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DATE

Monday, February 2, 2026 at 5 p.m. ET

CALL PARTICIPANTS

  • Chief Executive Officer — Javier Rodriguez
  • Chief Financial Officer — Joel Ackerman
  • Operator

TAKEAWAYS

  • U.S. Adjusted Operating Income -- $2.094 billion for the full year, with Q4 at $586 million, matching guidance midpoint.
  • Adjusted Earnings Per Share -- $10.78 for 2025 and $3.40 for Q4, based on continuing operations.
  • Free Cash Flow -- Just over $1 billion in 2025, including $309 million during Q4.
  • U.S. Dialysis Treatment Volume -- Declined 1.1% year over year, with a Q4 decrease of about 20 basis points compared to Q4 2024.
  • Revenue Per Treatment (RPT) -- $410 for 2025, up 4.7% year over year; Q4 RPT rose approximately $12 sequentially, driven by aged receivables, rate increases, improved yield, private pay mix, and seasonal vaccine effects.
  • Patient Care Cost Per Treatment (PCC) -- 5.9% higher than 2024, primarily due to supply costs and health benefits, with about half the increase attributed to binders in the bundle.
  • International Segment Operating Income -- $114 million for the year, with Q4 at $21 million, reflecting both organic growth and recent Latin America acquisitions.
  • Integrated Kidney Care (IKC) Profitability -- Achieved first profitable year in 2025; full-year adjusted operating income reached $22 million, ahead of schedule versus prior five-year target to reach profitability by 2026.
  • Share Repurchases -- Nearly 13 million shares repurchased for approximately $1.8 billion in 2025; 2.7 million repurchased in Q4, and 1.7 million more after quarter-end, with Berkshire Hathaway ownership kept at or below 45% by agreement.
  • 2026 Guidance: Adjusted Operating Income -- $2.085 billion to $2.235 billion, representing a midpoint growth of 3.2% year over year.
  • 2026 Guidance: Adjusted EPS -- $13.60 to $15.00, with midpoint of $14.30, reflecting a 33% increase from 2025.
  • 2026 Guidance: Free Cash Flow -- $1 billion to $1.25 billion, with $1.125 billion at the midpoint.
  • Elara Caring Strategic Investment -- Announced a $200 million minority investment, expected to close midyear and contribute positively to other income.
  • U.S. Dialysis 2026 Outlook -- Flat treatment volume expected, 1%-2% RPT growth, and 1.25%-2.25% cost growth, with the primary cost drivers being wage increases and G&A investments.
  • Share Repurchase Framework -- Ongoing large repurchases, primarily via Berkshire Hathaway, balanced against leverage and liquidity targets.

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RISKS

  • CEO Rodriguez cited "continued pressure on treatment growth driven by elevated mortality" and expiration of enhanced premium tax credits as current financial headwinds.
  • Joel Ackerman projected a "$40 million headwind from the expiration of enhanced premium tax credits for exchange plans" in 2026, with potential attrition from ACA participation still uncertain.

SUMMARY

DaVita Inc. (DVA +25.20%) delivered full-year and fourth quarter 2025 results in line with guidance, reporting growth in revenue per treatment, free cash flow, and operating income, while navigating cost pressures and modest volume declines. Management confirmed that its Integrated Kidney Care business reached profitability ahead of its long-range plan, projecting continued, but moderating, incremental operating income from this segment. A new strategic investment in Elara Caring was announced, intended to directly support patient care advances and other income. The company set 2026 guidance for adjusted earnings per share and operating income significantly above its historical growth targets, citing rising margins, lower debt expense, and elimination of losses at Mozarc as key contributors.

