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Fresenius Medical Care (NYSE:FMS)
Q1 2019 Earnings Call
May. 02, 2019, 4:30 p.m. ET

Contents:

  • Prepared Remarks
  • Questions and Answers
  • Call Participants

Prepared Remarks:

Dominik Heger -- Head of Investor Relations and Corporate Communications

(Starts Abruptly) Call for the First Quarter 2019. We appreciate you joining today. Also you might be already very tired from all the earnings releases today.

Before we start, I would like to use the opportunity for some short marketing. We will to do a conference call on home dialysis to explain the strategic logic and medical backgrounds. It will not be about how to model the financials. This will take place on the 20th of May at 2:00 PM CET and on 27th of June, we do offer a site visit to our production site in St. Wendel in Germany. Details for both events are posted on our website.

Now, it is my pleasure to start out the call by mentioning our cautionary language that is in our Safe Harbor statement as that as in our presentation and in all the materials that we have distributed the earlier today. For further details concerning risks and uncertainties, please refer to these documents as well as to our SEC filing.

As always, I'd like to limit the number of questions again to two in order to give everyone the chance to ask a question. I hope this works for everyone. I assume you might be tired anyhow on this eventful day.

With us today is of course Rice Powell, our CEO and Chairman of the Management Board. Rice will give you some more color around the strategy and business development goes with some of the major topics of the quarter, of course, also with us is Mike Brosnan, our Chief Financial Officer, who will give you an update on the finances and the outlook.

I will now hand over to Rice, the floor is yours.

Rice Powell -- Chairman and Chief Executive Officer

Thank you, Dominik. Good morning, good afternoon to everyone depending on where you are. We're great -- it's great to have you with us today and we appreciate your interest in the first quarter of 2019.

Turning to Slide 4, and looking at some key parameters of the service business. You can see our clinic growth in the quarter, patient growth and treatment growth. I would also say looking at our statement quality remains on a consistently high level.

Why don't we turn to Slide 5 and you can see that in print that our quality outcomes do remain on a high level, our quality indicators do look quite well. I would like to make one point you probably saw an announcement from us a couple of weeks ago that we've created the global medical office. Wanted to make sure you understand that we believe we are at the right time in our company's history to really take more of a global approach to the medicine in driving the clinical outcomes across the regions as we continue to see product businesses turn into service businesses, and the opportunities to try to work closer with payers.

I'm happy to say that Frank Maddux has been appointed the Global Chief Medical Officer. Frank has been with us a number of years and most recently was the Chief Medical Officer in North America. Frank will be working very closely with the other regional Chief Medical Officers and some small staff as well to help us make sure that we're delivering the best quality of care we can from the most developed markets, Germany, US, France et cetera to emerging markets in any region. And I think this will help us in the years to come.

Turning to Slide 6 and looking at the update of the quarter very quickly. You know that NxStage the acquisition has closed and we're beginning the integration process. You also have seen previously from us that we were able to negotiate a non-prosecution agreement with the US government, as it relates to the Foreign Corrupt Practices Act and that is for international business, not business in the US and we are glad to have that behind us and continue to move forward in our business.

Now, looking at the underlying business performance, it was in line with our expectations. We were pleased that the revenue growth for the quarter was on a higher end of our guided range. Looking at our earnings, we did see earnings being supported by some agreements that came to us earlier than they were planned in the year but my main point here is simply that this is a shift within the year.

These activities or these agreements that we reach were expected to come in this year and so there's no new change there, simply the categorization if you will or the accomplishment of it came a little sooner than Mike and I had anticipated. Then looking at our cost optimization program that is been initiated, so it is under way. And then lastly and most importantly, and Michael talked more about this but our outlook for '19 and '20 has been confirmed.

Turning to Slide 7, I do believe the first quarter was a solid start to the year. I will not run you through this slide, I will say, however, looking at the adjusted revenue EBIT and net income, you can see the performance, got a few bullets for you on the right part of the slide that probably give you a little more color. I would highlight for those of you that need more of a detailed reconciliation, we provided that to you on chart 19 and we hope that will be a benefit should you want to look at that.

