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DaVita HealthCare Partners (NYSE:DVA)

Q1 2013 Earnings Call

May 07, 2013 5:00 pm ET

Executives

Jim Gustafson - Vice President of Investor Relations

Kent J. Thiry - Co-Chairman of the Board and Chief Executive Officer

James K. Hilger - Interim Chief Financial Officer, Chief Accounting Officer, Vice President and Controller

Robert J. Margolis - Chairman and Chief Executive Officer

Matthew Mazdyasni - Chief Financial & Administrative Officer and Executive Vice President

Kim M. Rivera - Chief Legal Officer and Corporate Secretary

LeAnne M. Zumwalt - Group Vice President

Analysts

Brian Zimmerman - Goldman Sachs Group Inc., Research Division

Darren Lehrich - Deutsche Bank AG, Research Division

Michael A. Newshel - JP Morgan Chase & Co, Research Division

Matthew J. Weight - Feltl and Company, Inc., Research Division

Gary Lieberman - Wells Fargo Securities, LLC, Research Division

Kevin M. Fischbeck - BofA Merrill Lynch, Research Division

Kevin K. Ellich - Piper Jaffray Companies, Research Division

Ben Andrew - William Blair & Company L.L.C., Research Division

Whit Mayo - Robert W. Baird & Co. Incorporated, Research Division

Operator

Good afternoon. My name is Sharon, and I'll be your conference operator today. At this time, I would like to welcome everyone to the DaVita HealthCare Partners Q1 Earnings Call. [Operator Instructions] Mr. Jim Gustafson, you may begin your conference.

Jim Gustafson

Thank you, Sharon, and welcome, everyone, to our First Quarter Conference Call. We appreciate your continued interest in our company. I'm Jim Gustafson, Vice President of Investor Relations. And with me today are Kent Thiry, our CEO; Bob Margolis, the CEO of HealthCare Partners; Matthew Mazdyasni, HealthCare Partners' Executive Vice President and CFO; Jim Hilger, our Interim 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 annual report on Form 10-K. Our forward-looking statements are based on information currently available to us, and we do not intend and undertake no duty to update these statements for any reason.

Additionally, we'd like to remind you that during this call, we will discuss some non-GAAP financial measures. A reconciliation of these non-GAAP measures to the 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

Thanks, Jim, and welcome, everyone, to a relatively sober quarterly call. I'll first cover kidney care then HCP, and I [ph] discuss their near-term and longer-term outlook.

First, with respect to kidney care from a business performance point of view, another solid quarter, both clinically and operationally [indiscernible] loss contingency reserve, which of course, I'll discuss in a bit. We are first and foremost a caregiving company, serving approximately 153,000 kidney care patients [ph] [indiscernible].

[Technical Difficulty]

Operator

Ladies and gentlemen, I apologize, but there will be a slight delay in today's conference. Please hold and the conference will resume momentarily. Thank you for your patience.

[Technical Difficulty]

Jim Gustafson

This is Jim Gustafson again. My understanding is that you have -- were able to hear the disclosures statement I was making at the beginning. And so with that understanding, I would like to turn the call over to Kent Thiry, our Chief Executive Officer.

Kent J. Thiry

Okay. Thanks, Jim, and I'm going to assume that nobody heard anything I said clearly. So I will start from the top.

First, this is relatively a sober quarterly call, somewhat symbolic that we had telephone problems. From a business point of view, kidney care performed fine in the quarter, both clinically and operationally. I will discuss the loss contingency reserve a little bit later, as well as normal covering clinical outcomes and a public policy update before I talk about HealthCare Partners and then ultimately our outlook. We will continue to present our clinical outcomes first because that is what comes first. We now serve approximately 1 out of every 3 dialysis patients in America, as well as about 800,000 population health members to HealthCare Partners.

On the kidney care side, first, with respect to adequacy, which is essentially how well we're doing at removing toxins from our patients' blood. This quarter, 98% of our hemodialysis patients had a Kt/V greater than 1.2. Second, with respect to vascular access, 71% of our patients have fistulas, which is the preferred form of vascular access. For these and virtually all other clinical measures, including nutritional status, vaccinations, et cetera, our patient outcomes compare very favorably with national averages. This quality care not only results in healthier people but also drives reductions in hospitalizations and surgical procedures, and therefore, drives significant savings to the U.S. health care system.

Now, on to the issue of the reserve. This is regarding the 2 physician relationship investigations that we've previously disclosed, now for about 3 years in total. We took a reserve, as you have noted, for $300 million. That is a part of a comprehensive offer to settle all the related civil, administrative and criminal matters. To be clear, we may not reach a final settlement. This is an estimate. An important reminder, this investigation is solely about physician relationships. It primarily relates to our physician joint ventures that, as you know, are subject to complex regulations under both anti-kickback and other laws. There have been no allegations concerning: One, the quality of care we provide; number two, the cost to the government; or number three, the utilization of medical services.

Nonetheless, the government attorneys have taken the position that some or all of our joint ventures do not comply with the anti-kickback statute. We disagree, but we are talking with the government about its concerns and perspectives. We believe our joint venture practices were consistent, not only with regulations and the law, but with the kidney care community and with health care services overall. We look forward to working with the government to establish greater clarity and a level-playing field for JVs in the industry.

