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Fresenius Medical Care AG & Co. KGAA (NYSE:FMS)

Q1 2013 Earnings Call

April 30, 2013 9:30 am ET

Executives

Oliver Maier - Head of Investor Relations & Corporate Communications

Robert Maurice Powell - Chairman of Management Board - Fresenius Medical Care Management AG and Chief Executive Officer of Fresenius Medical Care Management AG

Michael Brosnan - Chief Financial Officer of Fresenius Medical Care Management AG and Member of Management Board - Fresenius Medical Care Management AG

Analysts

Lisa Bedell Clive - Sanford C. Bernstein & Co., LLC., Research Division

Martin Wales - UBS Investment Bank, Research Division

Michael K. Jungling - Morgan Stanley, Research Division

Veronika Dubajova - Goldman Sachs Group Inc., Research Division

Jonathan A. Beake - Citigroup Inc, Research Division

Thomas M. Jones - Berenberg Bank, Research Division

David Adlington - JP Morgan Chase & Co, Research Division

Holger Blum - Deutsche Bank AG, Research Division

Ingeborg Øie - Jefferies & Company, Inc., Research Division

Ryan K. Halsted - Wells Fargo Securities, LLC, Research Division

Operator

Ladies and gentlemen, thank you for standing by. Welcome to the Fresenius Medical Care Q1 2013 Conference Call. [Operator Instructions] I would like to turn the conference over to Oliver Maier, Head of Investor Relations. Please go ahead, sir.

Oliver Maier

Great. Thank you very much, Jerry. Thank you, everybody for being back. I would like to welcome all of you to Fresenius Medical Care's earnings call for the first quarter of 2013. Also a warm welcome to everybody who joined us today actually on the web. We very much appreciate your interest.

With us today are Rice Powell, our Chief Executive Officer and Chairman of the Management Board of Fresenius Medical Care; and Mike Brosman, our Chief Financial Officer.

As always, I would like to start our presentation also by mentioning our cautionary language that is in our a Safe Harbor statement of our presentations and the material we distributed today. For further details concerning risks and uncertainties, please refer to our filings including our SEC filings.

One more housekeeping item from my end, I would like to ask those who have dialed-in today to limit their questions to just the 2 -- to just about 2, maximum 3 questions, per round in an effort to get everyone actually an opportunity to participate in the Q&A portion since I know that quite a lot of people actually have dialed in. Obviously, feel free to re-enter the queue if you wish.

So that it is from my end, Rice. The floors is yours.

Robert Maurice Powell

Thank you, Oliver. Good afternoon to the folks here in Europe. Good morning to the folks in the U.S.. Welcome to our Q1 Earnings Call. Let me start by saying to our FMC employees and management board members, please accept my thanks for all of your hard work in the first quarter. I appreciate the efforts that you make each and every day.

I will start, I've got about 9 slides I'd like to walk through with you today. I'm going to try to make sure I stay on the high points. I'll turn it over to Mike. He will then take you through the financials and some details, and then I'll come back and summarize before we move in to taking your questions.

Again, looking at Slide 4. First quarter 2013 in the blue shaded area. I won't go through each and every number. I know you've seen this since our press release has been out earlier this morning. You can see the 7% growth in net revenue, approximately $3.5 billion even at $493 million, down 2%, and you can see the net income as well as the net income adjusted. I think what's important on this slide is to say that we are pleased with the organic growth in North America at 4%. The dialysis services group in North America had a very good first quarter and we appreciate that. And as we talked quite a bit in the February full year presentation and guidance that we wanted to see improvement in our payer mix in North America. We've seen a slight improvement. We like the way that's going, not nearly where we need it to be, but there has been some improvement there in the course of the first quarter.

Looking at Europe, Middle East and Africa, I don't believe that the performance that you see in this first quarter, which is disappointing to all of us, is a trend necessarily. I'll give you some more color on this in a slide or 2, but we do have to recognize it wasn't where we had hoped it would be. But again, we saw strong growth in Asia as they continue to grow strongly throughout the region. This is not a set of results for my first quarter as a CEO that I'm thrilled about, but we will continue to work hard, things will improve. We are continuing to maintain our guidance. Mike will give you some more color on that. But it is work and we intend to be here everyday, trying to get better and improve.

Looking at Slide 5, again good revenue growth, but weak in Europe. North America at roughly 66% of the revenue. $2,287,000,000 for North America and 9% revenue growth with an organic growth of 4%. Internationally, looking at just shy at $1.2 billion, 4% revenue growth in constant currency and organic growth at 5%. When you look at the various regions in International, Latin America was very strong at 12% constant currency growth in revenue, Asia Pacific at 7%. And the surprise you see here is Europe at 1% constant currency growth. Now a couple of things here that we understand have gone on in Europe. Number 1, we saw slower de novo growth than we had anticipated, generally in the area of Russia. We were hoping that we would have had clinics up and running and patients being treated and reimbursed, but we're a little behind schedule there. There were a couple of tenders in the product business that we chose not to participate in. I'll give you a little more color on that later. But in addition to that, just generally speaking, the product sales in Europe in the first quarter were down. If you look at Gambro's earnings release, you can see that in EMEA, Europe, Middle East and Africa, they were 2% up on constant currency, Baxter in their international division, not exactly a one-for-one comparison, but they were at 1% growth in constant currency. I can't really tell you why. We do think there's some effect of Easter and the Holiday, and people not being around, if you will, to sell to. But it just seems to be generally speaking a down quarter, and I do believe it will come back. I have great faith in our team in Europe and their ability to drive their business.

Looking at global market leadership in terms of the franchise, 3 key numbers, and then let me come back and give you a little more detail. Clinics grew 2%, treatments were up 5% and patient count was up 3% for the global franchise. Now just a little detail for that, you can see at 3,180 clinics, North America was just shy of 2,100 and just shy of 1,100 clinics in International. That 5% shipment growth is approximately 9.7 million treatments in the quarter and then approximately 262,000 patients drove that 3% increase in patient count in the first quarter.

Moving to Slide 7. Looking at the revenue growth in dialysis services. When you look at it on the accumulated basis, you can see first quarter $2,678,000,000, that's 9% growth in constant currency, organic growth at 5% and same market at 3%. And again, I will highlight that North America had a good performance, 10% growth in constant currency, organic growth at 5% and same-market growth at 4%. And if you recall a year ago this time, we were pushing hard to get away from the 2.3%, 2.2% that we had, so we have, as we discussed, re-engineered that process, we've work hard at it and it would appear that we've made progress and we continue to do much better than we did a year ago.

Now looking at Slide 8, let's talk a minute about this chart. I need to make sure you realize that we've done something different here. For years, we would have looked at Q1 2013 compared to the first quarter of 2012 year-over-year. And quite honestly, if you think about it now, we believe that's a long time in between to measure these clinical outcomes, so we've decided to do this in sequential quarters. We think it's a little more prudent, little more up-to-date, if you will. So please note that change. So looking at this, Q1 2013 versus the Q4 2012, you generally see hospitalization days, which I always like to look at, we've had a slight improvement in each of the regions. And generally speaking, we've had very similar performance from one quarter to the next, in some cases slightly up, in some cases slightly down, but not a particularly big trend in any 1 area, but at the end, I want to make sure you understood that we have made a change in the way we're looking at that.