Turning to Slide 8, taking a moment to focus on organic growth. We had 6% organic growth across the world on a global basis and yet we also had good contributions from all of the regions. Obviously, when you look at the constant currency revenue in North America, you have to consider the impact of the sound divestiture which I know you're all well aware of, and if you do that and some other adjustments that we've stated for '19, we see about 5% constant currency growth in North America, and the other businesses are as they are laid out on the chart for you. But again, we are seeing good contributions from each region and we're seeing some very nice progress in Asia-Pacific and Latin America as well.

Turning to Slide 9 and focusing on the service organization in the quarter. I would say that what we are seeing is very good delivered growth was good, it was solid on an organic basis but additionally to the organic growth that we generated in the quarter, the volume or same market treatment growth was also very good

If you paid attention and had a chance to dig into the press release, you know that we did highlight for you that the same market treatment growth in the United States was at 3.7%, which is an improvement for where we have been.

We also are happy to report that we continue to see slight improvement in our payer mix in the United States. We had slight improvement in Q4 and we saw continuation of that in Q1, more to do, we are not where we want to be or where we need to be but we have some more quarters to continue to focus on that.

Looking at EMEA, the positive development for their organic, due to their organic growth and acquisitions that's what contributed to their performance in the quarter and with Asia Pacific, their growth was driven by same market treatment growth and acquisitions as well.

If we turn to my last slide, which is slide 10, take a minute and talk about the products business in the quarter. As you well know, our products and the technology that we bring to the market is the center of our vertical integration and I'm pleased to see that we delivered a solid first quarter with 5% organic growth in the new year and this is on top of strong performance in the fourth quarter as well, so we do like the trend that we are seeing here with the products business.

If you take a moment and you look at EMEA, you can see the mix of products that they sold through the quarter to deliver their growth. You see the same with Asia Pacific, I won't lead you through each and every one of those, but needless to say, we're pleased with that. And yes, this was the first quarter in North America, where we used or we captured the revenue from NxStage as a result of the acquisition closing, and we're happy to talk about that if you have some questions.

In summary, Q1 was a good start for the year. We are seeing improvement in key areas that we know we need to improve in. We're not done. We believe that the guidance that we've given you is appropriate. We have a lot more to do and we will be very busy as we go through the rest of this year.

And with that, I will turn it over to Mike and he can give you more color on the financials.

Michael Brosnan -- Chief Financial Officer

Thanks, Rice and hi, everybody. So moving to chart 12 and just starting with revenue and income. You can see the high-level reference slide to guide you through the developments of the first quarter. Starting with revenues, we have adjusted the base period, Q1, '18 for the divestiture of sound, so that was EUR251 million in revenues for Q1, which gets you to the base of EUR3.7 billion into the 6% business growth that we had or roughly EUR210 million on a constant currency basis.

The 6% growth as Rice mentioned, reflects an organic revenue growth of 6%, 2% growth from acquisitions, this was partially offset by about a 1% decrease related to close their sold clinics and a 1% decrease related to one less dialysis day. The revenue development is clearly within our guided range of 3% to 6%.

As you continue to move through to the reported numbers for the first quarter 2019, currency translation was favorable,EUR190 million top line. In addition, we've added EUR22 million for transactions that under the old leasing standard, prior to the adoption of IFRS 16. We've been classified as revenues and EUR30 million revenues generated since are close of the NxStage transaction to get to the reported revenues of EUR4.1 billion.

Continuing on the bottom of the page with regard to net income, we're adjusting in the base period for the loss from divestitures in our Care Coordination activities in the first quarter last year and a loss generated by the sound operations of EUR4 million, which gets you to a base of EUR296 million.

Business growth of EUR9 million, which on a constant currency basis, which gets you to 3%.This is slightly above our target range of minus 2% to plus 2%. Following on there were favorable currency translation effects of EUR13 million, and unfavorable frontloading effect from the implementation of IFRS 16 of EUR18 million, largely driven by interest expense.

