the impact of effectuation rates per exchange plans.
Speaker #3: And third, our efforts to provide broad access to metal molecule clearance for our patients. With consideration of these factors, we're reconfirming our full year 2026 guidance ranges.
Speaker #3: This reflects a midpoint of 2.2 billion dollars for adjusted operating income and a midpoint of $14.65 for adjusted earnings per share. We look forward to continuing our clinical, operational, and financial momentum in the back half of the year.
Speaker #3: I will now turn the call over to Joel to discuss our financial performance in more detail.
Speaker #1: Thank you, Javier. I'll begin with the details on our second quarter results and close with some additional color on the remainder of the year.
Speaker #1: Second quarter adjusted operating income was $579 million adjusted earning per share was $4.02 and free cash flow was $256 million. Beginning with US dialysis, treatments increased 56 basis points versus Q2 of 2025.
Speaker #1: Treatments per normalized day also increased 56 basis points as there was no impact from the calendar as compared to the same period last year.
Speaker #1: Volume growth was slightly higher than expected as a result of lower-than-expected mortality offset by fewer admits from closed Fresenius clinics and higher-than-expected mistreatments. Our confidence in our treatment volume trajectory for the year continues to grow, and we now expect 2026 growth in total treatments near the top end of our previous guidance range of 25 to 50 basis points.
Speaker #1: As a reminder, our treatment volume expectations are for nominal treatment growth. This would translate to approximately 50 to 75 basis points of growth when normalizing for year over year calendar impacts.
Speaker #1: The calendar impact in the back half of the year will result in a year over year tailwind in Q3 and headwind in Q4. Revenue per treatment decreased by approximately $2 sequentially primarily the result of favorable revenue timing in Q1, lower sequential revenue from phosphate binders, and a decline in commercial mix related to the expired ACA subsidies in line with our guidance from last quarter.
Speaker #1: These RPT headwinds were partially offset by the typical sequential increase from higher patient responsibility amounts in the first quarter and higher average rates. Although year-to-date revenue per treatment has been 3.6% higher than the first half of 2025, we continue to expect full year 2026 RPT growth of 1 to 2%.
Speaker #1: The midpoint of that range implies that RPT growth in the second half of 2026 will be slightly negative as compared to the second half of 2025.
Speaker #1: This is a function of declining commercial mix, lower phosphate binder revenue, and the benefit in Q4 2025 from the timing of aged claim resolutions.
Speaker #1: Patient care cost per treatment declined approximately $3 sequentially as a result of operating leverage on labor and other fixed costs driven by increased treatment volume in Q2 and a decline in phosphate binder costs offset by higher benefit costs.
Speaker #1: Year-to-date PCCs have grown more than 3% versus the first half of 2025, above our expected range for the full year growth. Similar to the dynamic in revenue per treatment, we expect year-over-year growth in patient care costs to decelerate in the back half of the year.
Speaker #1: Driven by decreasing phosphate binder expenses, and lower year-over-year growth of facility maintenance spend. In other costs, US dialysis G&A increased $11 million versus the first quarter and US dialysis depreciation and amortization decreased by $9 million sequentially.
Speaker #1: We continue to expect total cost per treatment to grow between $1.25% and $2.25% for the full year. Turning to our other segments, international adjusted operating income was $25 million in Q2 in line with expectations.
Speaker #1: IKC delivered positive $40 million of adjusted operating income above our expectations for the quarter as a result of timing of revenue earlier in the year than anticipated, we still expect international and IKC growth to contribute approximately $20 million each to full year enterprise adjusted operating income growth.
Speaker #1: Regarding capital allocation, in July we closed on our minority investment in Alara Caring which provides an exciting opportunity to help bring dialysis-tailored home health services offerings to our patients.
Speaker #1: As a reminder, we invested $200 million and expect Alara to provide a small benefit to other income in 2026, likely mid-single-digit millions. Additionally, we repurchased $2.2 million shares during Q2 and additional $183,000 shares since the end of the quarter.
Speaker #1: As a reminder, we buy shares from Berkshire Hathaway each quarter pursuant to our repurchase agreement to maintain their ownership near 45%. Our leverage ratio at the end of the quarter was 3.37 times consolidated EBITDA within our target range of 3 to 3 and a half times EBITDA.
Speaker #1: Debt expense in the quarter was $152 million. During the quarter, we issued $500 million of incremental debt with proceeds primarily used to repay Revolver borrowings.
Speaker #1: For the full year, we are reiterating our adjusted operating income guidance range with a midpoint of 2.2 billion dollars and our adjusted earnings per share guidance range with a midpoint of $14.65.