Then for Slide 9, again, we've made a format change. As you recall, for years, we would show you the total revenue which is both internal, which we sell through ourselves and in the third-party external. We just thought it might make the slide a little simpler to show you the external revenue, which again, is the way we judge our ourselves as to what goes on with third-party sales. So looking at this, again, you can see first quarter, $786 million, 2% growth in constant currency. International was at 3% and North America down 2%.

To give you a little more color on this, looking at renal products or just the dialysis products, not looking at pharma, we were up in the external market, about 2.4%. We had a couple of things that really impacted the International piece of the product sales. They just seem to generally be weak. Again, we had some tenders that we did not win, and also we had a decision on a couple of unprofitable businesses. And let me just kind of walk you through that. There are, time-to-time, particularly in Mexico, where tenders have come available for us to bid on and we see a reference price that we bid against that reference price. In a couple of instances, the reference prices were so low. It just didn't make sense to us to go after a piece of business that was unprofitable. So we chose not to participate. Tenders there are usually are 1 to 2 years. We'll get back in the saddle depending on what the reference prices look like at a later date.

In the case of Turkey, we had a pharma business in Turkey that has been struggling for a while, just didn't make sense to stay in that business. And so we decided that we wouldn't continue there.

And then not on a piece of paper, but in Saudi Arabia, we had another tender. It was a product tender that we chose not to participate in. If you put those together, we're somewhere in that low-double digit million of dollar range. Don't think it's important to break those out individually for you, but I wanted to give you some sense of the impact of us just making a decision that not profitable business wasn't a place to go for us.

Looking at the U.S. and having a chance to look at some of your reports. Today, I know people were disappointed that the sales were down. Again, as I usually try to do to give you a little color on that, if you look at the hemo disposable business in the U.S. dialyzers, saline, concentrate, bloodlines, the growth was 3.4%. And then if you isolate the PD disposable business in the United States, excluding Mexico and what we just talked about, the growth there was at 7%. So we're continuing to get good growth on PD disposables in the U.S. markets. And hemo equipment in the U.S. was up about 2%. And if you recall, we were down in the fourth quarter. We knew where that was in the independent markets, so we've seen a nice pick-up in some return to buying patterns in the independent market on the machines there.

My last slide before I turn it over to Mike, I do think it's important because it's such a big piece of our business to continue to update you on our legislative activities in Washington, D.C. This tends to be fairly U.S.-centric, but in the case of sequestration, we don't really have an update for you. It is in force as we speak. It's an impact. We'll see where it goes as we go through the year.

Looking at the re-base of the bundle, we've been very busy in D.C talking to congressional members, working with CMS to educate and to make sure they understand how serious this re-base activity is and making sure that we give them as much data and can answer as many questions as possible, because we think the better armed they are, the better decision makers they will be. The calendar for re-basing has not changed. We expect that we will see a draft proposal from them sometime in the July timeframe, probably early July. We'll get a 60-day comment period, and then we think late October going into November, we would see the final rule come out as we've indicated before.

And then lastly, on integrated care, a little bit of movement there and that the deadline for applications to participate had been May 1, and that's been pushed to July 1. And the reason for that is simply that the dialogue on some of the structural questions that we talked about in February continues. We've been able to ask questions, provide data. There's back and forth, so that's still in play and a little bit of a change there. Letters of intent had been due to come in earlier in the quarter, I believe, and now they pushed that date out to May 15 as well to try to give people more time. So we continue to work there.

The update on former management. We spoke about this in February, where are we with our data analysis for OMONTYS. We're wrapping that up. It's pretty much done. We've submitted an abstract of our experience to a third-party peer-reviewed publication. We hope to hear from them sometime soon if they will publish our results. So I would tell you that, I think, there's still the very good chance you'll see this in published publication from a third-party peer-reviewed journal probably in Q3, could maybe slip to Q4. Should it not be accepted for publication, we are prepared to publish it ourselves. Either way, we'll get that data out, but we're very anxious and happy to share our experience with people on the OMONTYS experience that we have.

And then under other matters, we had mentioned to you in February that on March 20, there would be a multi-district litigation hearing in Boston that did take place on March 20. The multi-district litigation is going to continue in Boston. A judge has been assigned. It's a judge that we have experience with. We've dealt with this gentleman on other matters. So that is some progress on that front, and we'll continue to keep you posted as time allows when we go forward.

And with that, Oliver, I think, I will turn it over to Mike for financials and outlook, Mike?

Michael Brosnan

Okay. Thank you, Rice, and good morning, and good afternoon to everyone today. Rice spoke to the quarter in terms of revenues, so I'll move on to the operating income and the operating margins for the business in the first quarter.

Despite our revenue growth of 7% constant currency, our operating margins were down 2% or about $10 million from $503 million to the $493 million that you see on the page. And this was principally due to 2 effects: First, we had 2 fewer days for treatments in the first quarter this year compared to 2012. This is a natural progression of the calendar. In fiscal '13, we lost the day from leap year 2012, and there was an extra Sunday in the first quarter of this year, which is typically not a day that we dialise patients.

In addition, the Venezuelan bolivar was devalued. This impacted our operating earnings in the quarter by about $10 million. The effect is weighted to the first quarter as we had to revalue our in-country balance sheet immediately. Going forward in fiscal '13, we anticipate a modest single-digit millions effect on the remainder of the year.

As you can see, our worldwide margins reflecting this were down 130 basis points from 15.5% to 14.2%. And looking at the segments, I'll provide you some additional explanations.

Margins in North America were off 40 basis points, influenced principally by the 2 fewer dialysis days. We also had some divestiture gains reported in the first quarter of 2012 for the Liberty acquisition and increased personnel expenses essentially just simply reflecting the merit increases that people are due on an annual basis. This was partly offset by the increase in the Medicare reimbursement rate.

If we look at this on our rate-per-treatment perspective, you can see that our revenue per treatment in the U.S., increased $6 a treatment from $353 in 2012 to $359 currently. That's about a 2% increase. This was the result of the Medicare rate increase and growth of our expanded services. The growth was partly offset by the effects of lower pharma utilization and the commercial revenue effects that I've described with regard to that many times over the course of the last several years, and rate effects related to the new commercial contracts we signed in fiscal 2012.

Cost per treatment increased $8 a treatment, so about $2 more than what you're seeing on the revenue per treatment. This was principally from investments in our expanded services, increased personnel costs, partly offset by cost savings associated with the reduced pharma utilization.

Looking year-over-year, we can also see an increase in cost per treatment due to a legal case currently underway in the U.S. where we recorded what we anticipate will be the full effects of that in the quarter and the effect of fewer treatment days on our fixed-cost per treatment. Essentially, you're taking your fixed costs over a lower number of treatments year-over-year. So the combined effect of those 2 elements accounts for about $2 or essentially the delta between the revenue and the cost increase.

Margins on the International side were down 150 basis points. This decline was due to the bolivar devaluation, the revenue effects that Rice just described a few moments ago, particularly in EMEA, and higher manufacturing cost in the International business year-over-year. These were partly offset by lower bad debts, growth in our business in Asia, which gives us the opportunity to further leverage the SG&A in that region, and favorable foreign exchange.