Unfavorable effects from the NxStage operations of EUR14 million and EUR12 million of costs associated with the transaction and integration activities. We had EUR3 million of cost related to the cost optimization program, which gets you to the reported net income of EUR271 million.

Turning to Chart 13, and now looking at the regional margin profiles. Just a reminder, these two pages are running as reported basis not an adjusted basis. You can see in our press release tables, which are on page 18 of the material we distributed that on an adjusted basis, EBIT margins went from -- declined from 13.6% in the first quarter to 13.4% roughly 20 basis points just to give you that one data point on an adjusted basis.

So reported margins improved from 12.5% to 13% or 50 basis points. The weighted contributions to this increase were favorable impact from EMEA of 60 favorable impacts from Asia Pacific of 30 basis points, partly offset by unfavorable effects from corporate, decrease in the margins of North America and a mix effect.

So now looking at North America, is the first regional margin profile. Operating income was up EUR10 million to EUR372 million. This is a 4% increase in constant currency. The EBIT margin was 12.9% and the operating income includes favorable effects from IFRS 16.The integration and operational costs associated with NxStage and costs associated with the sustainable improvement in our cost base.

Dialysis business operating margins decreased from 15.4% to 12.9%.The margin decrease was driven by higher personnel expense, the integration and operational costs associated with NxStage and unfavorable impact from legal settlements, and this was partly offset by positive impacts from the consent agreement on some pharmaceuticals, a favorable effect from the IFRS 16 implementation. Some favorable manufacturing variances and little bit of unfavorable foreign currency transaction losses.

Revenue per treatment increased by $7 from $348 to $355 and cost per treatment adjusted for the effects of IFRS 16 increased by $12 from $289 to $301. The drivers for the revenue per treatment increased with a higher utilization of oral based ancillaries. The impact from an increase in the ESRD base rate on Medicare and this was partially offset by lower revenue from commercial payors. The increase in cost per treatment was caused by higher utilization of oral based ancillaries -- higher personnel expense -- excuse me -- and the effect of one less dialysis day.

Care Coordination margins increased from 2.6% to 13% and on an adjusted basis from 8.3% to 12.3%. The margin increase was naturally driven by losses related to the divesture of Care Coordination activities in the first quarter of last year. Increased member months in our health services business, increased volumes coming from our vascular access business and a positive effect from IFRS 16.

Turning to Chart 14, I am going through the main ingredients in EMEA. Operating income was up EUR29 million or 26%, 27% at constant currency. Margins increased from 17.1% to 21.1% driven by a reduction of the contingent consideration liability related to Xenios. This was partly offset by higher bad debt expense, some higher rent expense, the impact of one less dialysis day and a favorable effect associated with foreign currency translation.

Asia-Pacific operating margins increased from EUR74 million to EUR95 million or 28%, that's 25% on a constant currency basis. And this increase in margin was primarily driven by favorable foreign currency transaction effects, a favorable impact from business growth partly offset by an unfavorable margin development in Care Coordination business in Asia, and unfavorable effect of foreign currency translation.

Care Coordination margins in the region decreased from 13.7% to 11.3% largely related to higher start-up and operating costs in that business in the first quarter of this year. Latin America operating income declined from EUR14 million to EUR11 million resulting in a margin decrease of 120 basis points from 8.3% to 7.1%. This was mainly due to the impact of hyperinflation in Argentina partly offset by favorable foreign currency transaction effects.

Our corporate cost which are not on the slide increased by EUR17 million from EUR62 million to EUR79 million mainly due to higher stock compensation, stock compensation expense unfavorable foreign currency transaction effects and higher project costs.

Turning to Chart 15 and going through cash flows and our leverage ratios. Cash flows in the first quarter of 2019 increased compared to the comparable period of last year. The implementation of IFRS 16, which led to the reclassification of rental payments into financing transactions had a significant effect on these values. This resulted in cash from operations of 1.8% of revenues compared to the minus 1.1.

