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Davita Inc (NYSE:DVA)
Q1 2021 Earnings Call
Apr 29, 2021, 5:00 p.m. ET

Contents:

  • Prepared Remarks
  • Questions and Answers
  • Call Participants

Prepared Remarks:

Operator

Good evening. My name is Sheila, and I will be your conference facilitator today. At this time, I would like to welcome everyone to the DaVita First Quarter 2021 Earnings Call. [Operator Instructions]

Thank you. Mr. Gustafson, you may begin your conference.

Jim Gustafson -- Vice President, Investor Relations

Thank you, and welcome, everyone, to our first quarter conference call. We appreciate your continued interest in our company. I'm Jim Gustafson, Vice President of Investor Relations. And joining me today are Javier Rodriguez, our CEO; and Joel Ackerman, our CFO. Please note that during this call, we may make forward-looking statements within the meaning of federal securities laws. All of these statements are subject to known and unknown risks and uncertainties that could cause actual results to differ materially from those described in the forward-looking statements. For further details concerning these risks and uncertainties, please refer to our first quarter earnings press release and our SEC filings, including our most recent annual report on Form 10-K and subsequent quarterly report on Form 10-Q and any subsequent filings we may make with the SEC. Our forward-looking statements are based upon information currently available to us, and we do not intend and undertake no duty to update those statements except as may be required by law. Additionally, we'd like to remind you that during this call, we will discuss some non-GAAP financial measures. A reconciliation of these non-GAAP measures to the comparable GAAP financial measures is included in our earnings press release submitted to the SEC and available on our website.

I will now turn the call over to Javier Rodriguez.

Javier J. Rodriguez -- Chief Executive Officer

Thank you, Jim, and good afternoon. Over the last several months, we have made incredible progress in our efforts to combat the COVID-19 pandemic. And it's with continued optimism that I provide several updates today, starting with vaccination followed by a summary of the first quarter performance then an update on our improved outlook for the year and finally, an overview of our ongoing commitment to ESG. Q1 brought a lot of smiles as the Kidney Care community administered hundreds of thousands of vaccines to its patients. Providers worked closely with the Biden Administration, the CDC and state government so that dialysis patients could be vaccinated in a trusted and convenient side of care. We knew that this would help our patients overcome transportation and other access challenges getting to third-party sites. And we had confidence that the hesitancy rate would decline when they received education from a trusted caretaker. Thanks to all the hard work by our teams and the government partners, I'm proud to say that as of yesterday, 72% of our patients nationwide have received at least one vaccine dose. We also saw an opportunity to positively impact health equity by administering COVID vaccine in our clinics. Similar to the early results in the broader U.S. population, in the first few weeks of the vaccine rollout, we saw the vaccination rate for Black and Hispanic were approximately 40% below that of White and Asian American. This did not sit well with us. We've got to work and mobilized our care teams, including social workers, dietitians and medical directors to have one-on-one conversations with patients to address common causes of hesitancy.

Our Hispanic patients have now been vaccinated at nearly the same rate as white patients and the gap for our black patients has been reduced to 10%. We are not done. Our pursuit for health equity continues. On to our first quarter financial results. We delivered solid performance in Q1 as our operating margins returned to 15.7% in the quarter, while we continue to lead through the continued challenges presented by the pandemic. As we covered on our last call, treatment volumes declined in Q1. Our treatments per day hit a low point in mid-February, including the impact of approximately 25,000 missed treatments from the winter storm. Since then, our daily treatment trends have steadily improved. As these trends continue, absent any further infection surges, we believe that our sequential patient census growth through the end of the year could return to pre-COVID levels, which is what we incorporated in our guidance ranges we provided last quarter. Let me provide a bit more detail on volume that supports our outlook. First, since our update in Q1, COVID case counts and new infections within our dialysis population have continued to decline. As of last Friday, the number of active cases among our patients across the country decreased approximately 85% from peak prevalence on January 6, 2021, and the last seven-day incidence rate for new cases decreased approximately 91% from the week ending January 9, 2021. Second, we're grateful that we're seeing a dramatic decline in the mortality rates associated with COVID.