Continuing to move through our results. We don't show interest expense, but you may have seen it in our investor news, it's down year-over-year due to both lower rates and reduced levels of debt. Our debt is down about $800 million from Q1 2012. Interest income is also down due to the retirement of the loan to Renal Advantage which was part of the transaction that we executed with Liberty last year. And effective tax rate for 2012, if you adjust for the nontaxable investment gain, our tax rate is down about 70 basis points from 33.9% to 33.2% in fiscal 2013. Reported earnings, as Rice indicated, are down 39%. Adjusting to the investment gain, we're showing a decrease of about 8% from $244 million to $225 million.

Turning to my next chart, we'll start discussing cash flows. And as you know, we always start with DSO. You can see the reduction we achieved over the course of 2012 in our International business, starting the beginning of last year with 124 days and coming down to 115 in the fourth quarter of 2012. For the most part, we're holding that level of DSO in the International markets with just a modest one-day increase in the first quarter. North America is very solid, down a day to 54 days. And overall, total company DSOs were flat at 76 days with the fourth quarter.

Turning to the next chart and looking at the overall cash flows. This page will require a little bit of explanation. Our underlying performance for both years is very strong, but as you can see in terms of the recorded numbers, we had cash flows of $481 million in fiscal '12, 15% of revenues down to $315 million in Q1 '13, which is about 9% of revenues. The performance in the first quarter of this year was largely due to the payments of the $100 million that we disclosed in Q4 of 2012 to restructure the contract with American Regents. Adjusting for the impact of this payment, which was partly offset by other cash elements associated with amending that contract, would have given you cash from operations of about 11% of revenues.

And if you looked at that on a comparative basis to 2012 and considered what I mentioned last year, which was we had a substantial refund, tax refund, from the German government and settlement of litigation we had here and some rebates on multi-year contracts, you would've ended up in pretty much the same place of about 11% of revenues. So I think the cash flows in 2011 Q1 don't indicate any weakness in the underlying business from a cash flow perspective. Capital expenditures are consistent at 4% of revenues. And the acquisitions, we spent about $71 million in acquisitions. We invested in all regions around the world, Latin America, the United States, Asia, as well as Europe.

Going to the next chart and looking at our leverage and our debt. We have $8 billion in debt outstanding, as I mentioned earlier. That's down about $800 million from the beginning of 2012. And it's down about $250 million from the fourth quarter. And our leverage is expected in -- within the guidance that I've indicated to you previously. As you can see, there's no material change in our ratings on that page.

Finally, coming to my last chart and transitioning to guidance. Bear with me one second. The -- Rice has already indicated we're confirming our guidance. We went through the base period 2012 in February, so I won't repeat that here today. But I said -- as I said in the year end meeting 2013, we anticipated it would be a challenging year for us and for the industry. As a result, we did indicate a wider range of operating and earnings performance than you customarily see from us. And in that regard, in particular, I've highlighted sequestration, with the footnote at the bottom of the page. And when we announced our guidance, sequestration was not in force and now it is. Congress does not seem to have a strong desire to do anything dramatic, but they continue to monitor the effects that sequestration is having on the economy. The most recent example of that is the decision that some of you have seen in the last few days to bring back the furloughed air traffic controllers and address the sequestration that impacted the requirement to tell those people to stay home temporarily.

In that light, we've tried to give you an indication of the approximate effects that sequestration has on the range of guidance that we have provided to you. So in the footnote, essentially, what we're saying is, if sequestration remains in force, it would have an impact on the top end of our guidance of about $45 million after tax. Now if that's not clear, then we can obviously deal with that in the Q&A to follow.

Moving on to other elements of our guidance and just picking up on the bars to the right that we pick -- that we introduced to you at year end, and we'll likely to continue to comment on them as the year progresses. The device tax is here to stay. That was worth about $20 million to $25 million, and that was fully considered in the guidance we provided to you. Rice has already commented on our commercial mix that it was stable in the first quarter. We're going to continue to focus on improving that over the course of fiscal '13. We're going to monitor their reimbursement situation on a worldwide basis. And as you know, typically, when we see any potential for reimbursements decreases around the world, we focus our efforts in those respective countries to mitigate the impact of that cut with either different approaches to the therapies that we negotiate with the government or cost mitigation.

I will comment that we did announce since our last call a share buyback in March. We will use available cash and debt to finance that program. And I anticipate that will remain within our guidance in terms of our leverage ratios, inclusive of that program. We continue to believe we will deliver the performance indicated for 2013.

And with that, I will turn the call back to Rice.

Robert Maurice Powell

Thank you, Mike. So let's close on Q1. I'd like to just leave you with 3 points, and then we'll move into the Q&A. First point, our February 2013 assumptions that led to our guidance continue to be accurate today, I believe. We are reiterating our guidance range for the year, and so we continue to move forward. Historically, first quarter has been our most challenging quarter in a number of years, and this is no different. We've guided to the fact that we believe you'll see better performance from us as we move to the later quarters of the year, but no question Q1 historically has always been tough for us as it was again this year as well.

And then to put in perspective, again, 2 major issues in Q1 have made it difficult for us: The Valenzuela devaluation that Mike's talked about; and then the 2 less dialysis days in the U.S.. But we are off and running into a new quarter, working hard and we're going to do everything we can possibly do to deliver the promises that we've given you earlier in the year.

So with that, Oliver, I'll turn it over to you.

Oliver Maier

Great. Thank you very much, Rice and Mike for the presentation and the update. Jerry, I think we can start opening up the Q&A session.

Question-and-Answer Session

Operator

[Operator Instructions] First question is from Lisa Clive, Sanford Bernstein.

Lisa Bedell Clive - Sanford C. Bernstein & Co., LLC., Research Division

I really just want to focus on the North America margin. You mentioned specifically a rise in personnel costs. Could you just go into that a bit more? You're in the process of integrating Liberty Dialysis. One would expect that, that would lead to a few -- actually, a reduction in personnel costs. So could you explain -- so what exactly happened there and whether this is a onetime effect or can we expect a similar level of expense for the rest of 2013? And then second to that, sort of what measures can FMC take to limit further increases along these lines? And then the second part of -- the second question I have is on the products business. It was helpful to hear that -- the breakdown a bit between different parts of that around the disposables, machines, et cetera. It looks like, basically, the big weakness here is the pharma business. Can you just explain where your pharma business is today? Clearly, it's been under a lot of pressure, particularly because of bundled pricing and what we should expect from that business in the next 12 months; if you could even give us a size of what your pharma business is today. I think it would just make us a lot more comfortable that the underlying products business is stable, and it's really just a problem on pharma or is it a situation around the products business you may be losing market share? Are those things that we should be worried about?

Robert Maurice Powell

Okay, Mike, you want to take Lisa's first question?