Looking at CapEx it decreased by approximately 19 million year-over-year. Days sales outstanding increased from 75 days to 83 days that would be 75 days at the end of 2018 to 83 days. This reflects an increase in the DSOs of roughly 12 days in North America which is driven by the seasonality of our invoicing in the US.

Asia-Pacific and Latin America had a slight increase in DSOs just due to the results of the Chinese New Year and normal fluctuations in payments from public healthcare organizations. DSO in EMEA decreased by a couple of days due to improved collection efforts.

As a result of the development of our acquisition spending and the operating cash flows in the first quarter, our net debt which is debt less cash on hand excluding IFRS 16 has increased from EUR5.5 billion at the end of December 2018 to EUR7.7 billion as of March 31. If we include the addition of lease liabilities as a result of the implementation of IFRS 16, that would have increased to EUR12.3 billion.

From a leverage ratio perspective, if you exclude the new leasing standard, the leverage is at 2.5 times EBITDA, an increase from up from 1.8 at the end of 2018. If you include IFRS leverages at 3.2 obviously having closed the NxStage transaction these values reflect that closure.

Turning to my last page and taking a moment on the outlook. As Rice indicated, we're confirming our outlook for 2019 anticipating revenue growth at 3% to 7% on a constant currency basis using 16 billion as the base and net income growth of minus 2 to plus 2 at constant currency. Also confirming our target for 2020 anticipating increases in revenue growth and net income growth of mid to high single digits.

As I stated before and I'll just repeat here, the targets for the outlook in 2019 and 2020 have been adjusted to make the business performance comparable to 2018 having made adjustments such as the FCPA related charges, the IFRS 16 implementation, the gains and losses related to the divestiture of some of our Care Coordination activities, and the expense for the cost optimization program. All the effects also from the acquisition of NxStage are excluded from the outlook provided for 2019 and 2020.

So with that, I'll turn the call back to you Dominik and I think we're ready for questions.

Dominik Heger -- Head of Investor Relations and Corporate Communications

Thank you, Rice, thank you, Mike for the presentation. And I'm happy to open the Q&A for more insights now. Hailey?

Questions and Answers:

Operator

Thank you. (Operator Instructions) The first question comes from the line of Tom Jones of Berenberg. Please go ahead.

Tom Jones -- Berenberg -- Analyst

Thanks for taking my two questions. The first is my pet subject very commercial pricing. If I look at the revenue per treatment in North America. If I ex out maybe $5 per treatment from that number for the increase use of Calcimimetics. I look at what's going on Medicare rates, which went up about 7.5, it does suggest that the commercial book of business was only down very slightly. Now we know payor mix is still down reasonably year-on-year. So just wondering what I can infer from those numbers about like-for-like commercial pricing trends, I know the Q4 numbers might give you kind of caution just to expect little bit softness this year, I just wondered how Q1 developed relative to your initial expectations.

And then my second question probably for Rice. I was quite surprised by the -- you calling out growth in your health plan business as a driver of revenues in North American care coordination. My understanding was you -- going back quite a bit of your seasonal (ph) business. So I was just wondering where this is coming from, is this more subcontracted risk base type stuff you're taking on or is there something else going on that I am missing?

Michael Brosnan -- Chief Financial Officer

Tom, it's Mike Brosnan. I'll take the first question as you anticipated. The short answer will be yes, I mean I elaborated quite a bit in our guidance in February that we were expecting flat to slightly down in terms of revenue per treatment. That was at least in part driven by our expectations with regard to some of the contracts we'd be negotiating in 2019. I think you are seeing some softness in the commercial rate in the first quarter.

When I look at that and put it together in terms of confirming the revenue per treatment guidance I provided, I would still stick with what I had indicated flat to slightly down for the full year. But you are basically seeing in Q1 what I expected would take place over the course of 2019.

Tom Jones -- Berenberg -- Analyst

Perfect. So certainly now what you expected --sorry.

