DaVita Inc.
Q4 2011 Earnings Call Transcript

Published: 17 Feb 2012

[Operator:]

Good afternoon. My name is Jamaria, and I will be your conference operator today. At this time, I would like to welcome everyone to the DaVita Q4 2011 Earnings Conference Call. [Operator Instructions] I would now like to turn the conference over to our host, Mr. Jim Gustafson. Sir, you may begin your conference.

[Jim Gustafson:]

Thank you, Jamaria, and welcome, everyone, to our fourth quarter conference call. We appreciate your continued interest in our company. I'm Jim Gustafson, Vice President of Investor Relations, and with me today are Kent Thiry, our CEO; Luis Borgen, our CFO; and LeAnne Zumwalt, Group Vice President. I'd like to start with our forward-looking disclosure statements. During this call, we may make forward-looking statements within the meaning of the federal securities laws. All of these statements are subject to known and unknown risks and uncertainties that could cause the actual results to differ materially from those described in the forward-looking statements. For further details concerning these risks and uncertainties, please refer to our SEC filings, including our most recent quarterly report on Form 10-Q and annual report on Form 10-K. Our forward-looking statements are based upon information currently available to us, and we do not intend and undertake no duty to update these statements for any reason. Additionally, I'd like to remind you that during this call, we will discuss some non-GAAP financial measures. A reconciliation of these non-GAAP measures to the most comparable GAAP financial measures is included in our Form 8-K submitted to the SEC and available on our website. I will now turn the call over to Kent Thiry, our Chief Executive Officer.

[Kent J. Thiry:]

Okay. Greetings. Let me first repeat Jim's thanks for your interest in our/your company. The fourth quarter was a strong one, and 2011 was a strong year, both clinically, operationally and financially. Because we just completed a fiscal year, I'll cover a few more topics than usual

[Luis A. Borgen:]

Thanks, Kent. We had strong operating income and cash flow in the quarter, driven by strong treatment growth and improved cost per treatment. Offsetting these factors are lower revenue per treatment and a continued decline in commercial mix. Here's some specifics on the quarter. Non-acquired growth was 4.8% when normalized for days of the week. Dialysis revenue per treatment was down about $5. The primary drivers were a decline in commercial mix, our new agreements with the VA and a declining utilization of physician-prescribed pharmaceuticals and finally, declined revenue from vaccinations, which were seasonally high in the third quarter. Dialysis patient care cost per treatment was down about $7 from the prior quarter due to 2 main factors

[Operator:]

[Operator Instructions] Your first question will come from the line of Matt Borsch with Goldman Sachs.

[Matthew Borsch:]

Can you just talk a little bit more about the integrated care opportunity? And what do you think might be the fastest timeline along which that could progress? And what do you think you -- what capabilities do you think you'd need to build or partnerships you'd need to have, I don't know, with managed care or other, to be successful there?

[Kent J. Thiry:]

Certainly. We're a little bit schizophrenic on this issue, on the one hand, so excited, we've been working on it a long time. And on the other hand, we have great trepidation in talking about it since you can never predict for sure what the government will decide to do and when. And even if they come out with a request for proposal, will it be a quality one that we can participate in? So with all those caveats, we'll attempt to answer your question. As to timing, the soonest request for proposal might come out for comment would be in a couple of months. We're not predicting that, but that's answering the question. As to how late it could happen, it could be never, but we think we've got a good shot. As to capabilities, we've been preparing for some time, in part through our demonstration pilot, which we did with Medicare, with CMS, sharing all the data to define rules along the way, and so they've seen it in action. They know that medical costs go down, clinical quality goes up and patient satisfaction goes up, as well as physician satisfaction as a matter of fact. And they've seen some of the results from the work Fresenius has done, our competitor in the same area. And so in terms of capabilities, we can pretty much do it on our own, and while there will be some exceptions to that, we think they'll be relatively modest. Of course, I have to qualify that by saying since we haven't seen the RFP yet, well, we can't be sure that, that answer's correct. Did I hear every part of your question?

[Matthew Borsch:]

I think you did. Just on the last answer there. I gather you have the capability to do it with what's within your company in terms of maybe taking it to the optimal level, with everything that's involved in population health management if you're responsible for that cohort. Again, do you think, primarily, you have that in-house, you don't have to do significant investment to get there?

[Kent J. Thiry:]

Well, 2 different things. We have the capabilities in-house. It will take investment to scale those activities if we get the kind of pilot that we're hoping for. So big, big distinction to make there.

[Matthew Borsch:]

Okay, fair enough. And if I could just one more on the commercial mix. Are you -- would you say that there is incrementally more pressure from the commercial payers on reimbursement? Is dialysis something that they seem to be more focusing on more heavily? And how are your negotiations, if any, proceeding along that front?

