Fresenius Medical Care AG & Co. KGaA (NYSE:FMS) Q3 2022 Earnings Conference Call October 31, 2022 10:30 AM ET
Company Participants
Dominik Heger – Head of Investor Relations
Carla Kriwet – Chief Executive Officer & Chair of the Management Board
Helen Giza – Deputy Chief Executive Officer, Chief Financial Officer & Chief Transformation Officer
Conference Call Participants
Tom Jones – Berenberg
Graham Doyle – UBS
James Vane-Tempest – Jefferies
Hassan Al-Wakeel – Barclays
Veronika Dubajova – Citi
Oliver Metzger – ODDO BHF
David Adlington – JPMorgan
Robert Davies – Morgan Stanley
Falko Friedrichs – Deutsche Bank
Szegi Oezener – HSBC
Operator
Ladies and gentlemen, thank you for standing by. I’m Nathalie your Chorus Call operator. Welcome and thank you for joining the Fresenius Medical Care Report on the Third Quarter 2022. Throughout today’s recorded presentation, all participants will be in a listen-only mode. The presentation will be followed by a question-and-answer session. [Operator Instructions]
I would now like to turn the conference over to Dominik, Head of Investor Relations. Please, go ahead.
Dominik Heger
Thank you, Nathalie. As mentioned by Nathalie, we would like to welcome you to our earnings call for the third quarter 2022, which is a day earlier than originally planned. I do apologize for the inconvenience that might have caused.
We will start with our presentation followed by a Q&A session. As always, I start out the cautionary — I start out the call by mentioning our cautionary language that is in our Safe Harbor statement, as well as in our presentation and in all the materials that we have distributed yesterday.
For further details concerning risks and uncertainties, please refer to these documents as well as to our SEC filings. We are aware that this is a call on short notice in your calendars in the middle of the reporting season. Therefore, we will try to keep the presentation short and leave time for questions.
As always, we would like to limit the number of questions again to two in order to give everyone the chance to ask questions. Should there be further questions and time left, we are happy to go a second round. It would be great if we could make this work. The call is scheduled for 60 minutes.
With us today for the first time is Carla Kriwet, our new CEO and Chair of the Management Board, who has started less than a month ago. Carla will share with you her first impressions of the company and initial strategic thinking. Of course, also with us is Helen Giza our Deputy CEO Chief Financial Officer and Chief Transformation Officer. Helen will give you an update on the business development, financial performance and outlook. This quarter only Helen will be available for the Q&A.
I will now hand over to Carla, the floor is yours.
Carla Kriwet
Thank you, Dominik. This is a privilege [ph] for me to say hello and welcome everyone to our Fresenius Medical Care Earnings Call. Thank you for joining our presentation. I’m very excited to be here today as CEO.
Throughout my first months with the company, I’ve seen firsthand the incredible commitment of our employees around the world. The patient-centric mindset and clinical excellence is truly inspiring and it is just one example of the many great assets we have to build on. At the same time, there’s a clear urgency for bold interventions to drive business turnaround and to position Fresenius Medical Care for future sustainable and profitable growth.
I would like to share what I’m focusing on and will begin on slide three. Our FME 25 transformation program is already underway and on track to deliver much needed financial transparency and simplification. We are currently transitioning to our new global operating model centered around our business segments, care delivery and care enablement and supported by global G&A functions and our global medical office. Furthermore, our execution plans are on track to deliver €500 million of EBIT by 2025.
Within care delivery, we have already started to address the substantial labor challenges. We are employing bold measures to fix our clinical operations to drive higher efficiency and productivity without sacrificing patient care. In addition, we will further consolidate our footprint.
For care enablement, we are introducing mitigating initiatives, including pricing actions, to address impacts from inflation and supply chain constraints. We are advancing measures to reduce our cost of production, including platform strategies and optimization of our manufacturing footprint.
Furthermore, we will regain innovation leadership and are developing a winning digital strategy that will leverage our unparalleled patient data sets to deliver unique value for our patients and customers. In SG&A, we are reducing overhead costs by optimizing shared services, utilizing automization and transitioning basic operational tasks to low-cost locations. We will leverage business partnering and centers of excellence. Finally, we are reducing operational complexity by eliminating duplications.
We are defining our future strategy with priorities becoming clearer. We will optimize our care delivery and care enablement business portfolio allocating capital to growth areas within — with higher profitability. This also means that we will exit unprofitable businesses and apply a strict investment, and return on invested capital discipline.
We are planning additional structural savings beyond the current FME25 program derived from competitive benchmarks. At the same time, we will capture growth opportunities in attractive segments such as value-based care, home, self and assisted care, upstream CTD, critical care and pharma.