  • Management highlighted that positive vaccination trends correlate with reductions in hospitalization and mortality risk.
  • Guidance assumes near-flat U.S. dialysis treatment volumes with explicit caution regarding first-quarter negative year-over-year growth due to treatment-day seasonality.
  • Adjusted EPS guidance for 2026 does not include extraordinary or nonrecurring items, and CFO Ackerman indicated it should serve as a reliable baseline for future projections.
  • International segment performance contributed approximately 1% to enterprise-level operating income growth, reflecting a mix of organic gains and recent acquisitions.
  • Management expects incremental Integrated Kidney Care operating income of $20 million in 2026, signaling a gradual deceleration in segment growth rates as the business matures.
  • Rodriguez stated, "we continue to believe we're on a path back to at least 2% volume growth," but qualified that the benefit from clinical initiatives will likely materialize over a multi-year timeframe.

INDUSTRY GLOSSARY

  • Integrated Kidney Care (IKC): DaVita's care model combining clinical management, risk-based contracts, and technology to improve outcomes and manage financial risk across kidney care populations.
  • ESKD (End-Stage Kidney Disease): The final, permanent stage of chronic kidney disease where patients require dialysis or kidney transplantation to sustain life.
  • GLP-1s: Glucagon-like peptide-1 agonist drugs, used for diabetes and shown to reduce cardiovascular events and mortality in certain dialysis patients.
  • RPT (Revenue Per Treatment): Financial metric reflecting the average revenue earned by DaVita for each dialysis treatment provided.
  • PCC (Patient Care Cost) Per Treatment: The average direct cost incurred in delivering each dialysis treatment, excluding administrative expenses.
  • Binders in the Bundle: Oral phosphate binders included within the CMS Prospective Payment System “bundle” for ESRD-related drugs and services.
  • Mozarc: Referenced joint-venture investment in renal care, which previously resulted in reported losses for DaVita.

Full Conference Call Transcript

Javier Rodriguez: Thank you, Nic. Good afternoon, everyone, and thank you for joining the call today. As we evaluate 2025, the year represents the latest evidence of our differentiated capabilities, strategy and platform. We executed with discipline, met challenges head on and delivered on our commitments we set at the beginning of the year. At the same time, we continue to invest to enhance patient care and fuel growth in the years ahead. As a result, we're well positioned for 2026 and beyond with opportunities to deliver clinical and financial results consistent with our long-standing track record and guidance. Today, I'll review our fourth quarter results, share insights on our clinical strategy and wrap up with guidance for 2026.

But first, as always, I will start with a clinical highlight. This quarter, I want to spotlight the clinical results achieved in our Integrated Kidney Care or IKC programs. Patients managed under our IKC models consistently achieve better outcomes than the broader dialysis population. Our IKC patients are 35% more likely to start dialysis with a permanent vascular access, resulting in a better patient experience and costs that are 3x lower during the first 180 days of dialysis. IKC patients also experienced fewer bloodstream infections, achieve higher vaccination rates and are more likely to choose home dialysis. We also see more than 10% improvement in treatment adherence with fewer missed treatments.

Most importantly, these outcomes lead to what matters most, a better quality of life with fewer hospitalizations. Transitioning to our fourth quarter performance. We delivered results in line with our expectations. As anticipated, revenue per treatment accelerated in the quarter alongside strength in IKC. This was partially offset by higher-than-expected health benefit costs. For the full year, we achieved adjusted operating income and adjusted earnings per share in the top half of our guidance range despite the impact of cyber incident on our U.S. dialysis business. Let me elaborate briefly on our IKC performance. As we've noted previously, we analyze IKC results on a full year basis, given quarterly volatility driven by timing of revenue recognition.

As we look back to our Capital Markets Day in 2021, we outlined a 5-year path to IKC profitability by 2026. Our strategy is centered on sustainable contract, physician partnership and a scalable care model supported by technology. With full year 2025 results, we're reporting our first profitable year in IKC, which is slightly ahead of schedule. This milestone reinforces 2 key learnings. First, our hands-on clinical models work as reflected in the outcomes I highlighted earlier, our dedicated IKC caregivers are delivering on the promise of value-based care by keeping patients healthier and out of the hospital.