[Kent J. Thiry:]

Okay, I'll tackle that one too. Before I do, as you refined your question, I feel I should add one additional note to my answer, which is in the beginning of scaling for a big integrated care undertaking, it could be we would do some outsourcing as we build our scale, so I was giving you a longer-term answer and recognize that you might have in part been asking about the scaling period. And if we get the scale, we are not sure which parts we'll be able to scale on our own versus temporary use of others. But now on to your question. On the private payer side, it's super, super intense, which is the same way it was last year and the year before and the year before that. It doesn't seem like that ever changes.

[Matthew Borsch:]

And so in terms of the rate of increase, you're not really seeing differences in terms of outcomes with a greater, I don't know, whether we can even call it, maybe it isn't a greater focus on cost containment, it's the same focus on cost containment. The dynamic is about the same. Is that fair?

[Kent J. Thiry:]

I think the dynamic is about the same. And what we've always said is every year, we win some victories, we suffer some defeats, there are a bunch of ties, and it's a little bit like one football season to the next. It's real dangerous to extrapolate because you got tough opponents out there. And so while we wouldn’t posit any particular structural change in the world nor any sort of systematic change in intensity, nonetheless, you never want to get complacent and certainly, we don't.

[Operator:]

Your next question will come from the line of Kevin Ellich with Piper Jaffray.

[Kevin K. Ellich:]

Kent, going back to your prepared comments or maybe it was Luis. I think you indicated the physicians have stated that Epogen use or the physician-prescribed drugs would be either flat to maybe slightly higher in 2012. Just wondering what type of visibility or why that would -- why it would go up.

[Luis A. Borgen:]

That remains dynamic. We have rolled out various protocols, and as we settle on the final one, we think that flat to up is the most likely scenario at this point in conversations with physicians and the data we're seeing.

[Kent J. Thiry:]

It's so difficult to predict because there's been such change in the science, in the government guidance, in the debates, in the articles on the anemia management that you have a lot of doctors making some changes to their prescription pattern for any of those number of reasons, and then waiting a month or 2 or 3 to see what the results are and see if they're content as they stare at their patient population and look at the percent that's between 10 and 12, sub-10, between 12 and 13, above 13. And so what we do is the best we can in incorporating all their opinions into any amendments into the protocol, so they essentially end up being the physicians on protocols, and then helping facilitating, supporting them as they stare at their results and the results of the broader population and continue to fine tune what they think is right for their patients. So it's pretty dynamic, but the general drift of what we hear from our doctors is exactly what Luis said.

[Kevin K. Ellich:]

Got it, okay. And then, I guess, just shifting back to the integrated care. I think maybe a month ago, we noticed that you guys opened up a primary care clinic in Tacoma, Washington. Just wondering what the strategic rationale is behind that. Is that a revenue driver or a way for you guys to curb your own health care expenses? And then, what's the expansion plans for other primary care clinics?

[Kent J. Thiry:]

The short answer is both. We have about 1,000 citizens of what we call the DaVita village in the Tacoma area, and there, as is happening elsewhere in the country, our medical costs continue to go up and up and up, placing whatever burden on our people and on us, and we're hoping this clinic can be a way to change that trend, while simultaneously providing better service to our people and their families. Having said that, we think there could be a real business model there that we can provide to other employers of different sizes, but way too soon to make any forecasts. I would characterize it as very spirited new business R&D right now.

[Kevin K. Ellich:]

Understood. And then just thinking about home hemodialysis. Earlier this month, UnitedHealthcare issued a medical policy for home hemo. Just wondering if that's changed your opinion. Or I guess, what's your take on home hemodialysis at this point?

[Kent J. Thiry:]

I'm not familiar with the new United policies so perhaps you could fill me in there or certainly, I'm sure 6 or 7 people will, once the call is over. But our posture on HHD, home hemodialysis, and we do more of it than anyone in the world at last look, is unchanged, which is there's -- what we always say is people who say that it's going to grow, grow, grow dramatically, it should be right for lots and lots of patients. We don't see yet the data to support that conclusion at all. On the other hand, those who say that it should apply to no patients our data doesn't support that either. As to what percentage of patients it will be a superior form of care for is not clear yet. And then, in addition, there's all the complexities and subtleties around government reimbursement, what they allow, what they don't, what constitutes evidence to them, et cetera. And so the picture is pretty murky once you combine those 2. We remain very, very committed to the work we're doing in that area, and our collaboration with the federal government to try to figure out what the right policies are based on high quality, objective, nonpartisan, if you will, analysis.