We will inspire around our vision and global strategy to foster a one SME winning high-performance culture, while ensuring role model accountability and teamwork at all levels. Finally, compliance sustainability inclusion and diversity are all key requirements for our success. We will remain a mission-driven company striving to improve the lives of our patients.
You will understand that one month is not enough time to have a full strategic plan detailed out, and I will not be in a position to answer questions today. And we need to present this to our economic council first.
But I want to be very clear that, speed is of utmost importance. There is an urgency to address our operational performance now and interventions are already underway. I look forward to sharing more details with you in February, when we present our results for 2022.
At the same time, I will be very open to answering your questions. For the rest of today, I would like to hand it over to Helen, who will walk you through the developments of the quarter, and will handle today’s Q&A.
Thank you. Over to you, Helen.
Helen Giza
Thanks, Carla. Hi, everyone. I’ll pick up on slide 4. I’d like to start my prepared remarks with a quarterly performance before we go to the update on our outlook and implications for 2023.
In the third quarter, our business delivered revenue growth of 15% reported due to the weak euro and 3% at constant currency. On a constant currency basis and before special items, the operating income declined by 18%. On the same basis, our net income declined by 25%, which brings us to an 18% decline year-to-date.
Our business development continued to be impacted by the US labor market situation and slower organic growth in healthcare services than anticipated. Additionally, the persistent challenging macroeconomic environment with inflationary pressures and global supply chain constraints continues to heavily impact our Healthcare Products business.
COVID-19-related excess mortality was somewhat elevated during the third quarter, but has broadly developed in line with our assumptions for the year. We are closely monitoring the development of infection rates in the fall.
The closing of the InterWell Health merger during the third quarter marked an important milestone for our value-based care capabilities and our continued leadership in this highly relevant strategic area. The numerous challenges that we and many others in the healthcare industry need to master right now are unprecedented.
Following our guidance revision in Q2, we immediately initiated necessary interventions in our North America healthcare services business. However, these initiatives are taking longer than anticipated to show the expected results. While we expect to see some benefit from these measures in the fourth quarter, we are expecting a more meaningful contribution in 2023. We had assumed flat organic growth in health care services in North America for the second half of the year. It has sequentially improved, but not to the degree expected. And therefore, we now expect it to remain slightly negative.
As a matter of caution, in light of the delayed improvement in North America, and the associated impact on our downstream assets, continued labor challenges, accumulation of excess mortality, and the uncertainty in the macroeconomic environment we are extending our guidance range for 2022. Carla already mentioned that, we are working on a broader turnaround plan, which involves bolder interventions, including capacity adjustments.
Turning to slide 5, you all know me by now, and I do my utmost to be very transparent with the sizable moving parts. From the beginning of this year, we shared our assumptions and how actual developments we’re tracking. I’d like to update you on where we now stand through the first nine months, and how we see the full year finally shaping up. Unfortunately, the delta of the changes of our major heads and tailwinds is negative by around €60 million.
Starting with the headwinds. Of the €450 million to €460 million for the full year, we have already realized €282 million. The macroeconomic inflationary environment remains challenging, and we continue to see elevated raw materials, logistics and energy prices.
Year-to-date, we have already realized €175 million in macroeconomic inflationary headwinds. And in accordance, with the current run rate, we now expect this to be around €10 million higher than previously assumed. We have guided COVID-related excess mortality to impact us with a €100 million headwind for the year. And through the third quarter, we have realized €84 million.
In the third quarter, we experienced COVID-related excess mortality of around 1,100 and the year-to-date number is around 4,300. While excess mortality was somewhat elevated in the third quarter, it was not a huge spike like we saw with Omicron at the start of the year, and we will continue to support that our excess mortality for 2022 will end at or below 6,000 as we have previously guided.
Of course, we are watching closely as we move into the winter months in the Northern Hemisphere. For labor costs, beyond the typical 3% inflation, we assumed a €100 million headwind net of US provider relief funds. Through the first nine months of the year, the relief we received offset these labor costs. There is now only €9 million left from the provider relief fund, leaving minimal offset for the additional €100 million labor cost assumed for the fourth quarter.
Following the analysis and interventions to address our clinic staffing situation in the US, we have adjusted how we manage these critical personnel vacancies through prioritization, focused recruiting efforts, and tailored training programs. We are just starting to see these initiatives, translate into improving trends in our labor KPIs.
While the labor market remains challenging, during the third quarter, we saw stabilization and net hires, and we have rebased the number of critical open positions to around 5,000. For the ballot initiative, we have spent €23 million to make our case. And as the election is next week, we are comfortably within the assumed €20 million to €30 million range.
Turning to tailwinds. Of the €130 million to €160 million, we have assumed for the full year, we have only realized €78 million through the first nine months. For business growth, we had previously assumed €70 million, and so far have only achieved €15 million.