Speaker #1: To help you model the back half of the year, we anticipate a sequential increase in adjusted operating income of $50 to $100 million from Q3 to Q4 with timing of IKC being the biggest driver.
Speaker #1: That concludes my prepared remarks for today. Operator, please open the call for Q&A.
Speaker #2: Thank you, sir. If you would like to ask a question during this time, simply press star and then the number 1 on your telephone keypad.
Speaker #2: If you would like to withdraw your question, press star, then the number 2. Our first caller is Andrew Monk with Barclays. Your line is open, sir.
Speaker #3: Hi, good afternoon. Despite the growth in treatments, U.S. dialysis OI was relatively flat year over year, while lapping a $45 million cyber headwind. So, can you help us understand why we didn’t see better leverage from the treatment growth? And can you comment on the elevated CPT in the quarter?
Speaker #4: Yeah. I'll take that, Andrew. So OI for the quarter at the enterprise level was up about 5%. You're right on the RPT dynamic. I think there are a bunch of other moving pieces on the cost per treatment side.
Speaker #4: So cost per treatment growth is elevated in the first half of the year, similar to RPT. So I think there's a bit of an offset there.
Speaker #4: And G&A growth continues to grow. It was roughly 10% for the quarter. So those would be the big items that I'd point out in the US dialysis side.
Speaker #3: Got it. Okay. And maybe on the volume side, there's a lot going on that's impacting volume trends. You spoke to an acceleration in volumes, continued improvement in mortality, and the high end of treatment growth for the full year.
Speaker #3: But when I look at the two LDOs reporting together, it looks like same store treatment growth was negative in the quarter. Is it your sense that industry volumes were negative or did smaller chains take market share?
Speaker #4: No, we can't comment on the combined, because we obviously don't have visibility to everyone else. But what we can tell you is that our growth is mainly performance clinical, clinically that expands life, and therefore you get the volume treatment.
Speaker #4: And so I can't speak to what's going on in the rest of the industry. But we are gaining that through clinical outcomes.
Speaker #5: Yeah. And just to build on that, if you think about our performance for the quarter, as Javier said, it's clinically driven—also, that's mortality.
Speaker #5: And admits was largely in line with our expectations.
Speaker #3: Great. And maybe just last one. On the RPT side, you noted that declines sequentially due to commercial mix and phosphate binders. Can you give us the sequential change in mix and RPT from phosphate binders?
Speaker #3: Thanks.
Speaker #4: Yeah. So mix was complicated this quarter because we saw some coverage updates. Remember, in Q1, the impact of the ACA was lower than we expected, although we were waiting to see what happened with effectuation rates and how that would play through with coverage updates in Q2.
Speaker #4: Turned out it played out largely as we expected. So if you look at the average mix for the first half of the year, it's in the high 10s and really tracking as we expected in line with the 40 million dollar headwind that we'd expect for the full year.
Speaker #3: Great. Thanks.
Speaker #2: Thank you. Our next caller is AJ Rice with UBS. Your line is open, sir.
Speaker #6: Hi, everybody. Maybe just the first question: if you deploy the expanded HD capability, I just want to make sure I understand—the way that would impact the economics of the company would be if it results in improved mortality?
Speaker #6: Are there any other economic implications for you in the near term related to deploying that?
Speaker #4: Thanks, AJ. I think when you think of the deployment of this new technology, we divided into sort of three categories. The first is clinical.
Speaker #4: And you know the results of that and we talked about the studies being encouraging and you talked about the improvement in mortality. Of course, you also have to put physician preference and what they choose.
Speaker #4: Then you have to kind of move on to operational. And the experience on this is, we've switched dialyzers before. It's simple, and we can do it quickly.
Speaker #4: And then you have to kind of shift into the supply. And we are now confident that we could get supply. And that leads you to sort of the third one, the financial.
Speaker #4: And what I would say is that in 2026, it's included in our guidance. When you think of the future, for 2027 and beyond, there are several puts and takes.
Speaker #4: But at the end of the day, it will not be significant.
Speaker #6: Okay, all right. And maybe just to follow up—oh, go ahead.
Speaker #4: Let me just. Let me clear on that. The impact is insignificant until the mortality benefit kicks in. And that's when you'd see a positive economic impact.
Speaker #4: We wouldn't expect the positive mortality impact to start until 2028. There is a delay from when the new dialyzers are put in place until you see it.
Speaker #6: Okay. Interesting. Okay. I think in the prepared remarks, you did mention there was a little bit of elevated mistreatments. You also mentioned you didn't pick up as much as you expected from the Fresenius closures.
Speaker #6: I don't know whether there's anything to expand on there. Is it just normal ebb and flow with respect to the mistreatments? But I wanted to just give you a chance if there was some more color there.