We've previously shared that the unfortunate incremental mortality associated with COVID was approximately 7,000 in 2020. In 2021, both our patient mortality count and mortality count in the general population peaked in January. In the first quarter, incremental mortality associated with COVID was approximately 3,300 lives, with more than half of that number occurring in January, decreasing to approximately 600 in March. It is too early to provide an estimate for April, but we expect the results will improve versus March. Shifting to full year outlook, our view of core operation performance for the year remains largely unchanged from our original guidance. However, now that the likelihood of some downside scenarios have decreased due to the trends I've previously mentioned, we are increasing our adjusted earnings per share guidance range to $8.20 to $9 per share and our adjusted operating income guidance range to $1.75 billion to $1.875 billion. At the midpoint of our revised adjusted operating income guidance, this would represent approximately a 4% growth year-over-year. These revised ranges assume no further major disruption from the virus strain. My final topic is our ongoing commitment to environmental, social and governance matters or ESG. ESG has become a more significant topic of conversation in the investment community over the last couple of years, but these are not new areas of focus for us at DaVita. Our beliefs are incorporated into our stated vision of social responsibility that has three components: caring for our patients, caring for each other and caring for the world around us, including both our communities and our environment.

DaVita continues to execute against this vision, providing top quality clinical care for our patients is at the core of what we do and because I've already spoken at length about our patients care and our efforts to vaccinate our patients, I would like to highlight a few of our achievements in caring for our teammates and caring for the world around us. I believe that fostering an environment rich in diversity and where we all feel that we belong is imperative to our culture and how we connect with each other and how we connect with our patients every day. And our commitment to cultivating diversity is evident throughout the organization. It starts with the Board of Directors, currently made up of nine leaders, of whom 67% are diverse, including four women and three people of color. The diversity of our team extends to the leaders who run the core operations in our clinics of whom 52% are female and 27% are people of color. These results have been achieved through thoughtful and deliberate practices to create a diverse pipeline of talent. In 2021, we published our first report on diversity and belonging, disclosing many of our company's diverse metrics and our ongoing efforts to cultivate a diverse organization in which everyone feels that he or she belongs. We also recently published our 14th Annual Corporate Social Responsibility Report and our first ESG Report. These reports disclose the progress we made in 2020 and lay out our ambitious ESG goals for 2025, including goals to reduce carbon emissions by 50% and to have vendors representing 70% of emissions set by climate change goals and to achieve engagement scores of 84% or higher among our teammate population. We are pleased with our progress to date on diversity and ESG. And as you can see by our goal, we have a lot more we hope to accomplish.

With that, I will turn the call over to Joel.

Joel Ackerman -- Chief Financial Officer

Thanks, Javier. Q1 was a strong start to the year with solid financial performance. For the quarter, we recorded revenue of approximately $2.8 billion, operating income of $443 million and earnings per share of $2.09. As Javier referenced, treatment volume was a large headwind and our nonacquired growth was negative 2.2% compared to negative 0.3% in Q4. While COVID presented the main challenge to NAG in Q1, winter storms, particularly Uri, were responsible for about 30 basis points of the NAG decline. Treatments per day bottomed out during the first quarter, so we expect to start seeing quarter-over-quarter growth in Q2. We continue to expect that NAG will be negative for the year, although we expect to see an acceleration of NAG in 2022 and 2023 as mortality rates may be lower than the pre-COVID levels for a few years. U.S. dialysis revenue per treatment grew sequentially by almost $3 this quarter as a result of the Medicare rate increase, higher enrollment in MA plans, a slight improvement in commercial mix and higher volume from our hospital services business, partially offset by the seasonal impact of coinsurance and deductible. U.S. dialysis patient care costs declined sequentially by approximately $6 per treatment. Although we continue to experience elevated costs due to the pandemic, such as higher PPE and certain clinical level expenses from continued infection control protocols, our Q1 patient care costs included a nearly $2 per treatment benefit from our power purchase agreement, a benefit that we do not expect to persist through the rest of the year.