[Kevin K. Ellich:]

Well, United's policy basically says that HHD is a proven therapy as an alternative to facility-based hemodialysis for patients who apply to -- for the criteria. So basically, I think they're basically saying the clinical data is good enough.

[Kent J. Thiry:]

That is good, and again, there's an entire spectrum of opinions on this subject, which is why we advise you to be careful about paying too much attention to people at either end of the distribution. And clearly, by the number of patients we have on it, we think it's very, very justified for some patients and better for them, either in terms of quality or life convenience, the ability to keep on working and the ability to integrate dialysis care more into their lives and their families' lives. So we're clearly supportive, but we wouldn't be doing everything we're doing.

[Kevin K. Ellich:]

Understood. And then just one last quick question for maybe LeAnne. Just wondering if -- what's the latest on the doc fix? Is there anything such as the bad debt coverage that could impact you guys?

[LeAnne M. Zumwalt:]

Yes. As a matter of fact, the preliminary analysis or information is out. We're reviewing that and it would appear that dialysis bad debt reimbursement will be part of the pay-for, for the policy.

[Kevin K. Ellich:]

Do we know how much it will impact you guys? I mean, your bad debt is only what, 3% , if that?

[LeAnne M. Zumwalt:]

You're speaking to the provision on the income statement? Yes, 2.9%. Yes, that is a much -- that number encompasses more than the Medicare bad debt.

[Operator:]

Your next question will come from the line of Gary Lieberman with Wells Fargo.

[Gary Lieberman:]

Maybe just a follow-up on that last question, LeAnne. In terms of thinking about the bad debt provision in the doc fix deal. So the way -- could you just maybe give us a refresher on the way it works now? So 20% of the composite rate is a co-pay? And is that the piece that's going to be affected by this potentially?

[LeAnne M. Zumwalt:]

Yes. So it's a little complicated. Let me see if I can be clear. Right now, we're able to claim Medicare bad debt in certain circumstances on what used to be the old composite rate, so not on the drugs. And yes, that would be the 20% that would not be paid by a third -- or second party or third party. And that calculation is further reviewed in a way that if the dialysis facility was profitable or lost money on a Medicare basis. So couple of filters that you have to go through before you're determined to be eligible for the bad debt.

[Gary Lieberman:]

Okay. So that composite rate is it around -- it's like $135 or somewhere in that range, so is that the story number and the way to think about it?

[LeAnne M. Zumwalt:]

Yes. I'd like to track it probably to $150. I can't remember if -- of the – drug add-on was in there or not. Maybe Jim Hillter [ph] or someone could help us out with the exact number, but it's in that $135 to $150 range.

[Gary Lieberman:]

And then what are the additional filters? So if we were to kind of just walk through the process to filter it down, so if we were to try to estimate an impact, what would some of those filters be?

[LeAnne M. Zumwalt:]

Yes, the filter -- the primary filter is whether or not that facility lost money or made money on a Medicare basis. And so if it's making money, you're going to be limited as to what you could claim, and you may not be able to claim any of it.

[Gary Lieberman:]

Got it. And so that's how it currently works?

[LeAnne M. Zumwalt:]

Correct.

[Gary Lieberman:]

Okay. And any estimate in terms of what percentage of your facilities wouldn't be able to claim anything since they're making money?

[LeAnne M. Zumwalt:]

I don't have that number handy for me.

[Gary Lieberman:]

Okay. And then on the -- I guess, just on the income statement. The bad debt expense that you're currently reporting, is that primarily -- is there a split? Is it 1/2 commercial, 1/2 Medicare? Or how should we think about that?

[LeAnne M. Zumwalt:]

Again, I don't have that data right in front of me.

[Gary Lieberman:]

Okay. I guess maybe on another topic, Kent. There's -- for the first time this year, I guess, there's the potential that a competing ESA might come to market, and you all have signed a long-term contract with Amgen. But how should we think about the, I guess -- I would assume it's a potential benefit to you still, if a potential drug -- competing drug comes to market. How should we think about that?

[Kent J. Thiry:]

Yes, very fair question. And the answer is it's not clear in the short term, whether it's in our best interest or not for something new to come out. We signed a long-term agreement as you know. We signed it with Amgen for EPO, which is the gold standard for anemia management. And we walked through kind of the strategic and logical filters for the decision we made and said that over the 7 years and on a net basis, this could work to our advantage or our disadvantage. But one thing that is very clear is that Amgen and our interests are aligned for the most part, and so I can't give you a generic answer whether a new entrant coming out soon is good or bad for us without waiting to see what happens and at what price, what pickup there is, et cetera, et cetera.

[Operator:]

Your next question will come from the line of Justin Lake with UBS.