Second, we've proven there's a viable business model that is good for our patients, good for the health care system and can generate value for DaVita and our partners. The business will continue to evolve over time alongside changes in government policy, competitive dynamics and innovation. Building from this 2025 benchmark, we expect to deliver an incremental $20 million of IKC operating income growth in 2026. Looking more broadly at our business, we see significant opportunities ahead and believe DaVita is uniquely positioned to deliver on them. Before turning to those opportunities, let me provide some context on our journey to date.

Over the past 5 years, we've navigated wide range challenges from macro events like global pandemic and inflation to supply chain disruption and cyber incident. And through it all, we delivered on our multiyear commitments. We provided high-quality care for our patients, built a solid foundation for the future and generated compound annual growth in line with our long-term target for adjusted operating income and adjusted EPS. This performance reflects the determination of our teammates and the resilience of our operating model. This experience also gives us the confidence as we look at the opportunities and challenges ahead of us.

We're managing 2 near-term financial headwinds, continued pressure on treatment growth driven by elevated mortality and the revenue per treatment impact from the expiration of enhanced premium tax credits. Even with these headwinds and the reality of unknown challenges, we remain confident in our ability to sustain our track record of profit growth. That confidence starts with the most important driver of our long-term success, an unwavering focus on clinical excellence. We're executing a set of targeted initiatives designed to enhance patient care, reduce mortality and missed treatment rates and ultimately support higher treatment volume growth. I will highlight 4 specific examples. First is vaccination.

For many years, we achieved flu vaccination rates above 90% for our patients and clinical teammates, and we're working hard to return to that benchmark. Our patients who received a vaccination early in this flu season have shown a 9% lower risk of hospitalization and a 27% lower risk of mortality compared to their unvaccinated peers. Protecting our vulnerable patients from the flu, COVID and pneumonia is a clinical imperative. Second is GLP-1 adoption and adherence. A growing body of evidence confirms that GLP-1s can reduce major adverse cardiac events and mortality for many dialysis patients. We're actively working with physicians to help our patients navigate the clinical, operational and financial complexities of these drugs.

Third is advancing dialysis technologies to remove middle molecules. Innovations such as medium cutoff dialyzers and hemodiafiltration enable the clearance of a broader range of toxins from the body during the treatment. These technologies help the patients recover more quickly after dialysis and show promise of reducing mortality by as much as 20% or more. Finally, today, we announced a strategic clinical partnership with Elara Caring, a leading home care provider to establish an ESKD-focused offering. This model spans Elara's skilled home health, personal care and hospice service lines and is designed to lower hospitalizations and missed treatment rates while improving the overall patient experience. Joe will provide more details about the investment we're making alongside this strategic partnership.

Together, these clinical initiatives demonstrate how our patient-centered strategy directly supports our business objectives. By improving quality of life, reducing hospitalization and advancing clinical outcomes, we continue to believe we're on a path back to at least 2% volume growth. In parallel, we maintain a diligent focus on cost and innovation to improve efficiency, continue sustainable U.S. dialysis margins and deliver durable financial performance. With that backdrop, we remain confident in our ability to deliver adjusted operating income growth over the next 3 years that is consistent with our long-term growth target of 3% to 7%.

On adjusted EPS, with our current capital allocation program and removing the headwinds from our investment in Mozarc, we see an opportunity to exceed our long-term adjusted EPS guidance of 8% to 14%. Taken together, these priorities reinforce our ability to generate sustainable shareholder value and continued leadership in Kidney Care. I'll wrap up my comments with our guidance for 2026. We expect adjusted operating income within a range of $2.085 billion to $2.235 billion, which represents 3.2% growth at the midpoint. Our guidance for adjusted earnings per share is $13.60 to $15 even, reflecting a 33% growth at the midpoint.

This guidance exceeds our long-term EPS targets, reflecting our expectation for another year of strong operating performance and the cumulative benefits of our capital allocation strategy. Finally, we expect to generate free cash flow between $1 billion and $1.25 billion. I will now turn it over to Joe to discuss our financial performance and outlook in more detail.