For the quarter, the net headwind related to COVID was approximately $35 million, consisting primarily of higher PPE costs and the compounding effect of patient mortality associated with COVID, partially offset by the benefit from the sequestration suspension with a number of other items that largely offset each other. For fiscal year 2021, we now estimate the net negative impact from COVID to be approximately $50 million lower than our guidance last quarter. This is the result of lower COVID impact in Q1, the recently passed extension of the Medicare sequestration relief through the end of the year and lower other offsets, including T&E in the back half of the year. At the middle of our guidance range, this would equate to $150 million negative impact from COVID in 2021. Our DSO increased by approximately seven days in Q1 versus Q4, primarily due to temporary billing holds related to the winter storm and the changes in calcimimetics reimbursement. In certain circumstances, we hold claims to make sure we have complete and accurate charge information for payments. This quarter, we had more of these holes and the single largest driver was related to winter storm Uri, which impacted more than 600 of our centers until right in the middle of the quarter.

This has the effect of pushing a significant amount of cash flow from this quarter to the next and caused the corresponding DSO increase in the interim. While claim holds shift cash flow between quarters, they have no negative impact on what we ultimately expect to collect. We've already seen a significant increase in cash collections in April and expect a corresponding positive impact on both cash flow and DSOs over the next two quarters. A couple of final points. In the first quarter, we repurchased 2.9 million shares of our common stock. And to date, in April, we repurchased approximately one million additional shares. Debt expense was $67 million for the quarter. We expect quarterly debt expenses to increase to approximately $75 million beginning next quarter as a result of the $1 billion of notes issued in late February.

Javier J. Rodriguez -- Chief Executive Officer

Before we open up the line for Q&A, let me share some reflections. Over the past year, our teams and our business experienced unusual volatility and challenges due to the pandemic. We have weathered this very difficult period because of our dedication of our people, our scale, our innovation and our holistic platform and approach to patient care. As I look forward, our organization is stronger, our relationships with patients have deepened and I have even more resolve that our comprehensive Kidney Care platform is well positioned to deliver a best-in-class value proposition to our patients, physicians in hospitals and payer partners.

Now let's open it up for Q&A.

Questions and Answers:

Operator

[Operator Instructions] Our first question will come from Pito Chickering with Deutsche Bank. Your line is open.

Pito Chickering -- Deutsche Bank -- Analyst

Good afternoon, guys and thanks for taking in my questions. First one is on the operating income guidance. Like you raised it by 3.5% or about $63 million at the midpoint. And you talked about some of the gives and takes, sequestration and lower impact from COVID and lower sort of cost in the back half of the year. Can you just help us quantify which -- what were the drivers of those?

Joel Ackerman -- Chief Financial Officer

Sure. Hello Pito, it's Joel here. So I would think about three things really. We beat this quarter, so obviously, that helps with the full year. Sequestration was the biggest driver here, and that's about $50 million. And then looking toward the back half of the year, we've taken down some of the COVID offsets that we were expecting from G&A and T&E as things get a little bit better. We've -- we're not expecting as much offset in Q3 and Q4. So you put that all together, and that's where you wind up.

Pito Chickering -- Deutsche Bank -- Analyst

Okay. And then the treatment growth declined 1.3% sequentially and 2.2% year-over-year. I understand there are a lot of missed treatments from hospitalizations, from the storms are offset by your acute business and obviously, the mortality issue. With that being said, is there any chance you can give us monthly treatments during the quarter and through April? Just to help us understand the pace of recovery and how you plan to get back to patient census to pre-COVID levels by the end of the year?

Joel Ackerman -- Chief Financial Officer

Yes. Pito, I appreciate the question. We're not going to give monthly, but let me try and help out a little bit. February was the bottom, and that was driven largely by the mortality issue, but also Uri, the storm resulted in about 25,000 missed treatments.

We saw recovery in March, both as the mortality issue got better as well as the recovery after the storm. And then April trended a little better from there as well. I think it's a little early to quantify it and try and use a number to draw a trend line. These numbers can bounce around a bit. So that's where we are.