[Justin Lake:]

I guess I'll just take a quick shot at this bad debt first. Can you just give us the number in terms of, LeAnne, that 100% goes to the 65%, I believe? How much does that impact you by? Maybe just tell us how much you collect right now in Medicare bad debt.

[Kent J. Thiry:]

LeAnne, do you know the number? And for the folks out there, I just want to apologize. LeAnne's actually in a different city and so there might be some awkward handoffs back and forth. But LeAnne, do you know the number?

[LeAnne M. Zumwalt:]

I can give an estimate, and that estimate would impact us about $4 million in the first year. And it does -- it phases from 100% of recovery to 65% of recovery over the 3-year period.

[Justin Lake:]

Okay. So if it goes at 32% early on, that might be $12 million to, maybe with some growth, $15 million by year 3?

[LeAnne M. Zumwalt:]

That would be reasonable estimate.

[Justin Lake:]

Okay, great. Second question, Kent, on the integrated care, you talked about specific serious conversations. Just wanted to focus on a couple of issues there. In terms of if -- could you help us -- it sounds like you're as close as you've ever been, clearly an exciting concept. Can you tell us would -- what you think maybe the 2 or 3 kind of key issues that are keeping CMS from having published this or that you're working on with them? What's keeping this from having come out now that they’re past the 8 pioneer ACOs.

[Kent J. Thiry:]

Certainly. Before I do that, LeAnne did take her best cut in the spirit of trying to be responsive on the bad debt estimate, and so what you got was our absolute best estimate. I just want to emphasize that. It -- the thing came out so recently, my understanding is just today or yesterday or something, and so we're still processing away, and if those -- if the estimate that LeAnne gave in good faith turns out to be materially wrong, we'll get back to you as soon we can. But it is our first cut at it. Then second, on what's keeping them from coming out with it, it really is that they were so consumed by all the pioneer ACO work and related hospital stuff. And then they turn to all the rest, and they've got to finish comparing and deciding on which subset of all the rest they're actually going to take action on, and so that takes some time. We do have it on assurance from many, many people that we're among the finalists. But whether or not that means we make it into the next round, which would be imminent or whether we don't make it into the first round and have to wait for the second round or some other subsequent round, we just can't handicap. But it really is just them managing their workflow.

[Justin Lake:]

Got it. So do you expect in the next several months, there'll be another announcement with these kind of integrated care, like you said kind of vertical ACOs in different disease states and the question is not really in your mind around whether it's going to happen or not, more so are you going to be a part of it and you think will?

[Kent J. Thiry:]

That's too definitive. They may opt to do no verticals. That is still potentially the case. And remember, even if they issue out RFPs in the vertical, they may be so unattractive that no one does them. So while the odds are they're going to come out with some other types of ACOs beyond the hospital, it's unfortunately not 100%. So we’re excited because we're in the red zone, but that's a long way from starting.

[Justin Lake:]

Great. And then just 2 more questions on this. In terms of the timing between a release and when you think this would actually go into place, if you can help us there. And if it came in the next few months, could it start by 2013? And maybe how many patients you think it would start with.

[Kent J. Thiry:]

So all fair questions, and I'll throw out guesses as long as everyone appreciates that's what they are, but we're striving to be useful. If it comes out in the next few months, which would be the best case, and if it's a proposal that actually can work where we can add the value for society and share in it, there is a chance it could be implemented in January 1, '13. There's also a good chance that they would do a later date halfway through '13 or the beginning of '14. In our favor is the fact that we've been working so closely with them, and our industry works collaboratively in a very different way than many others. And so our ability to dance with them, to get something done where they feel they're going to get the right level of reporting, the right level of transparency, the right amount of accountability, the right amount of systems integration, our ability to deliver that is really superior to most other health care segments. All of that says maybe it could happen January 1, 2013, and then you know all the reasons why it might not.

[Justin Lake:]

Great. And number of patients?

[Kent J. Thiry:]

Number of patients, that's anybody's guess, Justin. I'm sorry, that one even I can't go venture in guessing on that.

[Justin Lake:]

Okay. And the biggest, I think, push back I get when talking to people about this, Kent, is that in terms of just the timing, right? If this starts in '13, by the time it becomes material, it's fairly far out in the future. And so I think the key in terms of kind of investor interest will probably be the level of transparency there is to further growth in the RFP, meaning this is not just going to be x number of patients and we'll take another look at for 3 to 5 years and come back. Do you expect that there's going to -- it's going to be fairly explicit in the contract that regardless of how many patients you start with, if the industry hits x outcomes data and y savings targets, then it will be very explicit that this will scale to something more meaningful without having to go back and request it, it will be kind of explicit in the contract?