Speaker #4: Yeah. Look, we're really parsing some pretty small numbers here in trying to bridge 10- or 15-basis-point changes. Nothing major on the mistreatment rate side and in terms of the Fresenius closures.
Speaker #4: It's probably five basis points of less positivity than we were expecting on the year. So again, a pretty small number. Nothing big that I'd call out.
Speaker #6: Okay. Thanks so much.
Speaker #2: Thank you. Our next caller is Justin Lake with Wolfe Research. Your line is open, sir.
Speaker #7: Thanks. Appreciate it. Can you first just, Joel, I want to make sure I have the numbers right here. For you said 75 or 50 to 100 million dollar increase in OI from Q2 to Q3?
Speaker #7: Is that right?
Speaker #4: No, no. That's about the phasing in the back half of the year. So we would expect Q3 to be $50 to $100 million lower than Q4.
Speaker #7: that makes a lot more sense than what I thought I understood. Okay. Great.
Speaker #4: Just to explain that, that's largely driven by IKC.
Speaker #7: Got it. And then you talked about mortality being a little better. Can you run us some of the numbers behind what you're seeing there?
Speaker #4: Yeah. I don't think we're going to call out quarterly mortality fluctuations. What I can say is the improvement is sustained. So we've seen it over a number of quarters now.
Speaker #4: It fluctuates. It was significantly better in Q1, which is what you'd expect because you have the flu dynamic there. But we continue to see improvements in Q2 as well.
Speaker #7: Okay. And what you're saying here is that your new patient starts are relatively flat and all the growth in is coming from mortality improvement.
Speaker #7: Is that the way to think about it?
Speaker #4: I think what we're saying is the benefit in the quarter relative to expectations was all mortality. It was actually mortality and then some because mistreatment rate came in a little worse than expected.
Speaker #4: And admits was in line with expectations.
Speaker #7: Okay. Great. Thanks for the call.
Speaker #2: Thank you. Our next caller is Peter Chickering with Deutsche Bank. Your line is open, sir.
Speaker #8: Hey, guys. Thanks for taking my question here. So the first one is looking at the route for treatment and the commercial mix. You said it was the high 10s and now you're seeing the impact of the 40 million dollars that you'd assume.
Speaker #8: Can you walk us through the process for those patients that are transferring from Hicks onto government coverage? Are you seeing new patients come in and go on government before they can go onto Hicks?
Speaker #8: Or are you seeing Hicks patients drop coverage? And do you see that mix change throughout the quarter? Did it start the same as the ended or did it change throughout the quarter?
Speaker #4: So, we're seeing both in terms of patients dropping coverage. We think the more sustained dynamic that we're expecting through the rest of the year and into next year would be that new admits are coming in at a lower commercial mix.
Speaker #4: Because of a lower QHP mix. So hard to predict exactly how it's going to play out, but we would expect that number to sustain itself through some part of next year.
Speaker #4: And that's what leads to the $40 million impact, and then the $70 million impact next year. The $70 million impact is a combination of the anniversary effect, or the annualizing effect, of the mix loss in 2026 that happened throughout the year, plus some additional mix loss in 2027.
Speaker #4: But again, largely the result of the new patient mix coming in lower.
Speaker #8: Okay. Can you remind us what the current occupancy of your centers is? So, where it was pre-COVID and, thinking about the pure variable costs and patients showing up, what does that look like?
Speaker #8: I'm just trying to figure out the sort of fixed cost leverage here of the business if you guys can keep on increasing the treatment growth throughout the year.
Speaker #4: Yeah. So capacity utilization is running in the high 50s now. It's been relatively steady for a number of years. If you went back pre-COVID at its peak, it ran about 65%.
Speaker #4: The question of fixed costs is a hard one because some things are fixed in the short term and less fixed in the long term. Also, the marginal profit of a patient depends on which patient it is.
Speaker #4: If it's a Medicare patient that has longer mortality, you'll get less marginal economics than adding a new commercial patient. So it's a hard number to pin down.
Speaker #4: It really depends on the situation you're trying to model.
Speaker #8: Okay. And the last one here, can you refresh us on sort of leverage ratios kind of what this doctorate in these levels kind of what do you think that the right leverage ratio is for you guys to be running at?
Speaker #8: Thanks so much.
Speaker #4: Yeah. We have not changed our view on that. And so we've given a range. And we are now at 3.37 for the quarter. And we had drawn down 65 million on our revolver.
Speaker #4: That's what we're seeing right now.
Speaker #2: Thank you. And as a reminder, that is *star 1* if you would like to ask a question. Our next caller is Kevin Fishback with Bank of America.
Speaker #2: Your line is open, sir.