For the full year, we now assume with €20 million, a €50 million lower tailwind for 2022. This development results mainly from the delay in our North American services recovery plan, since we continue to face the challenging staffing and retention issues. This has limited our ability to realize the planned organic growth recovery, and the delayed growth in our dialysis services business, also has the knock-on effect of impacting our downstream assets.
For PPE cost reduction, we have realized a €12 million tailwind compared to 2021. While we expect overall PPE spending to continue to decline, our clinics are not planning to modify our PPE policy for now due to the vulnerable nature of our patient population, especially as the annual influenza season is also underway.
On our FME25 transformation program, we have continued to make important progress. Of the €40 million to €70 million in savings we assume for 2022, we have already realized a €51 million tailwind through the first nine months of the year, demonstrating that we are well on track.
Turning to slide 6. On a reported basis, currency effects further extended our positive revenue development for both services and products during the third quarter. On a constant currency basis, Healthcare Services delivered revenue growth of 2%.
This was mainly driven by organic growth in the international markets. The positive effect was partially offset by negative organic growth in North America due to accumulated excess mortality, staffing challenges and capacity constraints in certain clinics.
The products business delivered revenue growth of 4% constant currency, mainly driven by higher sales of in-center disposables and renal pharmaceuticals, and partially offset by lower sales of machines for chronic treatment. To give you an update on the US FDA machine shipping hold, this has just been lifted and we can now resume shipments.
Next on slide 7. Here we show the operating income margin development for the third quarter on a reported basis. The largest negative impact on margins year-over-year, not surprisingly, relates to the unprecedented labor market challenges and macroeconomic inflation and supply chain disruption. The combination of business growth development along with COVID-related impacts also contributed to a negative margin development.
During the third quarter, we applied €93 million of the US provider relief funds. We are not expecting further relief funds at this time turning this into a significant headwind for next year. We also realized €30 million savings from FME25 during the quarter.
Looking at the most pronounced special items for the quarter, we had €53 million in FME25 costs and with the closing of the InterWell Health merger, we realized a net gain of €56 million before taxes.
Next on slide 8. During the third quarter, we generated operating cash flow of €658 million. Year-over-year cash flow development was impacted by lower net income. Compared to last year, we had lower recoupment of the US government advanced payments received in 2020 under the CARES Act. €44 million were recouped in the third quarter and the full recruitment effects were completed in October.
We remain committed to our self-imposed leverage target of 3 to 3.5 times. While we are currently at the upper end of that range, we are reasonably comfortable with our positioning given our solid credit profile.
Turning to slide 9. In September, we have proven our strong access to the capital markets with a successful issuance of a five-year bond with a volume of €750 million. This has further strengthened our solid credit profile and contribute to our financing strategy of continuously ensuring financial flexibility, managing financial risks and optimizing financing costs.
With the issuance of the new Eurobond, we have increased the percentage of fixed interest debt to 88% and have no major maturities to be refinanced until November 2023. This clearly underscores the long-term and sustainable nature of our well-balanced maturity profile. Following the refinancing of our syndicated credit facility in 2021, we are no longer subject to any active financial covenants.
Moving on to slide 10. Like the rest of the healthcare market, we continue to face a high degree of uncertainty in the macroeconomic environment that impacts both the med tech and services sector in different ways.
First, we are confirming our target for revenue growth at low-single-digit percentage range. Worth pointing out is the really high financial sensitivity of changes to our current low net income base. Every 1% of change to net income equates to only €10 million and also increases the tax rate due to a relatively higher proportionate share of the non-tax deductible expenses. Our tax rate guidance for 2022 is now 25% to 28%.
Consequently, as a matter of caution to reflect the additional risks of the range of headwinds and tailwinds already outlined, we are extending our net income guidance range for 2022. We previously guided for a net income decline of around a high teens percentage range and are now extending that to a net income decline from a high teens to mid-20s percentage range.
I’d like to finish my prepared remarks on Slide 11. The budget process is currently underway. And as every year, we will provide 2023 guidance in February. However, I recognize there are already many questions about our expectations for next year. And I wanted to share with you what we are currently weighing up.
I have to say in this environment with a number of moving parts, it is really hard to anticipate future developments and every month of additional insights is outstandingly valuable. So let’s start with the tailwinds, we expect in 2023.
Within business growth, we are evaluating the potential accumulation effect from COVID and its impact on organic growth in 2023. We assume an increased ESRD, PPS rate, hopefully, today for our Medicare fee-for-service patients and a smaller but incremental increase in our Medicare Advantage book of business. We are also well positioned for future expansion into value-based care and home dialysis.