Joel Ackerman: Thank you, Javier. First, I'll provide some detail on our fourth quarter and full year 2025 results and then share a detailed breakdown of our 2026 guidance. Fourth quarter adjusted operating income was $586 million, bringing full year adjusted operating income to $2.094 billion. Adjusted earnings per share from continuing operations for the fourth quarter was $3.40 with full year adjusted EPS from continuing operations of $10.78. Free cash flow was $309 million in the fourth quarter, which brings full year free cash flow to just over $1 billion. Starting with U.S. dialysis. Treatments declined about 20 basis points versus the fourth quarter of 2024.

Although our total patient census growth during the quarter was as we expected, the timing of the census gain was back-end loaded in the quarter. For the full year, U.S. treatments declined by 1.1% versus 2024, in line with our expectations from the Q3 earnings call. Next, revenue per treatment growth accelerated in the fourth quarter as anticipated, up approximately $12 sequentially. Fourth quarter growth was the result of 4 primary factors: First, the resolution of aged receivables, consistent with what we forecasted on the Q3 call. Second, normal rate increases and improved yield. Third, private pay mix improved slightly after a dip in the third quarter. And finally, RPT benefited from the typical seasonal impact of flu vaccines.

Full year RPT was approximately $410, up 4.7% for the year. As you think about RPT for the first quarter of 2026, keep in mind that Q1 bears a typical $5 or more RPT headwind due to patient responsibility amounts early in the year. Patient care cost per treatment increased by approximately $6 sequentially. The increase was primarily the result of seasonal increases, including health benefit costs and higher supply costs. PCCs per treatment finished the year 5.9% higher than 2024, near the top end of our revised range of expectations, but lower than our original guidance for the year. As a reminder, approximately half the year-over-year increase in PCCs was from binders in the bundle.

Turning to our other segments. International adjusted OI was $21 million, resulting in full year adjusted operating income of $114 million. This reflects strong operating performance for our international business as we delivered positive organic growth and integrated the recent acquisitions in Latin America. In IKC, as Javier noted, we delivered our first profitable fiscal year. Q4 adjusted OI was $46 million and full year adjusted OI was $22 million. We saw strength across all 3 of the businesses within IKC and final reconciliations of our 2024 performance resulted in higher-than-expected shared savings revenue. Switching to capital allocation.

During the fourth quarter, we repurchased 2.7 million shares, and we repurchased an additional 1.7 million shares since the end of the quarter. As is typical, a portion of these shares were repurchased from Berkshire Hathaway pursuant to the terms of our publicly filed repurchase agreement, which formulaically results in Berkshire's ownership remaining at or below 45%. For the full year 2025, we repurchased nearly 13 million shares for approximately $1.8 billion. At year-end, our leverage ratio was 3.26x consolidated EBITDA, down from the third quarter and at the midpoint of our target leverage range of 3 to 3.5x. With that, let me turn to 2026.

As Javier said, we are guiding to an adjusted operating income range with a midpoint of $2.16 billion. At this midpoint, we have built in the following assumptions for U.S. dialysis. Treatment volume will be approximately flat to 2025. This assumes a flu impact consistent with what we saw in the 2023/2024 season. We are not assuming any improvement in non-flu mortality, though as Javier outlined, we are working on a number of initiatives to actively drive down mortality among our patients. Last, on admissions, we are assuming 2026 looks similar to 2025, excluding the impact of the cyber incident.

To help with modeling our treatments by quarter, we have added a table to the press release showing normalized treatment days by quarter. This number adjusts for the mix of treatment days and holiday shifts, making it the most helpful number to model quarterly treatments. For example, you'll notice a year-over-year normalized treatment day headwind in Q1 2026, which drives our expectation for negative year-over-year U.S. dialysis treatment volume growth in the first quarter of this year. Moving on to RPT. For 2026, we are forecasting growth of 1% to 2%. The primary driver of this is typical rate increases.

We also expect an estimated $40 million headwind from the expiration of enhanced premium tax credits for exchange plans, which is largely offset by the elimination of the $45 million headwind in 2025 from the cyber incident. We expect total U.S. dialysis costs to grow 1.25% to 2.25%, mostly driven by typical wage rate increases and G&A investments, partially offset by a decline in depreciation and amortization. The net impact of all this at the midpoint of our guidance is an increase in adjusted operating income for the U.S. dialysis business of approximately 1.5%.