Pito Chickering -- Deutsche Bank -- Analyst

And the last question, the revenue per treatment was pretty strong with all the items you laid out. So two quick questions. The first is how much did co-pay pressure did you see in the first quarter? So what would be a good assumption for revenue per treatment in 2Q? And as you look forward for the next couple of years, is there any reason why a 2% revenue per treatment growth wouldn't be the right assumption to make?

Joel Ackerman -- Chief Financial Officer

Yes. So a couple of things I'd highlight about Q1 RPT. In terms of quantifying the co-insurance and deductibles, that's somewhere in the $5 to $6 a treatment range. So you'd add that to what you'd expect to see in Q2. We also had a pickup in Q1 over Q4 as a result of calcimimetics. I'll remind you, calcimimetics OI in 2021 will be similar to 2020, but the seasonal pattern will be very different. So we picked up $2 -- about $2 of RPT in Q1 over Q4 from that.

In terms of looking forward about what RPT will look like, we've moved away from guiding on RPT, as you'll remember. In terms of what's a reasonable number, is 2% reasonable? I wouldn't say it's unreasonable, but it might be a little on the high end of the range that I'd probably think about. But we'll have more to say on 2022 RPT, obviously, later in the year.

Pito Chickering -- Deutsche Bank -- Analyst

Great. Thanks so much.

Operator

Thank you --

Joel Ackerman -- Chief Financial Officer

I'm sorry, operator, Pito, just to jump in on that. That -- my comment, obviously, you'd have to adjust for sequestration, which would go away, presumably between '22 and '21, and that would be a big number.

Pito Chickering -- Deutsche Bank -- Analyst

Yes. Yes. of course. It's more so just excluding sequestration, the gives and takes within the overall market demand, the shift to MA, was the 2% reasonable.

Joel Ackerman -- Chief Financial Officer

Exactly.

Operator

Thank you. Our next question will come from Kevin Fischbeck with Bank of America. Your line is open.

Kevin Fischbeck -- Bank of America -- Analyst

Great. Thanks. Maybe just to stay on the RPT for a second. Is it fair to say that when you listed the things that drove RPT in the quarter that they were listed in the order of importance and the rate update was the biggest one?

Joel Ackerman -- Chief Financial Officer

There -- I'd say there are four things, and they're roughly all about the same order of magnitude. And that's the Medicare rate update, calcimimetics, the mix changes -- commercial mix change and then MA, they're roughly in the same order of magnitude.

Kevin Fischbeck -- Bank of America -- Analyst

Okay. That's helpful. And then I guess, when we think about the improvement in volumes that you expect to see as the year goes on, how should we think about that from a mix perspective? Is that volume improvement disproportionately a commercial improvement? And does that have any implications for margins or profits?

Joel Ackerman -- Chief Financial Officer

Yes. So I'd say the likelihood is that the mix will be more Medicare than commercial. Remember, the mortality we've seen as a result of COVID was disproportionate in the older population, as you would expect, and our older population is disproportionately Medicare.

So as you see, the unwind happened from COVID over the next X number of years, we think that would lead to a lower kind of our commercial mix trending down a bit. In terms of the implications for margin, there's an offset to that, recognizing that these new patients will be filling unused capacity, and that would have a tendency to drive margins up. How those two -- those countervailing forces play forth remains to be seen. And it's a tough number to predict. It's dependent on a lot of the -- some of the underlying assumptions.

Kevin Fischbeck -- Bank of America -- Analyst

Okay. That's helpful. And I guess it wasn't 100% clear to me what you were saying as far as your approach to the guidance. You said you took down some of the COVID offsets. Is that -- are you basically saying that you were prepared for things to get worse and you had cost cuts all lined up, and now that things are coming in better, you don't feel the need to push that as much? Is that the way to think about it?

Joel Ackerman -- Chief Financial Officer

No. I think -- our T&E is down, and it's been down since the beginning of COVID as teammates travel less, and we had modeled that continuing through the end of the year. And now we think, for example, that T&E in Q3 and Q4 could return closer to pre-COVID levels. So the offset, the benefit we got from lower T&E is probably going to be less than we anticipated.