The contributions of the interventions to address our North America dialysis services business should have a greater impact to the business growth in 2023. And business growth will of course be impacted by the full reduction of sequestration relief. FME is – while FME25 is well on track, we have said that we will achieve 50% of the savings by the end of 2023. And as Carla has indicated at the start of the call, we are initiating a broader turnaround plan beyond what we have already defined in order to fix our operational core, simplify and drive efficiencies. Although, we have not reduced our PPE protocol yet, we do expect the overall cost to further decrease next year. We are not anticipating costs related to balance initiatives to repeat in 2023 either.
Turning to headwinds for next year. At this time, we do not have any reason to expect any further provider relief funds to be made available. While we do expect some of the 2022 one-time measures for labor not to repeat, we do anticipate annualization of the temporary adjustments made in 2023. Higher merits and historical norms and potential mix changes from permanent to more temporary labor, due to a persisting labor shortage are expected to overall result in a net headwind.
Even though we have seen some stabilization, the pressure on the macroeconomic environment persists and there is no indication that inflation, interest rates and higher energy prices will abate by the start of the New Year. Of course, we are diligently working on pricing action initiatives.
Finally, our 2022 earnings benefited from some one-time items. For example, lower compensation for our broader leadership teams due to underperforming short- and long-term incentive plans. This will have to be rebased for 2023. Other examples are the partial reversal of an accrual related to a revenue recognition adjustment for accounts receivable in legal disputes, and by increased income attributable to consent agreement on certain pharmaceuticals in North America.
With that I’m happy to take your questions. And next quarter, Carla will join us for the Q&A. With that I’ll hand back over to Dominik to start the questions.
Dominik Heger
Thank you, Carla. Thank you, Helen for the presentation. I’m happy to turn it over to Q&A. Nathalie, could you please open the line.
Question-and-Answer Session
Operator
Thank you. Ladies and gentlemen, at this time we will begin the question-and-answer session [Operator Instructions] And our first question is from the line of Tom Jones from Berenberg. Please go ahead.
Tom Jones
Good afternoon. And thanks for taking my questions. Helen, I had two really. We’ll have more, but I’ll stick to two. The first is on labor. Obviously, it’s been a bit of a headwind for everybody in the industry and many other healthcare businesses.
You talked a fair bit about recruitment, but it also feels that employee retention has been a bit of an issue. So I just wondered if you could comment on what you’ve been doing to improve employee retention across the business.
And the second question was just on the cost savings. Forgive me, I know, it’s early in the process for you, so you may not be able to say too much. But from my recollection this will be the fifth cost-saving program.
We had GEP I, GEP II, the group optimization program FME25. One does have to start to wonder where the cost savings are going to come from given this is a fifth go-round on trying to find incremental cost savings.
You’ve gone through the fat into the muscle down to the bone where else is there to go? Short of chopping hole lins off, I guess is the question. So maybe it’s just a bit of sort of broad high-level color on, how you’re thinking about making yet more cost reductions across the business without meaningfully impacting the revenue growth of the business.
Helen Giza
Thanks Tom, great to hear from you. So let’s start with labor. You said labor continues to be a headwind also headache, I think at this point. Clearly there’s a lot going on in our efforts here on recruitment as you said, but more importantly, retention.
We are experiencing higher turnover and retention challenges with our newer tenant employees. And we’re really getting into a lot of the analysis root cause and KPIs around that. We’re really focusing on selecting the white focused and tailored training.
We’re adopting a buddy system in our clinics. And all of this is — we’re making sure we have the right leadership support within our clinics as well. So I think a lot going on in that area. And I think we’re starting to see the benefit of that pull-through.
On cost savings, you’re right, we have done a number of cost saving programs. And I know you’ve been here long enough to remember them all. Look, I think FME25 was more around the operating segments and organizational design and getting the structure set-up I think what we obviously need to do now as we talk about a turnaround plan is really focused on our structural cost.
As we know, we have been with COVID for 2.5 years and we haven’t really adjusted our clinic structure as an example, because we know that we were leaking on operating leverage. So I think the — as Carla outlined the areas of focus, I think it’s kind of just going more deeper now into the structural with this reduced kind of profit margin profile that we have.
So, more to come in February, but yes, I think we can clearly then speak to why it’s different to where we’re going to look at the cost.
Tom Jones
Sure. And maybe just a quick follow-up on the recruitments and retention side, nurses in particular tend to boomerang a bit as the macroeconomic situation improves and then wanes again. Obviously things have been pretty good for health care staff in the last couple of years, COVID aside but pretty good financially for them.
Are we starting to see any evidence yet that the more challenging broader economic picture is pushing more nurses back into the workforce or encouraging the nurses you do have to work longer hours and I ask the question last quarter but it might be worth an update now as…
Helen Giza
Yeah. No, I mean it is a metric that we track and we are seeing about third of our new hires about 13% are actually coming from Boomerang. And I think a testament to our strong employee base is about third of our employees are coming from the retention — sorry the referral program.