Also baked into the midpoint of our adjusted OI guidance range is an expectation for each of IKC and International to contribute approximately 1% to enterprise adjusted OI growth. Altogether, these results reflect our expectation for 3.2% adjusted operating income growth at the midpoint of our range versus 2025. For seasonality, we expect first quarter adjusted operating income will represent approximately 20% of our full year guidance. In other words, about $430 million at the midpoint. Below the operating income line, we expect positive other income of approximately $10 million for the year.

This represents significant year-over-year improvement in this line item, resulting from no further losses from our investment in Mozarc since we have now recognized the cumulative losses equal to our investment. We expect debt expense to decline by $20 million to $40 million versus 2025. This is driven by lower interest rates year-over-year, both from the decline in rates and from our repricing and refinancing transactions, which lowered spreads. We expect noncontrolling interest to be approximately 16% of U.S. dialysis OI, and we expect effective tax rate to be in the range of 24.5% to 26.5%.

Regarding capital allocation, related to Javier's comments, we announced the signing of an approximately $200 million minority investment alongside a majority investment from Ares' Private Equity Funds to acquire Elara Caring. After the transaction closes, which we expect to happen midyear, we expect this to contribute positively to our other income line. In addition, we will continue to repurchase shares in line with our typical framework, keeping in consideration our liquidity, leverage and the price of our stock relative to our view of intrinsic value. As a reminder, a significant portion of our repurchases will continue to come via direct purchases from Berkshire Hathaway as part of our ongoing repurchase agreement.

At the midpoint of the range, we are guiding to adjusted EPS in 2026 of $14.30. This does not contain any unusual or nonrecurring items and is a good starting point from which to model future EPS. Our 2026 guidance represents a 33% increase over last year, which is the result of 2 familiar drivers: increased operating income and lower share count, plus the elimination of the headwind from our share of the losses at Mozarc, as I previously noted. Finally, on free cash flow, the midpoint of our guidance for 2026 is $1.125 billion, reflecting a resilient business with discipline in the deployment of our capital resources. That concludes my prepared remarks for today.

Operator, please open the call for Q&A.

Operator: [Operator Instructions] Kevin Fischbeck with Bank of America.

Kevin Fischbeck: I wanted to get a little more color on the commentary around, I guess, the confidence in getting back to the 2% plus volume number. Obviously, I guess, this number you're looking for in the guidance for '26 is a little bit better than '25, but it's still well below that 2%. So is it all about executing on mortalities? Or is there something else that you're kind of pointing to that gives you that confidence?

Javier Rodriguez: Yes, Kevin, this is Javier. I appreciate the question. The reality is it is a clinical story. And if you go back and you look at the time when the industry was at its peak of growth, many people thought it was the incidence, but the reality is, is that it was also a clinical story throughout, meaning mortality was improving year after year. And so to get to that 2%, you have to assume that the things that we outlined in our prepared remarks come to fruition. And we think, of course, there's a lag between all of the implementation clinically and the full effect.

And so we think that you will start to see some benefits in approximately 2 years, and you probably see the full effect by '29 or so.

Kevin Fischbeck: Okay. That's helpful to get that timely. I forget, you gave some kind of multiyear guidance ranges. Was it 3 years you said? Or was it 5 years that you were giving those OI and EPS comments?

Javier Rodriguez: We didn't say a year, but we think of it in a 3-year or so time frame.

Kevin Fischbeck: Okay. And then just last one on the free cash flow number. So I guess the way to think about it is that number, the $1.125 billion, that's before the $200 million investment. So like if we thought about share repo or so, we should take $200 million out of that to think about additional deployable capital? Or is there some other adjustment...