Michael Brosnan

Sure. Yes, I think that -- let me back up first and then I'll talk about personnel costs in North America. As you know, we are always very focused on margin accretion in the business. We're always looking to slightly improve the margins year-over-year, and typically, our guidance is based on that premise. So in terms of the personnel costs in North America, there's nothing unusual or extraordinary about that. I mean, typically, you see normal merit increases that come into play as the year starts off, and Q1 this year is no different. I know there may have been some remarks earlier today in the press that related this to onetime or variable compensation. It really is simply based on the underlying normal payroll increases that you see year in and year out, and we've done a very good job over the years in terms of mitigating the effect of those by looking at other efficiencies in the business. And I would expect that we'll continue to those efforts in fiscal 2013. But clearly, I reported earlier that we were looking at about a $6 increase in revenue per treatment. And when you take out the effects in the first quarter that I think just relate to that quarter, booking on legal case and the short period for fixed costs, you're looking at about a $6 increase in revenues and a $6 increase in cost, which is typically not where we like to be. So we're going to be very focused on finding ways to mitigate. And in our guidance in February, we had that as a bullet point on the chart that we would seek to mitigate our costs in 2013. In that regard, we have put together an efficiency program, a global efficiency program. We typically look after cost mitigations on a regional basis, but we have organized a global team to focus for the balance of this year on ways of reducing the cost base of the business. So as the year progresses, we'll be talking more about that as we make progress on that initiative.

Robert Maurice Powell

Lisa, it's Rice. And let me pick up your other question on products. But let me also just highlight, as Mike says, this is a global project that we've got. We ask people to come do this full time for us. It's global enough and high enough that we're going to run this out of the -- my office. Mike and I, with the help from the management board, we just think it's time to kick all the tires in all the corners of the world to look at where we can be more efficient and can we do things to mitigate cost in what I would say are some fairly uncertain times in many, many parts of the globe. Looking at the products business, what I would say to you is, I think, the products business is strong, I think it's fine. We are not -- we are not losing market share. I'm comfortable that we will have a better performance than we saw in Q1 in Europe. I think it is sort of an anomaly, but we are not getting our pockets picked, if you will, from a share perspective, particularly in the U.S. When you look at the pharma business, what I would say to you, I'm probably not going to give you the size of the business. We've never really broken that out. No question, your intuition is good. We see pressure on pricing there. Part of what led us to redo the Venofer deal was that we needed to clear some headroom for our sales if we could. As I look out over the next 12 months, I would say to you that we are pushing and working hard. We're seeing a trend in the U.S. in the case where Venofer and the dosing with Venofer had dropped. That part of '11, all of '12, and we've seen some uptick in that dosing regimen, I think, as I mean new management has sort of settled out and people are kind of in the space that they feel they understand that interplay and what they're doing. We've seen a little bit of rise in Venofer. So we'll keep our thumb on that pulse and see how it goes. But I think it's going to continue to be a hard slog. We're going to work hard on it. But no sugarcoating, it has been problematic for us. We are looking forward to the PA21, a new binder, getting approved in -- around the world. And we need to do more work there. We'll continue to do it, but I recognize that it may cloud the product business. So I want to make sure that I give you some comfort there that this is not a share loss on our part. We're continuing to push, and again, you know the usual things that happen with us, buying external customers, and then becoming internal. There is an effect there. But hopefully, that's given you enough to at least give you some sense of what's going on.

Lisa Bedell Clive - Sanford C. Bernstein & Co., LLC., Research Division

That's helpful. Just one follow-up on the efficiency program that you mentioned. Is this something that at some point later in the year you'll give us an idea of potential impact this could have on your cost structure or timing of when we could see benefits from this?

Robert Maurice Powell

Yes. Let me say a couple of things, Lisa. Number 1, whatever we do, we're not going to allow that to affect product quality or service quality. Patients come first, and we're going to work around any situation which would put any kind of jeopardy on the quality levels and the care that we give our patients. So what that really means is we'll go through, look at the processes in all aspects of the company, is it accounting, is it distribution, whatever it may be, and look at how we can become more efficient. Not sure if we'll give you a range on this just yet. We're working on it now. We're well into trying to figure out how best to pull this off, if you will, and I don't think this will be a calendar year '13 thing only. I like being efficient all the time. So we get started. We see where this goes. Obviously, some projects are quicker to do than others. Let us wait and see how we communicate that to you, but we if we do our job and we're able to get more efficient around the world, I think the numbers will reflect that. So we will give that some time. I won't commit that I'm going to lay out in detail on that to you just now, but we'll see where that goes.

Operator

The next question is from Martin Wales, UBS.

Martin Wales - UBS Investment Bank, Research Division

Just one straightforward one. Can you just talk me through how the rest of the year is going to develop to make your revenue guidance in particular because you seem to have quite a lot to do?

Michael Brosnan

Martin, I think -- I think when you look at the first quarter in the U.S., you're looking about a 2% increase. And obviously, with some of the comments Rice made particularly around EMEA, we're looking for that to improve over the course of the year. But as we look at the business just in terms of confirming our guidance, we do see that we will have the ability to get to the $14.6 billion that we've indicated, which will be greater than a 6% revenue growth rate. It is going to take growth in a number of markets around the world to achieve that, and we are in the U.S. looking to the expanded services that we've mentioned as well.

Martin Wales - UBS Investment Bank, Research Division

So you think we could see a pickup in what was a pretty good organic growth from the United States, as well as a much stronger performance from EMEA for the rest of the year? Is that a reasonable summary or am I missing something?

Michael Brosnan

Well, I would agree with you. To achieve our guidance, we're going to have to do something like that, Martin, so.

Robert Maurice Powell

We're going to need to hit on all cylinders, Martin, including some of the ancillary or expanded services. But we like to think we can get this done.

Martin Wales - UBS Investment Bank, Research Division

Okay. And then just one quick one on PA21, I guess the PDUFA date, the 1st of December. What -- do you have any thoughts at all about where you might price that, given that obviously going to a market where there's existing non [indiscernible] phosphate binds are quite expensively priced but [indiscernible] goes off patent back in the '15? And also bear in mind that in theory, you're going into a bundled world with the orals in 2016. How does that influence your thoughts on pricing this product?

Robert Maurice Powell

Well, what I would say is we are actually looking in modeling where we go as you well know given your experience and background. How you peg this is really important. I can't really tell you where we're going to be other than we are looking at it not only in the U.S. but around the world and trying to decide with our partner where's the best place to peg this. We're working on it, but don't know that I honestly could give you a number because I don't have that level of detail, Martin. But it's -- clearly, key for us is to how we start out with that drug if we hit the PDUFA date or when it comes, it could be early January, if not in December.

Operator

The next question is from Michael Jungling, Morgan Stanley.

Michael K. Jungling - Morgan Stanley, Research Division

I have 3 questions. Firstly, on the guidance for 2013. If I look at your Q1 results, which is sort of fairly modest results, and I also look at sequestration kicking in, in the second quarter, is it fair to assume that the low end of your guidance for the full year is probably now a more appropriate number to look at? Question #2, on the other EBIT line, it sort of increased quite substantially. I suspect it's legal costs. What is a reasonable EBIT other line to go for in 2013? Is it -- is a run rate of $60 million per quarter the right number? And then, question #3 is on the EPO alternative. How much lead time do you need if you want to use MIRCERA in the U.S. in 2014? Would you need to start soon with some trials in the United States? And if so, are you able to do that without breaching the rules that currently are in place or -- which are in place between Roche and Amgen?