Michael Brosnan -- Chief Financial Officer

No, go ahead please finish.

Tom Jones -- Berenberg -- Analyst

Sorry Mike, just so I guess the key thing is that at least it's not worst then any worst do you expect is progressing to plan is that fair?

Michael Brosnan -- Chief Financial Officer

That's fair.

Tom Jones -- Berenberg -- Analyst

Perfect.

Michael Brosnan -- Chief Financial Officer

And I would also to your point because you mentioned the year-over-year commercial mix, yes and I said this in February measuring year-over-year, you're going to see that, but when you measure off our Q3 base coming into Q4 and Q1 that ties back to the comment Rice made that we are seeing improvement of -- our low point if you will with regard to where we finished third quarter of 2018.

Tom Jones -- Berenberg -- Analyst

Perfect.

Rice Powell -- Chairman and Chief Executive Officer

Yeah. Hey, Tom. So it's Rice. Talking about the health plan. As you remember correctly, we decided that the CSNP business was not really making it for us and so we exited that business that leaves us with the sub caps and with the ESCO obviously, and we feel pretty good about where we are there. But I think the bigger piece of this is simply we got rid of a fairly significant drag that we were seeing with the CSNPs.

Tom Jones -- Berenberg -- Analyst

Perfect. That's very helpful. Thanks so much.

Operator

The next question comes from the line of Veronika Dubajova of Goldman Sachs. Please go ahead.

Veronika Dubajova -- Goldman Sachs -- Analyst

Good afternoon, gentlemen and thank you for taking my questions. I will also keep it to two. My first bigger picture question is, just wondering Rice if you have any comments on the statements made by CMS around the home, hemo pilot. How you think an accelerated uptake of home hemo would play on your business and what it would mean for you guys. That's my bigger picture question, apologies.

And then my second question in terms of same-store or same market growth in North America, do you think that the growth that we're seeing at the moment is sustainable, any risks that it throws back down or conversely that you can see some acceleration from here? Thank you.

Rice Powell -- Chairman and Chief Executive Officer

Yeah. Hey, Veronica. I'm just writing feverishly. So on the home hemo pilot you know, we were delighted to hear CMS come out and talk about that but they are a little short on detail, so we don't really know where this will ultimately go but we are anxious to be part of the process and understand it.

I would say to you, when you think about the current book of business that we've got in the ESCOs, we are running today at around 8%, 8.5% of that, roughly I want to say about 47,000, 48,000 patient is they are home patients.

Now, the vast majority of that 8%, 8.5%, like 7% in change is PD and then there's 1.5%, 1.7% that's home, so we're kind of in that space today, not in a huge way but we are there and we look forward to seeing how they want to elucidate the other detail of where this -- where it could go. And we'll certainly see where that happens.

On same market growth, you would ask me this. We get to 3.7%. Now you are asking me, if I can keep it grow or I am not going to lose it. I would tell you that we worked hard at this. I would hope that we would continue to see good performance here. I don't think I want to speculate up and down. I'm just going bask in the moment that we got to where we are with a lot of good hardwork from people and we're going to do everything we can do to try to grow that and certainly make sure that we don't slip back down the mountain, if you will.

Veronika Dubajova -- Goldman Sachs -- Analyst

That's great, Rice. And can I just follow-up on the home HD front. I think one of the concern for investors out there is that as you see adoption of home HD, depress (ph) this profitability of your business. I know I don't want to our preview what your guys are going to say on the webcast in a few weeks but maybe just conceptually can you talk to us about within ESCOs, the experience that you have for the PD, HD and home HD patients, do you see meaningful differences in profitability between those three groups?

Rice Powell -- Chairman and Chief Executive Officer

Yeah, honestly, I could not seize that out for you because I haven't been close to it and if I did I'd get shot by the ESCO guys and probably the guys at CMS as well, CMMI. Look what we do know is generally we do see very good clinical outcomes with home patients, in some cases we see that they have less hospital days then the in-center patients and that is a very general trend Veronika. I'm not saying that specifically to this ESCO experience that we're getting.