[Kent J. Thiry:]

It's the right question, I cannot handicap the answer. I do think that if we get something good, we and Fresenius and others will do such good stuff with it that independent of what is contractually or regulatory stipulated, we're going to have a heck of a good story to tell. And even though penetration can take a while, if it's penetration of a relatively proven capability, valuing it becomes simpler.

[Justin Lake:]

Great. And one last question on mix. Can you tell us where you are now in terms of percentage of patients in commercial, how much that changed sequentially? Is it getting worse or better? And for 2012, can you walk me through -- the economy seems to be getting a little better from a jobs perspective, and then you have COBRA kind of expiring for some people and maybe talk to us about what you're expecting for '12 and that will be it for me.

[Luis A. Borgen:]

Sure, Justin. This is Luis. Where we are at the end of Q4 is that we are at 10% commercial mix. On a sequential basis in Q3 to Q4, we saw a similar rate of decline. And on your third question, it is one of our swing factors. It's highly uncertain where that's going to shake out, so it's difficult to predict.

[Justin Lake:]

Do you expect it to go down in 2012, to continue moderating or...

[Luis A. Borgen:]

Our guidance includes several scenarios. It's difficult to predict. And so it is something that we have factored into our overall guidance. Just one clarification, Justin, which may help you think about it, we are rounding down to 10% as of Q4 to be clear on that point.

[Operator:]

Your next question will come from the line of Ben Andrew, who's a sales research analyst (sic) [William Blair].

[Ben Andrew:]

Ben Andrew with William Blair. I don't know if I changed affiliations, but I wanted to ask Kent briefly about your thoughts on the risk profile of the integrated care model. Obviously, the demonstration work you've already done has given you some pretty good visibility that you’ve communicated. But how would you hope to treat outlier patients? And are there other parameters of an RFP that would make it more attractive or less attractive to you, you could walk us through please?

[Kent J. Thiry:]

Well, the larger the scale that they allow, the more open we can be on accepting versus not accepting outlier risk. And calibrating, regulating and administering outlier risk is actually something that CMS has to do a fair amount of, including in the bundle, under which we now operate. And so that will be a highly analytical exercise between us and Medicare if it happens. And so we're not at all worried about it as long as we bring the right attention to it and they share the numbers. It should be a case where both sides can win, and they want to give us enough scale so that the outlier pool is smaller and they capture more of our potential value. And we work collaboratively with them, and so they see the upside for them. But it's pretty impossible to predict ahead of time until you're doing that final serious number crunching.

[Ben Andrew:]

Okay. And then maybe talk about any other aspects of the RFP beyond that one that would be important to you as an organization to wanting to accept or to bid for an RFP.

[Kent J. Thiry:]

I would say the most important one is our ability to work with all Medicare patients in a clinic. What’s very, very difficult in terms of achieving the kind of systemic, dramatic change that we're contemplating here is when a subset of the patients in a given center are involved. Because without the upside, you cannot afford to add all the additional integrative services. And without that investment, you can't generate the results. And it's much, much more expensive if you're dealing with small pockets of fragmented patients who stretch across an entire country, as opposed to much more concentrated patient populations within a given geography. That's one of the primary fulcrums.

[Ben Andrew:]

Okay, great. And then as you think about, again, scale getting at this, are the sizes of the demonstration projects that you undertook, would those be compelling enough to, again, to want to participate? Or is that just wouldn't be enough to compel you?

[Kent J. Thiry:]

Could you say the question again, please, Ben?

[Ben Andrew:]

Yes. Given the size of the demonstration programs that you did and the cost savings that you appear to have seen and more importantly, the improvements in patient outcome, satisfaction and physician outcome, are those scale of projects sufficient for you as an organization at this point to want to participate if they try to severely limit the scale? Would it still be compelling just to, again, collect more, to get more experience and then hope that they would expand it over time?

[Kent J. Thiry:]

Well, I guess the answer -- Let me grope for a moment. If we got to do -- our existing demonstration project is in one geographic area. And if they allowed us to do that same thing in 20 geographic areas, we would absolutely do it. So there is enough local scale where if we've got to do multiple local things of that size and spread the fixed overhead above it, that would be attractive. Is that -- am I answering the right question?

[Ben Andrew:]

Yes, that's helpful. I know you're not going to give a number. I'm just trying to get a flavor for kind of where your interests are there. And then as you think about the skill sets that DaVita has today, and you talked about a transition period perhaps into a fully-integrated model over time, what would be the most critical aspects for you to outsource or to add, on kind of a transitional basis, if gave you the go ahead, say, for Jan 1, 2013?