Robert Maurice Powell

Please go ahead.

Michael Brosnan

Yes. Let me address your first couple, and then I think Rice will comment on the last. In terms of your guidance for the overall year, the way I'm looking at that, which is why I added the footnote, I had verbalized all of that in the year end conference call. We talked about sequestration quite a bit. But I just felt, because we moved from a few weeks before, it was implemented to, in fact, it, being in place now, that it was worth commenting on today's chart. So it's not new, it's just to provide you some additional clarity. So I would tell you that if nothing changes, sequestration is here to stay. That would obviously put you in the range of $1.1 billion to about $1.15 million, a little over $1,150,000,000. And I think that rather than being at the low end of that today, we're well within that range. On the legal cost in corporate, Q1 was high. In part what is adding to the first quarter is the fact that we did expand our management board. We now have a global R&D function that we're developing. We have some consulting costs associated with that development as well. So that will bump up the corporate costs a bit over the course of fiscal 2013. But I wouldn't say that $60 million is going to be the run rate. I wouldn't say that when we look at the full year, we're probably going to be up slightly, maybe even have a shot at coming in flat. That's the way I think of the corporate costs for the full year compared to '12.

Robert Maurice Powell

So Michael on the EPO alternative and MIRCERA, a couple of things. MIRCERA is certainly in a different situation than OMONTYS was. Just so you know, we've got a fair amount of patient data on MIRCERA here in Europe. The Euromedic clinics that we acquired, those patients were on MIRCERA, so -- they continue to be. So there's a good bit of data that we have. Now having said that, we would always do some sort of study in the U.S. I believe that our physicians and our chief medical officer, I know they would want to do something. It may not be nearly as long or involved as what we did on OMONTYS, but I just think it makes good sense, and as you well know, us having done the study, the way we did in OMONTYS turned out to be fortuitous given the events. I'm not the best guy to give you all the answer now to the Roche-Amgen settlement, but generally, as I understand it, I think Roche has the ability to come into the U.S. in the mid of '14. If they're coming without a partner per se, they're just coming in directly. But I think given the experience, Michael, that we had with OMONTYS and the ability that we realized, or capability that we have to get a study, get people in, generate data, we can move pretty quickly, and so this would not be as big a study. So I do think it's practical and feasible that we've been in a position to be able to do this. I think the biggest unknown is let's just -- I have to go back and talk to our legal folk. I may not be exactly right on their settlement, but from our own capabilities, we could do this fairly quickly, yes.

Michael K. Jungling - Morgan Stanley, Research Division

Okay. And let me just follow-up. If you wanted to use MIRCERA in the United States, are you able to buy MIRCERA from Roche today or would that -- or would you have to check with your legal department whether that's possible, because it's kind of critical as to how quickly you could act in the United States on MIRCERA? Can you do the work beforehand or you have to wait until mid 2014?

Robert Maurice Powell

Let me defer it to the legal guys. We can always come back to you. If it's left up to me, I'll try to go buy some tomorrow, but I can't do that. So let -- I'll -- somebody will come back to you and give you some insight on that. I, honestly, just not in the best position to give you that kind of detail.

Operator

The next question is from Veronika Dubajova, Goldman Sachs.

Veronika Dubajova - Goldman Sachs Group Inc., Research Division

I have 3, if I can. So one, Mike, just wondering, when we spoke -- when you spoke at the full year results, you discussed your expectations for revenue per treatment, including sequestration to be down slightly. Given what you've seen in Q1, I'm wondering whether that's still the appropriate number we should have in mind for the full year. And then as I look at the cost per treatment being up $6, you've discussed you'd like to mitigate that. I'm just wondering what might be the realistic level you're looking at for the full year. My second question is on the guidance, and excluding sequestration, I guess, the range is a 1.1 to 1.5 -- 1.155. I'm wondering what things might move the needle for you to end up in the lower or higher end of that range. And my last question is on the International business, where, if I look, especially on the services side, you growth rate has slowed down somewhat. And I'm just wondering what kind of effort you can drive going forward to increase your same-market treatment growth rate.

Michael Brosnan

Okay, Veronika. I'll take the first 2, and Rice will take the last one. On the first one, you have a great memory because you artfully moved me into a space where I made a comment, even though I had said earlier in the call I wasn't going to provide the revenue or cost-per-treatment guidance because of the volatility we saw in the business this year. So I'm going to go back to my original premise rather than making your question in the last call -- what drives me to do it. So I think you can see where we are. I think I've provided some pretty good detail on the overall effect of sequestration on the business. So I'll leave it at that. In terms of the drivers for the 1.1 versus the 1.155, I think you saw them on the right-hand side of the page and those continue to be the things that we're looking at, some of which have been addressed. We talked about the first 2. We also commented that the sooner we do some of the acquisitions that we've mentioned consistent with our guidance that has a beneficial effect on the year. We talked about the pharmacy services organization commercial mix, which Rice mentioned, and the cost mitigations that we both discussed. So I think those are the things -- there's 4 or 5 of them that will drive the numbers within the range of guidance that we've indicated. And I'll let Rice take the question with regard to International growth.

Robert Maurice Powell

Veronika, it's Rice. Yes, we've seen some slowing in the International network care side, which is how we refer to the services business. I would say to you -- we are certainly out working hard and getting de novos that were behind, getting them built and getting patients in. This is what I'd call fundamental operating that we have to do. We got to work harder at that. There's also some acquisition work that's been going on that we need to get closed out and get these acquisitions done. Don't read anything into that, that there's a big deal out there. These are just the types of acquisitions we do every year within the footprint of $300 million that we've allocated for that. So I don't want to leave the impression people aren't working hard. I know they are, but I think we've just got to make sure that we stay diligent and we press hard on getting de novos done where we've got good selective -- accretive acquisitions to make, the small ones here and there, we need to do that. And we just got to keep pushing and working hard on our growth and our operating principles, Veronika. I don't think there's a lot of magic there.

Veronika Dubajova - Goldman Sachs Group Inc., Research Division

And just a quick follow-up. Epogen utilization, can you give us an update on where you were year-on-year and sequentially versus Q4?

Robert Maurice Powell

Could you repeat that?

Michael Brosnan

Epogen.

Robert Maurice Powell

Okay, thank you, thank you. Yes, probably the best way to do that is on the dose drop. Year-on-year, we were down about 15%. And then when you look at sequential quarter, it's dropped a little bit. If I remember the number, we were like 35 50 or 34 50 and we've dropped a little bit below that. Now what I will tell you is we've stabilized. We've gone back, looked at our protocols, we're looking at -- within the various patients that we see, new patients, et cetera, how do we better maximize the protocols to make sure that we're keeping people in safe ranges. So that could drive a little more change for us, but I don't think it's going to be dramatic like we've seen as -- you and I have been through over the last 2 years or so.

Operator

The next question is from Jonathan Beake, Citi Bank.

Jonathan A. Beake - Citigroup Inc, Research Division

I've just got one. In Europe, I was wondering whether you could talk a bit about a bit more detail about what you're seeing on organic level when you take out sort of slow starts in de novos. And in particular, what countries are causing your problems there? And then also on the de novos, could you just explain exactly what you mean by slow start and how that will change going forward, and what you can do to change that?