Kevin Fischbeck -- Bank of America -- Analyst

Okay. That's helpful. And then I guess last question. Can you just give an update on your contracting outlook for Medicare Advantage? Are there any large books of business that are up for renewal next year? And how are things going as far as rates and conversations around going to more value-based models?

Javier J. Rodriguez -- Chief Executive Officer

Yes, Kevin, this is Javier. How are you? Thanks for the question. Let me just start off by saying that there is no spike or change in volume of renewals or anything like that. It's in its normal cycle.

The conversations continue to be highly, highly aligned in trying to make sure that we add more value to the patients and help in the -- in their care continuum. So -- and the fact that we're doing more complicated contracts instead of a fee-for-service means that it takes longer. So as it relates to that, there's nothing sort of there, there to talk about because the outlook is kind of unchanged, and it's incorporated in our guidance.

Kevin Fischbeck -- Bank of America -- Analyst

Thanks.

Javier J. Rodriguez -- Chief Executive Officer

Thank you.

Operator

Thank you. [Operator Instructions] Our next question will come from Justin Lake with Wolfe Research. Your line is open.

Justin Lake -- Wolfe Research -- Analyst

Guys, good afternoon. A few questions here. First, in terms of the guidance change, it looks like you talked about things getting a little bit better on the COVID front. I think you said $50 million when you net it all together, and that's basically what you took up or what you took the guide by. So does that imply that the first quarter looks better than my model and I think better than consensus. So does that mean that the quarter was actually kind of in line with your views? Or was the first quarter kind of materially better from an OI perspective?

Joel Ackerman -- Chief Financial Officer

Yes. I'd say, Justin, the Q1 was within the range of what we were expecting. I'd say a little bit on the positive side, but it's early in the year to start tinkering with our full year guidance and our full year forecast. So despite what I would characterize as a strong quarter, we chose to keep things in line.

Justin Lake -- Wolfe Research -- Analyst

Okay. And then the $150 million, I think you said, Joel, was the net COVID headwind?

Joel Ackerman -- Chief Financial Officer

Correct, for the whole year.

Justin Lake -- Wolfe Research -- Analyst

For the full year. Okay. So -- but it looks like that has a bunch of different components, right? If I think about it, there's COVID costs, right, as a part of it, there's the negative impact on treatments, then there's the benefit of sequestration, which it sounds like you put in there, and then there's some cost offsets. So I'm just trying to think about it, is there any way to help us understand those four buckets?

Joel Ackerman -- Chief Financial Officer

Yes. So you've got it right. And I think it -- ultimately, it's a pretty simple calculation. You take the excess costs associated with PPE and that roughly offsets with sequestration. And then everything else is awash and what you result in is basically the negative impact of mortality, which is in that $150 million range. So there are a lot of moving pieces, but net-net, they mostly cancel out and leave you with the impact of mortality.

Justin Lake -- Wolfe Research -- Analyst

Okay. And then as you think about the impact on mortality, obviously, to your point, we probably saw a bottom in the first quarter and things are expected to get better through the year. So I'm just trying to think about the pace of that $150 million right? Because the exit rate is going to be important coming out of fourth quarter to think about the impact on next year. So can you help us think about that in terms of where you think that impact is in this quarter? And where you think that impact will be kind of in the fourth quarter?

Joel Ackerman -- Chief Financial Officer

Yes. So this stuff gets pretty technical, pretty quickly, but let me try and help you out. I think the way I would think about it to simplify it as you start with what our typical NAG is. And if you want to grab a number, go back pre-COVID and pick something in the low 2s, 2.2%, something like that. And you really see that impacted by any continued excess mortality. But again, we think that's declining rapidly. You'd probably see some in Q2, but going down quickly. Again, assuming COVID plays out the way we expect, and it's on its way out, but obviously, things could be different.

So start with NAG, add excess mortality then adjust for what could be a challenge to the pipeline, if you want to assume there's any CKD four impact. We don't have data on that. But if we look at what we see in terms of new admits, we don't see any impact there that -- we don't see any impact from that right now, but you'd have to incorporate that. And then we see a tailwind coming up as patients who otherwise would have died in the next quarter or 2, passed away as a result of COVID. And that's a hard one to measure.