Joel Ackerman: Kevin, that's the right way to think about it then. And I'd say the starting place would be with leverage level where we came out right in the middle of the range, obviously, with EBITDA growth, if we didn't increase leverage, we'd wind up in the lower half of the range. So that would be the other thing to consider when trying to figure out what's the right number to put in for share repurchases.

Kevin Fischbeck: Okay. But there's no other like obvious use of capital that's kind of like the most likely use of capital after that $200 million?

Joel Ackerman: That's right.

Operator: And our next caller is Andrew Mok with Barclays.

Andrew Mok: I appreciate all the color on 2026 guidance. Can you help us understand how missed treatments and mortality trended throughout the fourth quarter? And is there any connection or causality that you've been able to draw between those 2 items as you've dug into this issue further?

Joel Ackerman: Yes. So nothing really to highlight on mortality during the quarter. Missed treatments were up, but typically, you'd see missed treatments up in Q4. And if you looked at Q4 '25 missed treatments, you wouldn't see much difference with Q4 '24 missed treatment. So year-over-year, not much of a change. I would say our clinical folks would say there absolutely is a correlation between missed treatment rate and mortality, but with some lag between those 2 metrics.

Andrew Mok: Great. And can you provide more detail on how you expect the ACA headwind to play out this year? And maybe comment on how open enrollment performed against your expectations and what level of attrition you're expecting from here?

Joel Ackerman: I'm sorry, Andrew, I missed the first part of the question.

Andrew Mok: Can you give us more detail on how you expect the ACA headwind to play out this year from a cadence perspective? And maybe comment on open enrollment, how that played out relative to expectations and whether -- what level of attrition you're expecting on that ACA enrollment throughout the year?

Javier Rodriguez: Thank you, Andrew. So the number that we gave, we said approximately $40 million this year, $70 million next year and $10 million the year after that. The reality is that we're seeing what you're seeing in the broader market, which is open enrollment performed better than forecasted by CBO or ourselves. And we're all waiting to see the real number, which is right now, we are measuring selection of a plan or enrollment of a plan. And then, of course, people are trying to see what the payment of the plan will be to see what the yield will be.

We don't have any additional color than what you or the marketplace has on what that will be since it's the first time that these enhanced premium tax credits have gone away. But so far, it has been more resilient than people expected, and we will see once the bills start to come if people pay. We will say that our patients during the pandemic and at other time periods because they are so ill and needing of the health care system, are really sophisticated understanding their insurance needs. So on average, they will go out of their way to stay insured.

And that's why last call, we said that there is basically 2 populations, our current patient population, which we think will be more resilient. And then you have the incoming population, which is, in essence, right now, a CKD population that might not value insurance as much as someone that's already had their kidneys failed, and that's why the number grows over time. But we will obviously be watching it during the quarter, and we will see once the payments go into effect.

Andrew Mok: Great. If I could -- can I just ask a follow-up on that? Do you have a sense for how many of your ACA patients receive premium assistance?

Javier Rodriguez: I do not because that obviously has a lot of categories from the enhanced premium tax credits to the normal ones and you get into the income levels and other things. So I do not break it down into more detail.

Operator: Our next caller is Justin Lake with Wolfe Research.

Justin Lake: A couple of things. First, on the ability to offset the exchange headwind with the tailwind or the kind of the nonrecurrence of that cyber headwind from last -- from 2025. My recollection was the last time you guys talked about this that the cyber headwind this year, while it hurt the second quarter, it was offset by some better collections and therefore, it wouldn't be as big a tailwind as it might have been in 2026. Did I remember that incorrectly? Or have you found other initiatives on the reimbursement side?

Joel Ackerman: Yes. So let me try and lay out all the pieces for you, Justin here. So we called out a $70 million headwind from cyber. $25 million of that is volume, and most of that recurs because it's just census that was lost and we're not going to get back in 2026. The balance was $45 million, and that was an RPT headwind. We think that RPT headwind is offset in 2026, basically by the enhanced premium tax credit headwind. So you don't see a year-over-year growth problem in RPT because both years have a $40 million to $45 million negative.