Robert Maurice Powell

Okay, Jonathan. I think I'll talk about the de novo piece, and then maybe I'll defer to Mike on the organic growth piece. We're looking for a couple of pieces of data here. What I mean on the slow start on the de novos is, basically, 3 things have to happen, Jonathan. We've got to get it built, we got to get the permits and everything we need to occupy, and then we got to populate with patients and start treating. In the case of the half dozen or so in Eastern Europe, we got caught with some slowdown in constructions, very tough winter, and we're just not at the point where all the permitting's done, patients are in and we're treating and revenue is coming. We're in various stages among those, but we actually, this is not necessarily European phenomenon, we see this in the U.S. sometimes too when we're building de novos. You lay it out on the schedule and you really have to push hard to maintain that exact schedule. And part of that time is not your own, you're looking for folks from the local authorities to come in and do the permitting and that sort of thing. So it's a -- got a couple of moving parts that you have to manage in order to have those come in and start up at exactly the time that you had projected for them to.

Michael Brosnan

Jonathan, I'm not sure I can add a lot to the perspective that Rice gave you, but I guess, other than to say that when you think in terms of de novos, as you know, that is part of our core business, the organic growth. You've got to build capacities where the patients are living, and you've got to keep pace with the growth in a particular region. Some region -- some smaller communities can grow substantially faster than the overall growth rate for the country or the regions. So an awful lot of the organic growth does tie in to maintaining the de novo program. I'd probably stop there.

Jonathan A. Beake - Citigroup Inc, Research Division

Are there any particular countries in Europe where you're seeing particular issues, maybe not in Eastern Europe, but in developed Europe where government's being difficult or anything like that?

Robert Maurice Powell

I would say probably the one place that we've had lots of dialogue and we'll continue to work with the government but it is moving much slower than we would like is Turkey. Beyond that, we have puts and takes in other countries, but we have a very good successful group in working with the governments to try to make sure things stay on schedule. But Turkey would probably be the one place I'd highlight for you.

Operator

Next question is from Tom Jones, Berenberg.

Thomas M. Jones - Berenberg Bank, Research Division

One, hopefully, is a fairly straightforward one. Mike, I think I heard you say but did you take a full provision for what you anticipate to be the complete legal cost related to Granuflo in the quarter or did you just book the expenses as occurred? If you did make a provision, would you care to quantify what it was? And then the second question was just on anemia management. If I look at your hemoglobin scores in particular, they've been trending down for the last 12 to 18 months, and sequentially dropped probably about more than I can remember. If you look at the number of patients in the 10 to 12 range, it dropped from 75 to 73. First question is kind of are you happy with that level? Is that the new norm? It used to be in the high 70s. And if not, what kind of costs should we be thinking about that you may incur to get that number back up into the high 70s or probably in the low 80s?

Robert Maurice Powell

You want to do Granuflo?

Michael Brosnan

Yes. Tom, as I was saying those words, I thought some folks might jump to that conclusion. So I'm glad you asked the question. The case that I was referring to in the U.S. is really a very isolated instance where we just had a decision come down from the courts and we've decided to book a medical case in full in the quarter. It's not related to GranuFlo at all, it's related to Apheresis. With regard to GranuFlo, we are incurring cost, so I think you can see in the SG&A percentages, there's some favorability in the U.S. year-over-year. But we are recording the costs we're incurring to deal with these -- the discovery associated with this multi-district case and some of the state cases that are developing. But those costs are being paid as we go. There's no overall accrual for that case at this point in time.

Thomas M. Jones - Berenberg Bank, Research Division

And then on the anemia side?

Robert Maurice Powell

Yes, Tom, here's kind of where we are. Maybe we should look at this 10 to 12 range and we could change that because what we're really doing is we're trying to hold ourselves to the 10 to 11 range. We're really trying to get very precise and very skinny within that range, and that's going to take us a little bit of time to do that. So we got some tweaks going on. What I would tell you is coming out of Q1, our mean hemoglobin is 10.7. We'd like it to be at 10.5. So it's pretty precise. So you're seeing some noise around us trying to get into that range. So we still got some work to do there, but that's really where we're headed and what we're trying to maintain once we got down to that mean of around 10.5 versus the 10.7 where we sit today.

Thomas M. Jones - Berenberg Bank, Research Division

Okay, good. So it'd be fair to assume that you kind in terms of EPO consumption, you're sort of basically about where you will be going forward now, maybe with some just very minor tweaks around it. Is that a fair interpretation?

Robert Maurice Powell

I think that's fair, Tom. I don't think I would contradict that.

Thomas M. Jones - Berenberg Bank, Research Division

Okay, perfect. And maybe just one quick follow-up if I may. I know it's still kind of doing a probe between you and CMS and Congress in Washington at the moment, but I wondered if you might be able to give some bit more color on integrated care. The investment community was I guess somewhat underwhelmed by the initial proposal when you look to the 15 ESCOs and times that by the 500 patient minimum enrollment per ESCO. With your discussions, is there a sense that the program might actually end up being significantly bigger than that? I know, the language that CMS uses is quite careful to suggest those were minimum numbers. But just your sense at the moment, do you think that's about it? We're going to have 7,500, 8,000 patients or -- could potentially end up with a few more in there from the get-go?

Robert Maurice Powell

Well, here's what I would say, Tom. We would certainly like to see a higher number. No question. And we've certainly made that, put that out in front of the government. I think CMS is going to do what they think is prudent. We're going to respect that We've had lots of dialogue. I realize you guys were somewhat underwhelmed that we spent a lot of time in February talking about the various reactions to what ended up. Let me say this, we're going to continue to work it. We'd like to see bigger numbers. I'm not going to predict that it'll go there. As late as last week, I know we were in talking with CMS. It's a work-in process. So let me leave it at that. But you know where I would like to see it go, but we've got to respect and work within the framework that the government's given us. But the key thing is we should all be worried if there was no dialogue. The good thing is we are meeting and talking, and they're listening, and it's back and forth. But we're going to have to get some clarity and get some closure on some of these things if we're going to be where we need to be by July when the applications are due. So we're still working that pretty hard.

Operator

Next question is from David Adlington, JPMorgan.

David Adlington - JP Morgan Chase & Co, Research Division

Most have been asked. Maybe I'll just follow up a little bit, I think, on Lisa's questions regarding the costs. Rice, you've been quoted on the wire today sort of -- talked about significant cost cuts. I just wondered if you're willing to expand on where you see the opportunities, maybe sort of some ideas about quantifying that, or if you're not willing to, maybe just in terms of timing when you expect those really to start coming through. And then secondly, just a follow-up on integrated care. Have you made any progress on the restrictions that were initially imposed on integrated care versus your first trial? Things like dental and travel and that sort of thing?