That something a lot of we talk about it at a later date. I need to spend some time with the folks that are really running that business. I just don't want to speculate on it. But we're happy to look into that maybe we can have a chat about that at another time.

Veronika Dubajova -- Goldman Sachs -- Analyst

That would be great. Thank you very much.

Operator

The next question is from the line of Patrick Wood of Bank of America Merrill Lynch. Please go ahead.

Patrick Wood -- Bank of America Merrill Lynch. -- Analyst

Perfect. Thank you very much taking my question. And I'm really sorry if you guys touched on this. There's been a lot of conference calls today, so trying to juggle things. Just curious in the Q1 numbers and I hate to be the quarterly guy on this one. But if you can give any kind of quantification of Xenios and some of the other, not one-off in the bare exceptionals but the phasing-related adjustments. I'm trying to understand how do you feel the performance of the business was before those factors kind of came into play the more underlying, underlying if you will. I'm just curious if you could quantify any of those that would be very helpful. Thank you.

Michael Brosnan -- Chief Financial Officer

Yes. Patrick. It's Mike. I guess because I did see in some of the material that all of you release before the call today some curiosity about a couple of things. So on Xenios, hopefully, you'll understand, we can't disclose the specifics due to -- we've agreed to confidentiality. But maybe to help folks size it I would offer that from a modeling perspective, you could look at the Q4, 2018 EBIT margins and maybe use that for EMEA as something indicative for full-year and I think if you do that, you'll get a sense as to what the Xenios effect was in the first quarter.

And with regard to the just anticipating some other folks questions. With regard to the consent decree, what I would say there again similar to what we did last year we have some confidentiality agreements in place. But I would say big picture for the full year we'd expect a similar amount, but as we mentioned last year, this is kind of lumpy in terms of when it's recognized, so the timing will be a bit different. Last year it more oriented around the second and third quarter. This year my expectation is it's probably going to be a Q1, Q4 overall impact, but the total value for the years will be roughly the same.

Rice Powell -- Chairman and Chief Executive Officer

Yeah. And Patrick is I think Mike's mentioned before, this is the third year where we've experienced this, so I appreciate calling it a really one-off because it is kind of an annual thing that we're seeing.

Patrick Wood -- Bank of America Merrill Lynch. -- Analyst

That's very helpful. And maybe one quick, more structural follow-up if I could. And apologies if this is out there already but I'm just curious on any update on either the PATIENTS Act or on the Medicare Advantage side, any discussions as to how that's progressing on those two issues? That would be kind of helpful to get your latest thoughts. Thanks

Rice Powell -- Chairman and Chief Executive Officer

Yeah. So on the PATIENTS Act, I would tell you that we are still bullish. We still have conversations for NDC (ph) on this, but in today's environment there, there are many, many distractions relative to what's going on, so I can't say that we've had long, long subjects to discussions about this. But it is on people's radar screen and people realize and when I say people I mean, health policy folks, staff in the Congressional offices, but I don't see a take-up in an action on it right now given what's going on in DC at this point in time.

Now, Medicare Advantage continues to be good for us, if we all know the Cures Act is going to come January 1, 2021 and that'll have some impact. But there's no real news that I would have to share with you. That's of great nature, negative nature. I think it's sort of trundling on as we thought it would on Medicare Advantage.

Patrick Wood -- Bank of America Merrill Lynch. -- Analyst

Super. thanks a lot for taking my questions.

Operator

The next question comes from the line of Edward Ridley of Redburn. Please go ahead.

Edward Ridley -- Redburn -- Analyst

Good afternoon. On NxStage, obviously, great that you mentioned -- closed it in the quarter. Could you just go back again and looking at that sort of the very helpful by the way breakdown you gave in the financials on the various NxStage effects. It seems to me that well, March, still look pretty good in terms of revenue side but also the operating cost was slightly higher than expected.