So yeah, look, I think we are seeing some stabilization as I mentioned. And I think we’re obviously looking at the kind of the macroeconomic environment from a recession perspective which may additionally push more people into the workforce.
So yeah, some — it’s nice to see this stabilize. And I think it’s good for us to see this focus on this 5,000 priority positions that we can really bring in the right people. And I think here as you’ve already had to say the focus on the training is really important.
Tom Jones
That’s all very clear. I’ll get back in the queue.
Operator
The next question is from the line of Graham Doyle from UBS. Please go ahead.
Graham Doyle
Thanks for taking my questions. Just one on Q4 and what’s implied around that. So we know you obviously flagged the provider relief funds into Q4 as being clearly within the guidance. Is there anything else we should be thinking about? And should we look at Q4 as probably the best indicators to the smooth rooting you have for next year. So maybe that should be our base for, which to extrapolate 2023? And then just one question on vaccination rates, can you give us any update in terms of the US specifically around booster rates there in your patient population? Thank you.
Helen Giza
Hi, Graham. Thanks. Happy to take your question. Yeah, as you mentioned in Q4, obviously, I think if you look about the midpoint of our guidance that does translate into a lower Q4. I think there’s a couple of things there. We did have some one-time items in Q3, I’ll say one-time maybe just unusual. We did have the long-term incentive plan benefit in Q3 as a result of the stock price true-up and the short-term incentive true-ups.
The — so — and then we also had a higher volume on consent payment for pharmaceuticals hit in Q3. So I think that artificially lifted up Q3 as you compare it to Q4. Obviously as you heard me speak on the call, for Q4 we are still expecting this lower organic growth to persist. And as you also rightly mentioned the labor costs are totally naked if you will in Q4 with no offset, so that kind of also impact the quarter. And obviously that’s how we spoke about it on the headwind tailwinds.
I don’t think it’s — I mean it’s a hard question. I’m not going to get into what you should start modeling 2023, but I think for 2022 what we do expect is a lot of these intervention measures that the North America team are executing on to really start to kick in, in Q4 but more importantly through 2023. So that obviously is an important driver for us.
On the vaccination rates, I mean, obviously we’re in flu season and boost the season. I don’t have the exact numbers to hand on the percentages, but what we’re seeing is just a slight increase in the vaccination rate, but nothing of note and nothing of concern I would say.
Graham Doyle
That’s super clear. Thank you. I’ll jump back in the queue.
Operator
The next question is from the line of James Vane-Tempest from Jefferies. Please go ahead.
James Vane-Tempest
Hi. Thanks for taking my question. Two if I may please. Firstly at 2Q, you mentioned how delayed new starts were impacting the business. Just wondering how that’s changed in Q3 and how that’s impacted mix as we move through the year as I imagine some of the new patients coming in are probably more commercial patients?
Secondly, just look on — I know you don’t want to comment on 2023, but perhaps I can keep my question to the nine months we’ve seen this year. I know you gave a net income bridge, but if we were to think about what the impact this year so far has been from the ballot costs and funding relief, which you’ve received. Are you able to give us a sense in terms of what the nine-month net income number would be excluding those two factors? Because I think from nine months in the relief, I think the net income ex special items was €660 million. So would that be closer to €500 million? Thank you.
Helen Giza
Cool. A lot to absorb there James. So on your 2Q mix and commercial mix, we’re not really seeing any variation there. That’s been very, very resilient and pretty stable. So nothing to note there as we now look at Q3 and our guidance coming out. I think, I probably have to have Dominik and the team follow-up with you on the net income bridge excluding those items. I don’t have the…
Dominik Heger
So I think the ballot was 2023.
Helen Giza
The ballot I can speak to. Yes, that was always 2023.
Dominik Heger
Both the funding relief and provider relief funds, we received I think €280 million or so.
Helen Giza
But James was your question what would net income be without those items?
James Vane-Tempest
Exactly yes. In terms of — because if we’re going to start thinking what the base is going to be for this year for items not expected to come into next year. I think people are after a sense in terms of, what the floor is to kind of grow the business from into next year.
Carla Kriwet
Yes, let us follow up with you on that James.
James Vane-Tempest
Thank you.
Operator
The next question is from the line of Hassan Al-Wakeel from Barclays. Please go ahead.
Hassan Al-Wakeel
Hi. Thank you for taking my questions. I have two, please. Firstly, — following up on Q4 and into next year, could you elaborate and potentially help us quantify some of the building blocks for next year given what is implied by your guidance for Q4, as an exit rate. Should we be thinking of a net headwind, and earnings potentially being down in 2023 given the size of the provider relief funding at €200 million plus that is not recurring next year?