[Kent J. Thiry:]

Well, I'm not prepared to answer that so I will try, and you'll have to recognize that my answer could be pretty feeble. But if they were going to give us the opportunity to take care of a lot of patients, we'd probably have some call center issues. We might have some technology and technology development issues just in terms of interconnectedness. Those are the 2 areas where we might have to outsource on a transitional basis.

[Operator:]

Your next question will come from the line of Matt Weight [ph], who's a private analyst.

[Unknown Analyst:]

One -- couple of questions here, going back to the EPO supply contract with Amgen. If you looked out in potentially 2 to 3 years, there was price compression from competing ESA drugs. Would the contract at all allow you to benefit from that?

[Kent J. Thiry:]

Matt, we can't, for all sorts of obvious reasons, disclose precise contract terms. And so maybe let me stumble my way through sort of the filters we went through in thinking about this contract, and we do feel very good about the new partnership we have with Amgen, and that's an important context within which to think about this. But you have to assess the probability that a new drug comes out in the market. Then you have to predict what price it will be at, how different from Amgen's price. Then you have to predict what percent of physicians will actually take the risk of moving off the gold standard, given the price. Then you have to take into account the pace at which they will do that. Then you have to take into account the price those providers have to pay for EPO on the patients and with the physicians for whom they still have to use EPO because not all their affiliated doctors are going to want to switch to a new and unproven drug. Then you have to take into account the fact that if a new drug successfully clears all those filters and how long it takes, you finally must incorporate the fact that, at that point, it is strongly in Amgen's long-term best interest to come back and work with us rather than become too noncompetitive because this is a very significant net present value drug for them no matter what because it's so important and so proven. So if you kind run through that gauntlet, then you can kind of answer your own question about what dynamics might exist 3 or 4 years downstream without me talking about exactly what the paragraphs of the contracts say. Is that helpful?

[Unknown Analyst:]

Yes, it is. I appreciate that. That's helpful. Two other quick questions here. Did you guys, looking back in 2011 here, notice -- was there any noticeable increase in blood transfusions relative to what you've experienced in the past?

[Kent J. Thiry:]

First of all, we don't have a good transfusion data, no dialysis provider does because we don't get to capture it. Almost all of that stuff happens outside our centers, and as much as we would love to get all that data, no one has an obligation to share it with us. So we look forward to working collaboratively with CMS, with Medicare in order to see if that's happening, and if so, to address it. As you know, doctors have this tough task in a world of very fluid science and very fluid clinical consensus on anemia management of, on the one hand, managing the risk on the downside, which means people get anemic and need a transfusion against the risk, on the high side, of having too high a hematocrit or hemoglobin and the potential for harm in that area. And so they have to balance those 2 and the exact science, an exact formula, is exact reality, exact analysis to drive a formulaic answer to that, that you can apply to each patient doesn't exist. And so you have thousands of docs out there using their best judgment to balance those 2 things. It's a long way of saying but hopefully, a helpful way of saying that we don't have the data. We'll work with Medicare to evaluate the data, and then we'll work with docs so that they can strike that balance.

[Unknown Analyst:]

Okay. And then last question just switching back to integrated care. Can you talk -- how do you see VillageHealth and DaVita Rx fitting in there? And what kind of potential synergies would you expect?

[Kent J. Thiry:]

So the question was how will DaVita Rx fit into integrated care?

[Kent J. Thiry:]

Right. Well, VillageHealth is, for those of you who don't know, the name of our integrated care group team effort, initiative, however you want to label it. And so it was founded based on the belief that one day, we'd be able to do truly integrated care. And in fact, it's the vehicle through which we've done the demonstrations and other analysis to show that it is the right path for American ESRD. So for VillageHealth, it is hand-in-glove if they give us the right architecture. And then DaVita Rx is a powerhouse capability that fits within it because once you're managing that total patient, you want to do integrated medication management. And that's what DaVita Rx does right now for our VillageHealth patients and would for any patients that came in under a pilot.

[Operator:]

Your next question will come from the line of Kevin Fischbeck with Bank of America.

[Kevin M. Fischbeck:]

A few questions here. Could you just talk a little bit about your international growth plan? Obviously, you guys have chosen the route of de novo startups but I've been a little bit surprised that you have done a number of things across a number of different countries all at the same time rather than focusing on a couple of geographies. Can you just tell us your thought process around that expansion?

[Kent J. Thiry:]

Very fair question. What has been safer to just go into 1 or 2 spots and focus and do that for a few years, stub our toes inevitably since we haven't done this stuff overseas before, so that would've been safer. We decided we would rather put incremental capital and talent at risk or in play in order to be more aggressive, recognizing we probably will make more mistakes, but in the end, hopefully put ourselves in a position where it's relevant sooner. In addition, in some parts of the world, we're worried that if we just sat out for the next 6 years in order to be conservative, that we would have significantly impaired our ability to become a leader or a co-leader, and so the extra cost and risk of doing more sooner has to be compared to the additional benefit if we pull it off.