First of all on revenue, obviously NxStage also had a good year, last year organically, would it be the -- we could infer that the run rate is pretty good relative to the guidance you've given on the revenue side, but equally, how much should we use, your disclosure that you have given for the underlying profitability of NxStage this year?

Michael Brosnan -- Chief Financial Officer

So it's Mike Brosnan. And I guess we did provide an estimate for NxStage at the time shortly after we closed the transaction. So on the top line I would say maybe the best way to look at 2019 and I mentioned this previously that you just need to keep in mind, when you look at NxStage's reported revenues that was inclusive of our business with them.

So obviously now just like all the other products deals, we've done over the years around the world, once we acquire that becomes an internal revenue and cost to us. So if I think in terms of the guidance we gave of EUR240 million to EUR260 million and you look at a 2018 adjusted taking us out of NxStage's 2018 results. And also doing some cost adjustments because NxStage for the next couple of years will be selling bloodlines to B. Braun at a lower value as agreed.

So when you look at that as a baseline, I'd expect we're not revising our estimate for NxStage, but I'd expect something in the kind of mid-single digits in terms of revenue growth off the new adjusted base excluding Fresenius Medical Care as a customer of NxStage.

And on the earnings side really not much more to say at this point. We did close the business, we are getting the teams put together in terms of the leadership that came from the NxStage business with folks in our existing business that will be working together to the integration process to get this off to the right track. So probably more to come as we get through 2019, but the estimates that we provided we're holding to at this point in time.

Edward Ridley -- Redburn -- Analyst

Very good. Thanks. Just quick follow-up on Patrick's question, just the legal costs that were one-off but not one-off in the first quarter that affected your North American dialysis margin, could you give us any more color on that?

Michael Brosnan -- Chief Financial Officer

Yeah. I will give you a bit more because, you know, our 6-K, which you haven't seen yet, but which will be filed shortly. Details potentially significantly around regulatory matters for the company. And based on our regular review of those outstanding matters, we sometimes will increase our legal accruals. So in the first quarter, we increased our legal accruals by about EUR20 million. The largest single item in that was made to address an agreement that we had to resolve the matter with the state of Mississippi.

The 6-K actually separately discloses that value. So I can just tell you today that that single item was $15.7 million and that should hopefully give you a sense of the overall earnings effect in the North American results.

Rice Powell -- Chairman and Chief Executive Officer

Yeah, Ed, I have -- Mike's nailed that. The only thing I'd tell you is this is sort of the Mississippi matter, was in that growth of the GranuFlo settlement that we did and this False Claims Act that, I would say, a very grave -- State Attorney General decided to file and we settled this fractionally for what they thought they might get. So that's kind of the sum and substance of what happened there.

Edward Ridley -- Redburn -- Analyst

That's very helpful. Thanks.

Operator

Your next question comes from the line of Oliver Metzger of Commerzbank. Please go ahead.

Oliver Metzger -- Commerzbank -- Analyst

Hi. Thanks for taking my question, First one is on the ESCO programs where -- from the (inaudible) program where that should come soon. You commented earlier that currently 8.5% of patients in the ESCO programs are already home HD patients. Are these patients valued under different criteria's and are also part of this 2017 review process. And my second question is for Mike. So the depreciation, amortization charge in the first quarter was $362 million. Can you just give us a split between the between the underlying D&A and where -- extraordinary amortization, please?

Rice Powell -- Chairman and Chief Executive Officer

So Oliver, it's Rice. Relative to the ESCO, it depends on which plan year these patients came into the program on and I can't tell you what number of that -- or what percentage of those patients were in plan year two or they got started in plan year three. I mean we haven't I just don't know it but they are part of the program and as we've talked before our understanding is plan year two resolution, if you will, or the calculations of how that turned out. We're expecting that we should hear something about that in the May or June timeframe coming from CMMI.