Secondly, at Q2, Helen you talked about wage inflation running at 9% to 10% in aggregate. I wonder if this has changed at all and how you think about this into Q4 and next year. Where have open positions trended? And how reliant are you still on contract stuff? Thank you.
Helen Giza
Thanks, Hassan. You know, what I’m going to tell you about the guidance for 2023 and the building blocks like literally we are in kind of budget meetings morning — noon and night right now. So really too early to tell, what that net outcome is going to be. We recognize that we have a number of headwinds to overcome and obviously, the kind of the growth assumptions here at key.
But also the turnaround plan and those kind of inventions are something that we need to spend more time on, so that we can realistically evaluate what contribution that can make in 2023. So we will ask for your continued patience there. I think on wage inflation, we are seeing it around 6% to 7% currently, I would say. I don’t know that’s an average and it’s not necessarily not just efficiencies. But I think that’s a good proxy, for what we’re seeing currently.
On open positions, and I know we have maybe in this call modified, how we’re thinking about open positions and I think appropriately, so. As we think about — we always said, 2,500 to 3,000 open positions was kind of a normal run rate for us. And then we started to track all open positions and you know, how that’s trended over the last few quarters 11,000 going to 8,000 and today we’re talking about 5,000.
And I think what’s really important there, is that this is about the critical positions that we are focused on filling, with the right — the right capability to the right hiring standard. So we feel really good about where we are there. And then you asked about wage inflation open positions. Did I miss something else? Agency. That’s, right. Thank you.
Now keeping me on is here today. The agency costs obviously, we’re focused on. We are starting to see that overall cost come down, not coming down as much as we needed to, but I think there’s very concerted efforts on there. I think we’re also seeing agency rates come down slightly too. So we have a volume and a rate there, but we are seeing the trend starting to come down. I think we’ll see more impact of that reduction in Q4.
Hassan Al-Wakeel
That’s really helpful, Helen. Maybe, if I could just follow up on the first part. You talked about one-offs in the quarter. Could you help quantify? I think one was around pharmaceuticals and the other one was around remuneration.
Helen Giza
Yes, well, happy to do so. So the remuneration is around €40 million and the pharmaceutical higher volume consent payment is also around €40 million.
Hassan Al-Wakeel
Excellent. Thank you.
Operator
The next question is from the line of Veronika Dubajova from Citi. Please go ahead.
Veronika Dubajova
Hi. Good afternoon. Carla and Helen, thank you for taking my questions. I’ll keep it to two please. One is, I guess, I mean, I’m going to circle back to what everyone else has tried to ask, but I’m going to ask it differently, which is, Helen, if I look at your guidance and what it implies for the fourth quarter, are there any reasons why that would be representative as a starting point for 2023? Are there either positives or negatives that might make it not a fair and true account of where the business is as we move into next year? So that’s my first question.
And my second question and I appreciate it. I think I ask you this every quarter. So far neither you nor I have been able to predict this correctly, but I’m just curious Helen on everything that you see when you feel that we might return to a positive same market or same-store growth rate in the US?
Helen Giza
Welcome back. It’s great to hear your voice again. So, yes, Q4, is it representative? I mean, look, I think, it’s what we’re thinking for Q4 is like it’s pretty kind of stable to kind of — be kind of what we’re seeing today. There’s not much of an uplift really projected.
I think the thing to think about for the quarter is what I touched on earlier with the previous question is, we are expecting our efforts to take hold. I mean, there’s a ton of work going on with the teams tackling labor and growth and kind of the clinic operations and so on, but we also — we’ve got a lot of volatility. We’re waiting to see kind of what the COVID numbers play out with and so on.
So you can kind of see is why I kind of have widened kind of the range somewhat. Look we’re working hard on it. I — hard to predict at this point, but we also hope for the improvements to start to take hold.
Gosh, Veronika, your second question on when will we see same-store growth, look, we’re kind of — we’re in the low negatives right minus one-ish. We hope that we will start to see that turn the corner early next year, but as we said, we’ve been running on it constantly. We keep trying to predict the impact of COVID and hard to imagine that since the start were just around 25,000 excess mortality at this point. So, again, the winter is key on that and maybe another one to ask for patients on, and obviously, more to come, a lot more to come in February.
Veronika Dubajova
Understood. Thank you so much, Helen.
Operator
The next question is from the line of Oliver Metzger from ODDO BHF. Please go ahead.
Oliver Metzger
Hi. Two questions from my side. The first one is on your development in EMEA. So it seems for me to be a quite good quarter on services as well as product. So last year was not ultra-high, but could you also comment on underlying trends in which you expect to continue into Q4.