[Kevin M. Fischbeck:]

I mean, I guess given that thought process and the willingness to deploy some additional capital, I mean, would you expect that 2012 might be a little bit faster deployment than what you kind of would've thought when you first announced this initiative? Or do you still feel like that kind of annual spend is the right spend?

[Kent J. Thiry:]

Well, first of all, right now, things are so uncertain, and there's so many swing factors. Since we're so tiny in a number of these countries, that is very difficult to forecast. We talked about this year, we'd be in the neighborhood of a $20 million loss, and we were at about $22 million. Right now, if we had to estimate, we'd say that we'll lose in the high 20s in this next year. Now that's actually a disappointment because we wanted to be at the same level of loss. And for us, that kind of percentage difference in what looks like it's going to happen versus what we expected is really embarrassing and unacceptable but that's where we are, and it gives you some flavor for right now the variability in our performance and accomplishments since we learned our way into the international world.

[Kevin M. Fischbeck:]

Well, I guess what is the delta to that? Is that because you're doing more revenue and therefore, more losses? Are you saying that actually, the actual performance, at -- the revenue has been in line, it's just the performance on that revenue has been disappointing?

[Kent J. Thiry:]

Yes, I think that's a level of detail I won't go to since the forecast is still so lively for such a small chunk of the business. I think that level of detail just wouldn't be very educational for you. But it's the net number, so it takes into account the overhead spending and the actual operating revenue and expenses. And to start parsing through it when it's so tiny, I think could be really misleading precision.

[Kevin M. Fischbeck:]

Okay. And then you mentioned that the VA rates were a headwind here, I guess, in the quarter. Are we now done with that? I mean, I guess obviously, VA kind of just come back and open things up again. But to your knowledge, are we done with that for the near term? Or is it more to come?

[Kent J. Thiry:]

Appreciate the question. And first, I was just advised that I gave you some wrong information that our international losses in 2011 were $20 million, not $22 million, which then makes the difference between the high 20s in '12 versus our actual in 2011 even worse. And now that I gave you that correction, your question was what?

[Kevin M. Fischbeck:]

It was the VA, and I guess you mentioned that was a little bit of a headwind.

[Kent J. Thiry:]

I've got it. I've got the question. Now this was, "What is the answer?". It's hard to know what they might do when and how we might respond. So there's nothing dramatic happening right now. But I wouldn't want to say to you we think it's going to be stable all year because we just don't know. And on the one hand, we take care of a lot of vets and they don't want that to change. They, on the other hand, have a lot of power. So how it plays out, I just think giving a micro-prediction would not be helpful because it would presume a level of insight on our part that we don't have. Suffice it to say that we are investing a bunch and trying to develop a stable, high value-added relationship with them where both sides feel that we're at a reasonable equilibrium. Maybe we are there now, maybe not.

[Kevin M. Fischbeck:]

Okay. And then last question, I guess everyone's focused on budget deficits and when the next debt ceiling is going to be hit and what might be a result. I mean, how do you think about your ability to offset rate cuts going forward? I mean, have you -- do you feel like your business is kind of fully adjusted to the bundled rate? Or are there more opportunity over time to become more efficient that might allow you to help mitigate what seems like inevitable rate cuts to most sectors going forward?

[Kent J. Thiry:]

I'd say 3 things. Number one, from an expense point of view, I think we're more or less in a post-bundle equilibrium. Number two, having said that, we strive for productivity improvements every single year. We always try to select some parts of our cost structure to focus on and see if we can innovate our way to savings. So when i say equilibrium, you need to evaluate the use of that word in that perspective. And then -- well maybe, I would just leave it at those 2 comments. Did I miss a part of your question?

[Kevin M. Fischbeck:]

No, I think that covers it.

[Operator:]

Your next question will come from the line of Gary Taylor with Citigroup.

[Gary P. Taylor:]

A couple of questions. I'm sorry, I must have missed right at the very beginning. I assume Luis kind of went through the change in revenue per treatment, sequentially, and obviously, the VA was part of that. Did you say the VA was the biggest part of that sequential decline?

[Luis A. Borgen:]

Gary, let me repeat those phrases for you. The 4 factors that we cited were first, decline in commercial mix. The second one was at new lower VA rates. Those rates came into effect on 10/1 of 2011, and so we had the full impact in Q4 versus just 1 month in Q3. The third factor was a decline in physician-prescribed pharmaceuticals, i.e. utilization. And finally, we had a quarter-over-quarter decrease in the amount of revenue related to vaccinations. So those are the main factors that reflect all our drop from Q3 to Q4.