In terms of some of the other stuff we called out, in particular, around Q4 and the resolution of some older claims, there's really nothing in the year from that to call out. We have resolution of older claims every year. Looking back now, the 2025 number is roughly the same as what we saw in 2024. And the 2026 number, we would expect to be similar in 2025. So I wouldn't call that out as unusual in any year. What was unusual was the concentration in Q4 of '25, which is why we called it out last quarter.

Justin Lake: Got it. And then going back to IKC, can you give us a little more color in terms of what drove the outperformance in 2024 versus what you had previously booked and the level of confidence you have that, that can continue and grow from there?

Javier Rodriguez: Sure. Let me grab that one, Justin. It's Javier. A couple of things that we've talked about as it relates to IKC. So just a quick housekeeping reminder. I have to look at it on an annualized view because it moves pretty dramatically quarter-to-quarter. We think of it in 3 categories. The first one is dollars under management, you can think of it as volume, and that's been relatively flat. We talked about it last time. Secondly, the model of care cost and the G&A costs, which we've done a nice job of remaining flat there. And then the third category, which is the shared savings.

And in that, of course, there is contracting and performance to what you're doing to add value to the system. As it relates to that 2024 reconciliation, we did better in that shared savings part that I just talked about. Is that help you?

Justin Lake: Yes. Just how did you do better? What was it the inpatient admissions, outpatients? Just curious for a little more color there and what gives you confidence that, that number is going to continue at that level given how much.

Javier Rodriguez: Well, I mean, look, there is a lot of little things, medication management, transitions of care, segmentation of patient population, having more access to patients earlier. We have new interventions and protocols. One of the difficulties of this business is, of course, understanding exactly what moves the needle, but rather the cumulative portfolio is working, and that's why we felt comfortable giving a plus $20 million for 2026.

Operator: [Operator Instructions] A.J. Rice with UBS.

Albert Rice: First, there's been a lot of discussion and even the talk about what you're doing with the IKC business about either people managing patients with CKD better and more effectively. And then obviously, there's drugs discussion about some of the drugs that could have an impact. And I wondered what are you seeing in disease progression with someone that has kidney disease time to get to dialysis? And then are they -- are you seeing them stay longer yet on dialysis? Or when do you think any of that would have an impact?

Javier Rodriguez: Yes. Thanks for the question. The reality is we have not seen anything shift. But you would think that, that would take some time as we've talked about. When you talk about these drugs, they're not magic drug, but rather it takes some time of being on them to have the effect that you're talking about. So right now, it's too early to tell. And again, we've only been managing these population, the CKD populations for 5 years or so. So that will take longer to play out.

Albert Rice: Okay. And then maybe a follow-up on the Elara Caring investment, how should we think about that? Is it just a financial investment from your side? Are you going to do things operationally that might make a difference for you? Can you describe a little more of what's going on with that?

Javier Rodriguez: Sure. Our investment thesis has 2 pieces to it. One is, of course, we have to have a good capital return on that $200 million. We want to be disciplined. We think it's a good-sized investment, and we wanted to have good capital returns. The second one is to help our patient population. Roughly 1/4 of our population uses home health. And by having a specialized kidney protocol, we think we can reduce hospitalization and readmissions and then, of course, try to reduce missed treatments. So it is connecting back to this whole loop of trying to do more for our patients while we have them in our clinic and now outside of the clinic.

Operator: Our next caller is Pito Chickering with Deutsche Bank.

Pito Chickering: Can you talk about the international business for a little bit, how we should think about the top line growth, whether it's M&A and -- versus organic and how we should think about margins within that segment?

Joel Ackerman: Yes. I think on international, generally, I would think about the growth, both top line and bottom line as half M&A and half organic. We would expect the margins to continue to improve as they leverage the kind of the fixed overhead, both at the international level as well as in the existing markets. So international has proven to be a good business for us, a relatively consistent performer and a contributor of about 1 point to OI growth over the last few years, and we're expecting more of the same in 2026.