Second question is following the closing of InterWell Health merger. So, where do you stand right now with medical costs under management in a moment please?
Helen Giza
Thanks, Oliver. Good to hear you. On EMEA, I don’t think there’s anything of note to call out on the quarter itself. We have a comp year-over-year from a license from one of our partners from that’s in the last year’s results. So, I think that kind of assists the year-over-year growth if you will, but nothing else of significance on the volumes. However, I would say, clearly in EMEA, the inflation and supply chain challenges are something that we’re watching and continuing probably into Q4.
On your InterWell question, we are kind of looking at €5 billion to €6 billion medical costs under management and that 1% margin is fully on track. And we’re really excited about this merger and the possibilities here, a real important foundational building block of our strategy.
Oliver Metzger
May I ask one follow-up to your second answer? So, when you say €5 billion to €6 billion medical customer management, I think you were at roughly €6 billion at the beginning of the year. So my thought was that the merger creates even more exposure to value-based care. Has anything changed over last months?
Helen Giza
No, I think that was always the plan. And I think what I’m just speaking to is kind of currently what we’re seeing it at a €5 billion to €6 six billion. So, no cause for concern there, Oliver.
Oliver Metzger
Okay. Great. Thank you.
Operator
The next question is from the line of David Adlington from JPMorgan. Please go ahead.
David Adlington
Thanks for taking the questions. Just coming back to the — those nonrecurring positive items in the — in third quarter you sort of quantified it. I just wonder, if you could quantify those year-to-date or perhaps better for the full year 2022. And second, just sort of conceptual one. I just wondered why you were recognizing those one-off gains within the kind of operating income. And were you assuming that those gains or those positive effects within your guidance at the start of the year? Thanks.
Helen Giza
No, it’s pretty clean, David. Let me take both questions. The long-term incentive plan obviously tied to our performance and stock price. That goes up and down every quarter. It’s just unfortunately with our Q2 announcement we had a big drop in Q3. So, that’s obviously favorable to our P&L. And obviously, that fluctuation will go up or down the next quarter. So, it’s not like a onetime. It’s just kind of — I call it unusual. It’s a big number, €40 million in one quarter, but we do that kind of market — kind of price adjustment every quarter.
The other one on payments for pharmaceuticals. That’s also normal business, we have them every year. Normally, they’re in Q4. We have this one in Q3. So, they’re not special items and don’t need an adjustment. I think, they’re just not large enough in nature and obviously, impacting the quarter to be worth talking about.
David Adlington
Excellent. I don’t think there’s accrual on legal dispute as well as able to quantify that.
Helen Giza
Yes. That was the accrual on legal dispute, that we did back in 2019, and we were able to release some of that accrual in Q2 — Q1, Q1 — kind of pull that number somewhere, yes. So roughly, yes maybe mid-30s €35 million or something. I don’t have the exact numbers to hand, but it sounds about right and that was in Q1. So — but that was — we took a bigger charge back in €36 million. So we took a big charge on that back in 2019. But as that case continues we have been able to release some of it.
David Adlington
Perfect. That’s helpful. Thank you very much.
Helen Giza
You bet.
Operator
The next question is from the line of Robert Davies from Morgan Stanley. Please go ahead.
Robert Davies
Thank you for taking my questions. I’d just be interested if you could give us some sense across your facilities at the current capacity utilization. I ask in context of your scope to reduce either site locations or headcount. I just wondering obviously you have certain minimum requirements of people or facilities in each location. Just wondered where capacity utilization sits? And where you see the most scope or if there is any scope to make changes there? And then the second one was just really if you could give us an update on what you’re seeing on the home dialysis front. Are you still seeing continued uptick there? Is it as fast as you expected — slower? Are the associated costs higher or lower than you previously thought? Those are my questions. Thank you.
Helen Giza
Hi, Robert, good to have you on the call. Look forward to getting to know you better. So welcome. On the site location percentage, as you can imagine that is part of our full assessment. We are doing a full scope analysis of all of our clinics and the utilization and the footprint. And I think that will be part of our kind of footprint analysis and turnaround plan. I don’t have the numbers kind of to hand of kind of the utilization of each clinic obviously, but something that we are doing a full assessment of. And you can expect to be in scope for part of that cost reduction and structural cost reduction plan. Obviously, that has been hurting our operating leverage where we do have underutilization.
On home, still growing. It’s kind of at 15.4% now of US treatments and we’re happy that it’s growing. It is slower than we would like. Obviously some of the training and so on has been impacted by the kind of lower staffing issues. And it does continue to grow more than the center and will be a key growth area for us. And for us we’ve not necessarily seen the full benefit of the lower costs yet, but we are absolutely kind of focused on that and continuing to pull that through as another one of our key strategies.