Robert Maurice Powell

Yes, David. So on the cost cuts, as I prefer the more elegant term, efficiency improvements, I'm not going to guide you or give you any detail here on the amount. Let me give you a little color maybe this will help for you. We had a meeting earlier in the year. We had our top 200 people in. We looked at the business. We talked about what works really well, what's not working so well, and we all got to a real common understanding that we could be more efficient in what we do. This is a program. It's not a project. Projects start and finish. Programs run, I think, a long time, can run forever. But we certainly have looked at and scoped what we think would be great contributions in terms of dollars saved. But honestly, I don't think it's the best thing for me to lay that out for you here. Just know that we're working on it. We're underway. We've got a team focused on it, but we're looking at a lot of areas. But what we're not going to do is go in and affect quality or patient care. We're not looking to go out where we have a clinic that normally has 20 nurses, make it 10 nurses, we're not going there. We're going to back and look at our procedures and our processes, the way we travel, the way we do all kinds of different things, the way we process bills, you name it, we're not going to go back and look at that to see can we be more efficient and effective in what we're doing. I think that's probably best I can do. And relative to integrated care, we've laid out our concerns. We've had dialogue back and forth, not done yet. I will tell you they're listening to the things like dental benefits and the waivers that we need. They took that information, and I really do think it's going to be fairly important that we hear back from them soon, and I think we will. But we're just right in the middle of the back and forth. So let me just leave it at that, Dave.

Operator

The next question is from Holger Blum, Deutsche Bank.

Holger Blum - Deutsche Bank AG, Research Division

Holger Blum from Deutsche Bank. Just wanted to follow-up on GranuFlo whether you can maybe provide us with some more background, how many maybe law suits by law firms, individuals that you see so far or if that was a one metric. Maybe any other sense to assess your potential magnitude, or alternatively, although what are your ongoing legal cost just for additional lawyers you have on that issue and then how long it might last?

Robert Maurice Powell

Holger, it's Rice. Boy, I'm probably not going to make you happy. Let me try it this way. I don't think it's in my best interest as I've been thinking about this that I would tell you how many lawsuits we have or how many law firms. What I would tell you is we're very organized. We believe that we've got a very good position. We're working on that position scientifically. And we think that all the right story will come out over time. I think this could be lengthy. I don't think the U.S. court system is fast and efficient by any stretch. But I just don't think, for a whole lot of reasons, that I know you understand us giving too much detail on a call like this, is in our best interest. But know that we're working on it. We're taking care of the costs as they come, and we're organized and we're focused. We're going to defend ourselves very vigorously, but let me stop it there.

Holger Blum - Deutsche Bank AG, Research Division

Okay. And then a final one from me. In your guidance for 2013, does that include any potential onetime gains like we have seen last year or was it a pure clean underlying number then for 2013?

Robert Maurice Powell

Go ahead, Mike.

Michael Brosnan

Yes. Holger, it depends on your definition of what one-time it is -- I think, you're referring to the fourth quarter, which I explained pretty carefully last year. We have a number of things that we're looking at in the business. I think between what Rice has said and what I've said today, you can see that we're looking at revenue growth, organic revenue growth. We're looking at our cost efficiencies. We're continuing to press hard on commercial mix, growing the business in terms of pharmacy services and vascular access. So those are the things that we're really focused on to deliver the guidance that we've given you.

Operator

We have a question from Ingeborg Øie, Jefferies.

Ingeborg Øie - Jefferies & Company, Inc., Research Division

A couple of things to clarify. Firstly on the same-store volume growth of 4% in the U.S.. Is this adjusted for the 2 fewer dialysis days or is this the number excluding that? And then secondly, in your comment about slight improvements in payor mix and this also being a driver for improvements going forward, what exactly will drive that improvement? Are there any renegotiations of bundled contracts with the payors or are there any bundling that you expect to be doing? And then just a final clarification was on the Venezuelan bolivar, given that in 2010, when there was greater devaluation, the impact didn't seem to be as big on your international margins. I just wanted to understand what's different this time?

Michael Brosnan

Ingeborg, this is Mike. The same-store volume is adjusted for the dialysis days. So that's a clean year-over-year indicator. In terms of the payor mix, I think we said last year that we had a couple of large contracts that we renegotiated and closed successfully. This year, I don't see that same level of activity in terms of having to close new deals of that magnitude. So this is about connecting with the patient. This is about identifying who the patients are and getting them into our clinics. It's blocking and tackling. It's on the ground across the country in terms of increasing that mix. The bolivar in 2010, I think it was actually about a $15 million effect in the first quarter of 2010. So order of magnitude, it probably had a similar effect. There may be some -- my memory doesn't go back that far, there may have been some other mitigating items in the quarter, but effect was larger in '10 than it was in 2013, if that's helpful. And I think that answers all of your questions.

Operator

We have a follow-on question from Lisa Clive, Sanford Bernstein.

Lisa Bedell Clive - Sanford C. Bernstein & Co., LLC., Research Division

Two questions. You mentioned in terms of getting to your revenue guidance, one of the things you're likely to focus on is ancillary services in the U.S. Could just give us some color on where the opportunities are? One area in particular I'm interested in is American Access Care. That was a business, I guess, you've closed at the end of 2011. I think at the time was around $175 million in annual revenues. You had an existing business, so your vascular access business today or at least back then was, what, probably in the $250 million range? What's the opportunity for that business over the next few years? Is that something you've been actively investing in? Number 2, apologies if you have mentioned this, but I think in one of the questions you just got around the efficiency program, did you answer in terms of timing of when we may see some improvements on the back of this efficiency program? Is this -- is this something that we could see in Q2 or is it the second half of this year? And then, let's see, last question, bundled pricing. Clearly, the introduction of that caused a lot of changes in pharma utilization, EPO utilization, IV Iron. Vitamin D is the other big area here where at least looking at U.S. RDS data for the first 9 months of bundled pricing, it looks like the industry cut down on vitamin D utilization quite a bit, but at your clinics, it seem to be pretty flat. I know we have asked you that more than a few occasions, but how close are you to revisiting vitamin D analogue use? And is that something that could lead to some cost reductions over the course of 2013?

Robert Maurice Powell

Lisa, okay, let me see if I can take this. In the case of the ancillary services, when you look at the vascular business today, Fresenius vascular care, we're looking at very good growth there. Let me try to give you just a couple of buckets. You're a little a high on thinking it was about $250 million a year or so ago. It was probably more in the $180 million to $200 million. We're looking at that as a $250 million to $300 million opportunity for us as we go through this year into the next year. The guys are doing a great job, a lot of good growth there, so we're very bullish on that business. And we think American Access Care acquisition was the right thing for us. When you look at the pharmacy and Mike's talked about that, FMC Rx, there is good potential there. I will tell you that we finished last year with about 20,000 patients in the pharmacy. We're at about 30,000 now. So just within 4 months, that's end of April number, approximated. We're up to about 35% penetration, so we're making progress there. That too has the opportunity to be a couple of hundred, $300 million business. We got to get well north of where we are today, but they're working hard at it. So there's a good opportunity there for those 2 businesses. And as Mike has said, we are investing in those businesses, particularly in the pharmacy. So we're certainly looking for a return. On the efficiency program, I don't think you're going to see anything in Q2, Lisa. The way I'm looking at this is we've gotten started. We're in place. We obviously had some projects that we're going on before, but we're really looking for, hopefully, back half of this year, well into next year, to see the bulk of what this could give us. And again, once you get on a role and you're really starting to pull the efficiency out, we don't intend to stop, we're going to keep going. But we're not at a point, I don't want to mislead you, we're not at a point where you're going to see a big chunk or an opportunity come right here in Q2. Think, latter half of this year going into full of next year. I mean, you and I have talked about vitamin D. We are approaching that. We've got algorithms on bone marrow metabolism that we're working through. I know you think this is slow, so do I, but I respect Frank Maddux and our physicians and the way they're approaching this, but there's got to be more work done there. I think there is some room there, and we're working on it. I think many times, people don't stop and think about the complexity of bone marrow metabolism, not that anemia management isn't complex too, but part of what makes this tough is it's oral. When you think about it, binders are involved and it's a little bit harder to manage it than when you're doing it just within the clinic as you do with EPO and Iron.