Michael Brosnan -- Chief Financial Officer

Yeah. And Oliver it's Mike, on Page 23 and 24 the material we sent out I think this would hopefully answer your question. We detail out the incremental depreciation associated with the adoption of IFRS 16. So that alone in Q1 was EUR167 million and in for the full year we'd expect it to be just under EUR700 million.

Oliver Metzger -- Commerzbank -- Analyst

Okay. Great. Thank you very much.

Michael Brosnan -- Chief Financial Officer

Yeah.

Operator

The next question comes from the line of Hans Bostrom of Credit Suisse. Please go ahead.

Hans Bostrom -- Credit Suisse -- Analyst

Hello. I just had one main question. Just to understand how I marry the 6% growth in in clinics, 4% in patients, and 3% in treatments, which seem to be an adverse change. I mean I presume the difference is the de novos that have been opened in the first quarter. How should we think of those metrics changing over the course of this year?

Rice Powell -- Chairman and Chief Executive Officer

Yeah, Hans, it's Rice. Obviously de novos do have a hand in that and so maybe let me give you a little bit of clarity. As we look at where we were coming out of 12/31/2018, we were basically looking at 59 de novos that were waiting certification. We were able in the first quarter of this year to get 15 certified of which the vast majority of those were done with the outside accreditation firm that we hired that we were able to hire as a result of legislation that was passed. But then just also keep in mind on the treatments we had one less dialysis day in the quarter.

Hans Bostrom -- Credit Suisse -- Analyst

And should we think about these numbers sort of equalizing each other by the end of the year or is this not really a way you managed the business?

Rice Powell -- Chairman and Chief Executive Officer

Well, we don't really look at it in that level of granularity. I mean we obviously know that having one less or one more dialysis day will make a difference in the quarter. But it is little more nuance then just trying to run those numbers out because obviously you have certifications, you got to be up and running the clinic things of that kind of nature. So it's not as straightforward, I would think as you might have expected it would be.

Hans Bostrom -- Credit Suisse -- Analyst

Okay. And actually one follow-up question. You did make specific comment about your Care Coordination business in Asia Pacific, which to my knowledge is mainly -- or maybe solely, the Cura Group in Australia weighing on your margins. Could you elaborate on that please?

Michael Brosnan -- Chief Financial Officer

Sure. They continued to acquire it you know and add to their footprint and so I mentioned some start-up costs associated with that and that's really directed toward just acquisitions and de novo development in that market for Cura.

Rice Powell -- Chairman and Chief Executive Officer

Yeah. Hans I think they had Mike and I looking to each other two or three acquisitions that would make the effect that Mike is talking about.

Michael Brosnan -- Chief Financial Officer

We still better. Yeah, we still feel very good about the business.

Dominik Heger -- Head of Investor Relations and Corporate Communications

Okay. So I see we have no further questions. I do apologize to everyone who dialed in. We had technical problems with the system provider. So if you dropped off I do apologize and we have no one on list, right now. So there's nothing on purpose. With that, I would say we can't answer question because no one is on the list. Therefore, we would close the call and I say thank you for taking the time on that busy day to dial-in.

Rice Powell -- Chairman and Chief Executive Officer

Thank you. We appreciate your interest. We know you guys and ladies are all very busy and it's something we appreciate. Thank you.

Michael Brosnan -- Chief Financial Officer

Thank you very much.

Dominik Heger -- Head of Investor Relations and Corporate Communications

Thank you.

Michael Brosnan -- Chief Financial Officer

Take care. Bye, bye.

Duration: 42 minutes

Call participants:

Dominik Heger -- Head of Investor Relations and Corporate Communications

Rice Powell -- Chairman and Chief Executive Officer

Michael Brosnan -- Chief Financial Officer

Tom Jones -- Berenberg -- Analyst

Veronika Dubajova -- Goldman Sachs -- Analyst

Patrick Wood -- Bank of America Merrill Lynch. -- Analyst

Edward Ridley -- Redburn -- Analyst

Oliver Metzger -- Commerzbank -- Analyst

Hans Bostrom -- Credit Suisse -- Analyst

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