[Gary P. Taylor:]

And then the impact of pharma on the top line under bundling is what? Which pharma would be driving that?

[Luis A. Borgen:]

It will be the unbundled contracts.

[Gary P. Taylor:]

On the commercial side?

[Luis A. Borgen:]

That's correct.

[Gary P. Taylor:]

Got it. And anything on just commercial bundled contracts in general? Any -- I know your competitors talked the last couple of quarters about some that has kind of weighed on sequential results moving unbundled commercial contracts into bundling. You guys haven't talked a lot about that. That doesn't sound like it was a material factor.

[Luis A. Borgen:]

That's correct.

[Gary P. Taylor:]

Okay. And on, Kent, just on your comment about the investigation. You were referring to Colorado, correct?

[Kent J. Thiry:]

Yes, sir.

[Gary P. Taylor:]

Okay, just want to make sure. And then on integrated care, I guess I have 2 questions. One, you would agree that the savings opportunity is on the incremental $50,000 or so of spend primarily, right?

[Kent J. Thiry:]

Yes.

[Gary P. Taylor:]

And is there, I guess when we look at -- we only have the benefit as far as I know of seeing publicly the first 3 years of those demonstration projects, and we didn't see kind of what the savings amounted to in years 4 and 5. And I know for example, in the Fresenius data, they saved more in year 2 than year 1. They saved more in year 3 to year 2. I think they've implied to the markets they saved even more in years 4 and 5. So the question is, if this was rolled out, is there still the effect that the amount of intervention and integration you're doing means that the savings grow cumulatively? Or is it that you're learning through the 5 years of that demonstration and the savings upfront could be more impactful than were able to be demonstrated through the demonstration project?

[Kent J. Thiry:]

Very fair question. Statement A, we have gotten better every year and that continues. Answer B, actually, in my mind, our way of learning has been disappointing, and we can get a lot better than we are. And so unfortunately, answer C is the impact, both because of the challenges of scaling and because we've not done as well as we should have in terms of being more creative, more aggressive, more innovative, that we've still got a lot more learning than I wish we had, enough to see great results, exacting results and be optimistic. But when you think about scaling it and executing, we don't give ourselves impressive grades for how well we've done in the last few years.

[Gary P. Taylor:]

Do you have an estimate on that $50,000, what a reasonable savings percentage might be? Or do you not want to go there yet?

[Kent J. Thiry:]

I don't think it's a good idea to talk about that.

[Gary P. Taylor:]

Okay. Very last question. Luis, on the tax rate for '12, is that primarily state local income tax effect that's bumping that up a little bit?

[Luis A. Borgen:]

Yes, it's 2 factors. It is partially state. It also has to relate with the international losses, deductibility of those. We can't do this in the current year, and so that puts up pressure on yields in the overall ETR.

[Gary P. Taylor:]

I'm sorry, I lied. I have one more quick question. You talked about kind of the pharmaceutical run rate having stabilized. Any additional thoughts to subcu? We've seen some data suggesting some of the small providers have moved a little bit more towards subcu dosing on EPO. Where are you -- where's DaVita at in terms of considering the possibility of that?

[Kent J. Thiry:]

I don't know of any significant movement among our physicians to use subcu, nor has there been any discussion that I've been a part of. So I don't have an answer other than probably there's nothing going on because none of our doctors are talking about it. If some of our doctors start to talk about that and move in that direction, we would certainly report back to folks. But I just haven't seen or heard of anything like it, and so that's where we stand.

[Operator:]

And at this time, there are no further questions. I would now like to turn this call back over to the panel for closing remarks.

[Kent J. Thiry:]

I'll just pick up on one issue that came up, which was Medicare rate cuts. That while it is true that we have a lot of Medicare patients and it's rational to expect that Congress may do something with Medicare rates, it is also true that we are about the most discreet health care service there is, with 85% to 95% of our centers freestanding. They only do one thing and all the expenses are submitted in a cost report to the government every year. We personally have about 150 centers that currently lose money as it is. And so in our segment, if the government will get inappropriately aggressive and cut rates, they could be faced with some serious center closures in centers that didn't have enough private patients to sustain the subsidy on the Medicare side. And so while all Medicare providers have to be worried about rate cuts, we, in some ways, have arguments of clarity of data and consequences of a mistake that other segments do not have. With that final comment, I want to thank everyone for paying attention to our company, and we will do our best for you in the next 3 months until we talk again. Thank you.

[Operator:]

Ladies and gentlemen, thank you for your participation in today's DaVita Q4 2011 Earnings Conference Call. You may now disconnect.