Speaker #9: Great, thanks. I was wondering about the change in the expectation from Fresenius. Is that just what you experienced in the quarter, or have you also changed your expectation for how much you'll pick up from them during the year?
Speaker #4: Yeah. So that is very specific to the 100 clinics that they called out, I guess, last quarter that they were going to be closing.
Speaker #4: To the best of our understanding, they are done with that effort and so the pickup is done. I don't expect that to change at all over the course of the year.
Speaker #4: This had nothing to do with any of the other volume dynamics that they've been talking about over the last 24 hours. This was purely about the 100 clinics they closed.
Speaker #9: Okay. And then as far as the AC dialyzers, so just to be clear because I think you just said you've got a supply of that.
Speaker #9: So, have you secured enough to completely transition all of your facilities over to that next year, or is it just a portion of the facilities next year?
Speaker #9: Or within the next year?
Speaker #4: We've got enough to supply to transition as many as the doctors demand, and so we obviously don't think it'll happen in one day or one week.
Speaker #4: It'll take a little bit of time as a science gets rolled out. But we do have enough capacity to fulfill all the demand.
Speaker #9: Okay. And then can you talk a little bit about the IKC business? Obviously, you're talking about 20 million dollar improvement this year. Can you just remind us, I guess, based upon where you think the margins in that business can get to, how many more years of adding call it 1% to IY growth can is that business steadily improve?
Speaker #9: Can that add? Is this something that can happen for the next two years, five years? How should we think about that?
Speaker #4: I don't see any reason it couldn't continue for a while. Again, it isn't purely a margin play. There's also a volume question of increasing the number of lives and the number of dollars under management.
Speaker #4: And I could see that continuing to grow and that being as important, maybe more important of a driver than margin expansion. So I think we've got a lot of room to run.
Speaker #4: Yeah. I think you should think of it as a maturing business that requires a lot of coordination between nephrologists, clinics, and our teams. And so as that matures, and we evolve our model of care and our health evaluations and all that goes into it, we hope that there's improvement that can be sustained over time.
Speaker #9: Okay. Then maybe just last question then on that. So what has been driving that this year? Is that a function of improved medical expense?
Speaker #9: Is it growth in GNA leverage? What's driving the growth this year?
Speaker #4: Well, right now, it's just timing on revenue recognition. But as we look out, we're getting a bit more confident in our ability to manage the total care cost.
Speaker #4: And so we're getting a little more confidence there, coupled with we want to continue to grow the business, as Joel said, which means more contracts with MA.
Speaker #9: All right. Great. Thanks.
Speaker #4: Thank you.
Speaker #2: Thank you. Our next question comes from Ryan Langston with TD Cowan. Your line is open, sir.
Speaker #4: Thanks. Good afternoon. On the share repurchase, I think you've only repurchased about 0.2 million since the end of June. Obviously, I see the stock price move this year, but does the move change your capital allocation priority such that we might see a little bit less share repo?
Speaker #4: Through the rest of the year? No. I think what you want to think about is more our capital allocation and our view on Vivax is been absolutely consistent throughout the year.
Speaker #4: This particular calendar year, we were heavy on the front end in Q1. We purchased a fair amount, and so we are in a good spot year to date at $785 million.
Speaker #4: And you saw where our leverage rate was at 3.37. And you have to remember we knew that AlaraCare was going to close in July and that was 200 million of cash.
Speaker #4: So it's very consistent and there's no change in our view of Vivax. Okay. And then any updates on what you're seeing on the M&A side?
Speaker #4: Is that still primarily focused on international or are there more domestic-based assets like maybe IKC that you'd consider if they came to market? Thanks.
Speaker #4: There's still onesies and twosies out there, small clinics. But the reality is that the United States is pretty consolidated now. The growth will come more through de novos as the industry starts to grow.
Speaker #4: And this year, we've had a couple of acquisitions, and we will continue to look at them, but there's not that many out there. All right.
Speaker #4: Makes sense. Thank you. Thank you.
Speaker #2: Thank you. At this time, I'm showing no further questions. Speakers, I'll turn the call back over to you for closing comments.
Speaker #4: Okay. Thank you, Michelle. And thanks, everyone, for joining the call today. As we wrap up, I'll leave you with three final thoughts. First, the year is tracking in line with our expectations.
Speaker #4: Second, I hope you heard in our voice, our clinical strategy is gaining traction. This means improved mortality, an extended life for more of our patients.
Speaker #4: And because our clinical and financial objectives are so aligned, this progress directly supports our volume growth. Finally, by delivering new metal molecule technology to our patients and physicians, we're advancing the standard of care to sustain our clinical and financial momentum into the future.
Speaker #4: Thank you for joining the call today. And we look forward to speaking to you next time.