So that's how I'd model it. If you want to get kind of simplistic, and I realize I'm throwing a lot of numbers in a complicated story at you, I think you start with that math, you add back the tailwind associated with lower mortality post-COVID. And that's how you start modeling what NAG looks like going forward.

Justin Lake -- Wolfe Research -- Analyst

All right. I'll -- I'm not smart enough to figure that out, but we'll talk about it offline. Just last question. The -- can you give us the commercial mix change from kind of what you were looking at in the fourth quarter kind of into the first quarter here?

Joel Ackerman -- Chief Financial Officer

It went up a small amount, not much, but it was up a little bit.

Justin Lake -- Wolfe Research -- Analyst

Alright. Thanks, Joel.

Operator

Our next question will come from Pito Chickering with Deutsche Bank. Your line is open.

Pito Chickering -- Deutsche Bank -- Analyst

Hey. Thanks for taking my follow up questions. A couple of quick ones here. It's been a pretty fun few years from a share repurchase perspective. I'm just curious what we should think about as the right leveragio for the business at this point? And kind of where should we deploy the rest of that ine ratto share repo? Because I think you're around 3.5 at this point. I just want to just get a feeling for how we should think about leverage ratios versus share repo?

Joel Ackerman -- Chief Financial Officer

Yes. So look, I think we've been pretty consistent on this, and nothing has really changed. We want to be in that three to 3.5 times. We're at 3.39 times right now. We did a $1 billion bond deal during the quarter. Cash flow for the rest of the year is likely to be relatively strong. You saw cash flow in Q1 was weak, and we think we'll make that up over the course of the year. But no reason to think our philosophy and approach to leverage ratio and buybacks is going to change over the near future.

Pito Chickering -- Deutsche Bank -- Analyst

Okay. The second one is a quick one. What was the percentage of your Medicare Advantage penetration this year versus last year?

Javier J. Rodriguez -- Chief Executive Officer

What we disclosed last time as our expectation is in line. What we said was mid- to high 30% and markets roughly around 43%. So we're slightly below the rest of the market, still in the mid- to high 30s.

Pito Chickering -- Deutsche Bank -- Analyst

Okay. Sort of what percent of your patients were treated in the home this quarter? And did you see that accelerating sort of in this post-COVID environment?

Javier J. Rodriguez -- Chief Executive Officer

The percentage hasn't changed much because with NAG decreasing, but that segment of our business did increase, in particular, PD. PD grew around 4%, home hemodialysis, the HH part of it decreased. But net-net, that's the segment of the business that continues to grow. We think that there is appetite from the physician community and the patients to have more flexibility and freedom, and we are innovating and creating a lot of technology so that the patients feel more comfortable and more confident, more convenient being connected to our care site. So we do expect that the modalities will continue to grow.

Pito Chickering -- Deutsche Bank -- Analyst

Okay. Great. Thanks so much, guys.

Javier J. Rodriguez -- Chief Executive Officer

Thank you.

Operator

Thank you. We are showing no further questions at this time.

Javier J. Rodriguez -- Chief Executive Officer

Okay. Well, hopefully, the short means that it was pretty clear. Let me just say some closing comments. Q1 2021, in my mind and in my heart and in many of our caregivers will always be remembered and come with a lot of fulfillment for vaccinating literally tens of thousands of patients, in many instances not being dramatic or overstating it, literally life-sustaining. Second, the quarter financials are pretty straightforward. And pending a shift in the virus, we begin a path toward our historical normalization. And then lastly, our teams continue unwavering commitment toward caring and innovating to improve the lives of our patients. We thank you for your interest in DaVita, and we look forward to talking to you soon. Stay safe.

Operator

[Operator Closing Remarks]

Duration: 34 minutes

Call participants:

Jim Gustafson -- Vice President, Investor Relations

Javier J. Rodriguez -- Chief Executive Officer

Joel Ackerman -- Chief Financial Officer

Pito Chickering -- Deutsche Bank -- Analyst

Kevin Fischbeck -- Bank of America -- Analyst

Justin Lake -- Wolfe Research -- Analyst

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