Pito Chickering: Okay. And then I'm going to ask Justin's question on IKC a little bit differently. But looking at the losses you guys had in '22 and '23 and '24 and just refresh us on those, if you could. I guess, why should we think about the rate of improvement in '26 sort of slowing dramatically? It just seems as though the losses have compressed quite significantly as you've gotten scale. And so I'm curious why we wouldn't see the benefits grow sort of levels that we've seen in the last couple of years.

Joel Ackerman: Yes. So look, your math is right. I think if you go back over the last 3 years, the average OI improvement has been somewhere in the $40 million to $50 million per year, and now we're seeing -- we're calling out a slowing of that. I think it's just a natural occurrence as the business matures and gets bigger, there's just less opportunity to continue to drive the margins up. We're not expecting a high-margin business here. And so I think $20 million a year is a comfortable landing spot for us right now in terms of contribution to OI growth.

Pito Chickering: Okay. And then last question here, just about new starts. I think you talked about new starts in the fourth quarter more back-end loaded. But as you think about new starts for 2026, how do you model that? And specifically, how do you break out the payer mix of those new starts versus, say, previous years as it relates to commercial or HICS or government patients?

Joel Ackerman: Yes. So we're not calling out any dramatic change in new starts for next year, similar to mortality and to some extent, missed treatment rates. When we see those things improve, we'll start calling them out. But until then, we're comfortable with flattish. In terms of mix, look, new patients have always had a higher commercial mix than the average patient. It's just the natural evolution of a patient as they get older, they tend to migrate towards Medicare. I don't see any change to that pattern going forward.

Pito Chickering: Okay. So just to be super clear, the new starts that we're seeing coming in are the same commercial mix we've seen for the last several years.

Joel Ackerman: Yes, with the one call out around HICS and that changing. But other than that, I don't see any other new dynamic.

Operator: Our next caller is Ryan Langston with TD Cowen.

Ryan Langston: On the flu vaccine commentary in the prepared remarks, did you say that there was an actual change in the vaccination rates this fourth quarter versus other fourth quarters? Or was that just more related to seasonal sequential -- or seasonality sequentially?

Javier Rodriguez: I believe what we said in the opening remarks is that in our high, we were in the 90 percentile, and we aspire to get back to that. And just to give you a bit of sense, right now, we're at 80%, which is, from a national perspective, quite healthy, but we could do better.

Ryan Langston: Got it. And I know the dialysis...

Joel Ackerman: The other thing I'd just point out is flu vaccines do go up in Q4 over Q3, and that does drive a little bit of RPT and a little bit of cost. So that's part of the Q4 over Q3 RPT dynamic as well.

Ryan Langston: Yes, that makes sense. And then just last thing. I know the dialysis population is a bit different from individual MA population. But if the kind of flat advanced notice hold for 2027 and the final notice, I guess, is there any maybe just directional change in what we could assume for outlook in terms of growth for '27?

Javier Rodriguez: Yes. Thanks for the question, Ryan. One of the things that is worthy of highlighting is that the ESRD population has its own funding pool in MA and that CMS has actually realized that there was an underfunding, so there was a catch-up. So the dialysis or ESKD population will receive a 6% increase in 2027, which from our perspective, reflects the reality and would put an MA plan in a position to want to add these patients to the risk pool.

Joel Ackerman: And Ryan, the one thing I'd add to that is not only is the reimbursement different, but the whole coding regime is different. So the questions around V28 and rebasing and the higher coding intensity in a given year, those are not part of -- they're a much smaller part of the math for ESRD MA rates. And if you look at the notice from last week, you'd see it in there all as well. So it's all spelled out.

Operator: At this time, I'm showing no further questions. Speakers, I'll turn the call back over to you for any closing comments.

Javier Rodriguez: Thank you, Michelle, and thank you all for joining. I hope it is 100% clear that our energy and excitement around clinical opportunities are absolutely off the charts to expand the lives of our patients. We have a powerful alignment between our clinical ambitions and our financial goals. By fulfilling our mission to deliver the best care for our patients, we can also deliver returns for our shareholders. Thank you for your interest, and thank you for joining the call today. Have a good day.

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