Lisa Bedell Clive - Sanford C. Bernstein & Co., LLC., Research Division

One follow-up question on Fresenius Rx. Remind me of the details here. But you had signed a deal with DaVita a few months ago. That was -- was that just on the distribution of drugs? And could you explain what that agreement was, and therefore, what exactly is the business presenting at Rx that you are expanding?

Robert Maurice Powell

Sure. You're exactly right. Your memory is good. So the whole process of signing up patients, managing the patients, managing their prescription is what FMC Rx does. What we contracted with DaVita to do is the fulfillment or the shipping and logistics of physically getting the pharmaceuticals to the patients or to the clinic. That's all that we've done. It could've been Express Scripts or Medco, and we chose DaVita for a whole lot of good reasons. But they're really doing what I call the back end piece of the process and its fulfillment.

Lisa Bedell Clive - Sanford C. Bernstein & Co., LLC., Research Division

Okay, great. And you mentioned that this could be a $300 million business in the future. Could you give us any indication of the size of it today?

Robert Maurice Powell

It's probably somewhere in the neighborhood, I'd say, around $50 million to $70 million, maybe $75 million somewhere in that range.

Operator

We have a follow-on question from Michael Jungling, Morgan Stanley.

Michael K. Jungling - Morgan Stanley, Research Division

A few more questions from me please. Firstly, on the acquired growth side, if I exclude strategic acquisitions like [indiscernible], and I just go North America, as well as rest of the world, what is the reasonable number to go for now in terms of acquired growth/de novos on an annual basis? Is it correct to assume that over the U.S. is 1% growth as a result of this and a U.S. market is more like 1.5%, 2%? Some sort of guidance would be useful. And then secondly, on the International constant currency revenue-per-treatment growth, 3% is sort of the best number that you had for a couple of years. Why is that revenue per treatment number so good? I would've thought that some reimbursement cuts in some regions would have impacted your business. And the last question is very brief one, and not meant to too critical, but we knew that sequestration was a risk in 2012 and also the medical device tax, why is that, that we're sort of starting so late with respect to efficiency programs in 2013 that may have an impact in the second half? Why is it taking so long perhaps to mitigate some of those risks that were quite well known?

Robert Maurice Powell

Mike, you want to take Michael's first question. I'll take sequestration and the cost of our program.

Michael Brosnan

Yes. I think, Michael, on organic growth or on I think your question specifically was acquisition growth. We -- we're going to be seeing many of you at the end of the year in terms of providing some mid-term guidance. But if I go back to how we used to guide you for an acquisition program in $300 million or $400 million range, we said that the add-on growth would be 1% to 2%. So I think that's still a reasonable guide in terms of the bolt-on growth. The de novo growth actually has always been part of the underlying organic growth, so it's really just the -- either the stock or asset acquisitions that add that incremental growth, if that's helpful.

Robert Maurice Powell

Yes. And Michael, on sequestration. I don't think it's inappropriate question. Here's things you got to think about. Yes, we knew that, that was coming in the very latter part of last year. Remember the Taxpayer Relief Act popped on January 2, but the trick in all of this is how do you become more efficient and you do not, in any way, affect the level of patient care that you give or the quality of your products and services. And again, I just want to remind people, we've been looking at being more efficient. We've worked on programs for years. But we've done it regionally, we've done it in manufacturing, but we got to a point when we began to see what I would call kind of the bumpiness with, not only sequestration, but the re-base of the bundle coming, where will that end up and will some of the reimbursement issues, as you pointed out that we see in some other parts of the world. We just decided it was time to put this on a global footing to put it on a very fast track, very visible track, but I -- if I take exception to anything, I don't think we're late. I think we're on time because we're trying to do this in a very thoughtful way so that we maintain levels of care and quality, and we don't do anything that's going to put somebody at jeopardy. So that's -- may not be quite as easy as you would think.

Michael K. Jungling - Morgan Stanley, Research Division

Great. And Michael, the International constant currency revenue-per-treatment growth of 3% in the first quarter, is that a sustainable number for the rest of the year?

Michael Brosnan

Yes, Michael. I was going to come back to that. I would say no. That was really a significant increase we got in Latin America that was an indexing of inflation in that market, so.

Oliver Maier

Jerry, I think we have time for one more question.

Operator

The last question is from Gary Lieberman, Wells Fargo.

Ryan K. Halsted - Wells Fargo Securities, LLC, Research Division

This is Ryan Halsted on for Gary. Just 2 quick ones, I guess. I was wondering if you could provide some color, I guess, on the pharma pricing that you saw in the North America cost-per-treatment statistic? And then, I guess, the second one is, could you give us just an idea of how much revenue you get from Venezuela and just any sense of your commitment to that market given a lot of the volatility you've seen historically?

Michael Brosnan

Yes. Sorry, I didn't catch your name at the start. Ryan, sorry. In terms of detailing out the expanded services, we have not been doing that because our view, since we've been doing pilots with CMS years ago, is that we're moving towards integrated care, so we don't see a lot of value in breaking out the componentry to what we ultimately envision will be the way services are delivered in the U.S.. And with regard to Venezuela, maybe the best thing to do is characterize it in terms of clinics and treatments, because in 2010, we had a devaluation, they do happen from time to time. In most countries, they don't affect us, but where we do have a base of operations, we look at it. So we're continuing to treat patients there. We have no current plans to change our footprint in that market. We've got about 17 clinics, and we've seen treatment growth in that country over the past 3 years of about 6% to 7% a year. But it's about 17 clinics, which gives you a sense as to the scale of the business.

Ryan K. Halsted - Wells Fargo Securities, LLC, Research Division

And actually, one last one, if you don't mind. Normally, you guys include a number of managed clinics in your North America breakout. Do you still -- are you still managing those 30 clinics or there was no disclosure?

Robert Maurice Powell

Yes, Ryan, that may have just been oversight. We still are in the business of managing clinics. I don't know, we're shuffling paper here to see if we're still at a 30-clinic mark or not. We may have to get back to you. We're still at 31 clinics, yes. It's just not in the way we reported the data to you today, but we're still managing 31 clinics.

Oliver Maier

Jerry, I think that was the last question.

Operator

There are no more questions Mr. Maier.

Oliver Maier

Okay, great. Okay, thank you so much, everybody, for joining this call. We much appreciated your -- for your listening, and talk to you soon. Thank you so much. Take care.

Operator

Ladies and gentlemen, this concludes the Fresenius Medical Care Earnings Conference Call. Thank you for participating. You may now disconnect.

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