Robert Davies
Thank you. Maybe just as a follow-up to the first answer you gave. Do you have any sense of the variability of utilization levels? Is it sort of plus and minus 5% around an 80 level? Is it — some at 90, some at 10. Can you give us some sense of where there’s real sort of low-hanging fruit across your business?
Helen Giza
It does vary by region. And obviously, the kind of geography of where our patients are. Look I think it’s too early to say. The capacity is adequate to take new patients. And obviously the goal here is to lose as few patients as possible, as we do the consolidation so more to come. Again, I’m asking everyone for a lot of patients today I know — but we need to get — we need — we’re doing the analysis. We need to evaluate the outcome of the analysis and then make the decisions on the number of clinic closures that we are targeting.
Robert Davies
Understood. Okay. Thank you.
Operator
The next question is from the line of Falko Friedrichs from Deutsche Bank. Please go ahead.
Falko Friedrichs
I have two questions as well please. Firstly, based on comments from your competitor it seems that fewer patients are transitioning from CKD to ESRD. So, my question is whether you noticed that as well and whether you have any potential explanations for that? And then secondly just a clarification question. Helen did I understand you correctly that the number of job openings went from 8,000 in Q2 to 5,000 at the moment?
Helen Giza
Hi, Falko let me take your second question first. The – it’s not that it dropped from 8,000 to 5,000. We are really — there was a lot of open racks and a lot of open positions that were maybe not as priority and as focused in area — in kind of the — where the postings were being targeted. So, we are just saying that for us the relevant open position number is 5,000 now.
It dropped a couple of hundred during the quarter. So we are hiring and bringing it down. And then on the CKD to ESRD, I know we kind of heard what Javier had to say and I think it’s not data that we have or have insight into something that we can point to, we are just seeing less diagnosis from patients on COVID-related patients who are kind of maybe avoiding hospitals.
But I think the question is, if we’ve got lower volumes where are the patients going. There is some going into hospitals some going into smaller dialysis clinics, but nothing that we are seeing kind of impacting that population. Our treatment numbers have been growing sequentially Q1 to Q2 and Q3. So, I think that’s important. I think we’re all continuing to dig into the data and the analysis of what — of what’s happening with our volume. And as I said that’s a big component of our 2023 outlook is getting the wide organic growth assumptions for next year.
Falko Friedrichs
Okay. A quick follow-up on the first question for the job opening. So essentially out of the 8,000 you had you essentially closed a couple of job openings. Did I understand that correctly?
Helen Giza
Yes, that’s correct. So, it’s like we had a lot of open racks. But now we’re like really focused on all the racks worth top priority and then close the racks that maybe diluting our recruiting efforts. So rather than trying to do maybe we don’t need 8,000 but maybe trying to do 7,000 at once. So, we’re trying to really focus on the 5000 that have biggest impact.
Falko Friedrichs
Okay, that makes sense. Thanks a lot.
Operator
The next question is from the line of Sezgi from HSBC. Please go ahead.
Sezgi Oezener
Hi, thanks for taking my questions. I will also three [ph] questions please. First of all, in previous call, I thought it was remarkable that they started closing some clinics and I see that you still have an expansion. Is that the differentiation and strategy or should we expect to see more closings next year?
And my second question — and congratulations on the list of the FDA hold. Can we expect to recover the entire loss business on the product side from the hold of the machines, or would you expect some of the lost market share to remain lost?
Your thoughts on how you expect to recover from that would be good, would be very welcome. Thanks.
Helen Giza
Yes, happy to take those questions. So, no I don’t think our strategy is different. Maybe the announcement of timing is. But no we — obviously, we saw that we have net five in the quarter of new clinics that’s kind of a function of where they were being built and where they are for our patient needs. But I think the strategy is the same.
We’re all looking at our cost structure and looking to see how we can optimize our clinic structures overall. So, I think that will be part of our update in February.
And then yes, we are delighted with the FDA release. We have already started resuming shipments. I think we won’t skip a beat. We have POs for those machines that were on hold. We already had assumed that we would resume shipments already in our outlook. So, we’re just glad to have confirmation of the date and kind of get that product base back installed.
Sezgi Oezener
Thank you.
Operator
This concludes our Q&A session and I hand back to Dominik for closing comments.
Dominik Heger
Thank you for being so flexible to join on short notice today. This is highly appreciated. Thank you for your questions and your interest. And if you have further questions as always reach out to us and we look forward to see you soon on the road at conferences and hopefully next year. Take care.
Helen Giza
Thanks everyone. Bye-bye.
Carla Kriwet
Thank you.
Operator
Ladies and gentlemen, the conference has now concluded and you may disconnect the telephone. Thank you for joining and have a pleasant day. Good bye.
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