We understand that you may have many questions on this topic. Please, we ask you to understand that we can't answer most of them until such time that the process is concluded in a settlement, hopefully.

In addition, as of April 2013, our HealthCare Partners subsidiary was served with a civil complaint regarding Medicare patient coding practices. The suit names HCP, along with a number of defendants, including several of the nation's larger health insurance companies. We also did have some good news on the legal front in the quarter. As the Turner-Hooks matter, one of the previous Qui tam matters that we have previously disclosed, was dismissed with prejudice, which means that the matter is done with, with no discovery, no trial, no settlement, no fine, no finding against DaVita at all.

On to public policy on the kidney care side. With respect to the ESRD Seamless Care Organizations or ESCOs, as most of you know, CMMI did delay implementation a couple of months. We now have a deadline of May 15 for indicating our interest, and binding proposals would be due by July 1. CMMI has continued to be a constructive partner, listening to the community, so we are hopeful that there will be some changes to the program design. And our participation, as you know, is contingent on seeing some changes in the design so that it is set up to be successful, because we do believe that if we're allowed to provide integrated care on a sustained basis to that population, we can do dramatically wonderful things for the patients, their families, physicians, caregivers and the taxpayer.

On that front, I'll actually share one new and bright success story in the area of kidney care services. A recent study published by the American Journal of Kidney Disease, a peer-reviewed article, found that patients who used DaVita Rx, our integrated medication management services, are 21% more likely to live longer and 14% -- have spent 14% fewer days in the hospital each year than patients who do not use that service. And we now have over 50,000 patients on that service, something that we invested in for several years before we could get it to breakeven and the wonderful clinical and economic results that we're now experiencing.

On the HealthCare Partners front. And very good news on that performance. And HCP's 3 legacy markets continues to be solid and in line with our expectations. On the growth front, we closed some tuck-in acquisitions in the first quarter. On the reimbursement front, the bad news is that the Medicare Advantage cuts that we feared would take place and talked about at the time that we announced the combination have actually taken place. It was on April 1 that CMS announced its final 2014 reimbursement decisions. While those rates were better than the preliminary ones announced in February, they still represent a significant decline for HCP, in particular due to the recalibration of patient risk coding when you compare '14 to '13. We estimate that, that final notice will represent a rate reduction of about 6% to 9%, somewhere in that range, on average, across our Medicare Advantage patient population. About 10% of that will be offset through contractual pass-throughs to the provider network. We, in addition, expect to offset some of the remaining rate cut impact but will not be able to give you very specific guidance with respect to that.

Up to half of the remaining hit could be offset through benefit design changes that our health plan partners can and may make, because CMS will allow up to a $34 increase in per member per month total beneficiary cost. And since our 3 legacy HCP markets are currently no-premium markets, that means more or less the average payer could use that full $34 a month and still [indiscernible] 75% of the current gap in benefits. In other words, the extra benefits that an MA beneficiary receives versus a normal fee-for-service beneficiary that you could use the full $34 allowance and still retain, on average, about 75% of the current superiority.

So given the size of that benefit gap, we do expect many plans will reduce their benefits or increase beneficiary cost, but we could be wrong. It is their decision, not ours, in virtually every case.

In addition to plan design, we will, of course, work on incremental cost and efficiency initiatives to try to offset even more of this dramatic rate reduction. And, of course, as we move forward, we will give you updates as we have them.

As to our overall outlook regarding the balance of 2014 (sic) [2013], we are increasing the lower end of our range. Our 2013 operating income guidance, excluding the impact of the loss contingency reserve, is now $1.8 billion to $1.9 billion. This includes dialysis and its related businesses' operating income in the range of $1.4 billion to $1.45 billion, and then HealthCare Partners OI in the range of $400 million to $450 million. As always, we could end up above or below this guidance, but it does capture a majority of the probabilistic outcomes and incorporates all known swing factors. I will now turn the call over to Jim Hilger.

James K. Hilger

Thanks, Kent. First, a few more dialysis operating metrics. Our non-acquired growth was 4.4% when normalized for days of the week, and our commercial mix improved slightly in the quarter. One of the reasons for a continued strong non-acquired growth is that we have closed very few centers over the last couple of years, choosing to continue to operate a large number of centers that are losing money. However, this could change with sequestration and rebasing, and a poor rebasing result could lead us to close more centers, which would adversely impact our growth.

Next, our U.S. dialysis revenue per treatment increased $10.28 from the prior quarter. This was driven primarily by increased Medicare rates, normal commercial rate increases and a slight improvement in our commercial mix. As you model revenue for the rest of the year, you should take into account the impact of sequestration, which resulted in a 2% cut in our Medicare rates, which is about $20 million per quarter reduction in our dialysis Medicare revenue.

U.S. dialysis patient care cost per treatment rose $3.52 from the prior quarter, driven primarily by seasonally higher payroll taxes and seasonally higher fixed cost per treatment due to fewer treatment days in the quarter. Dialysis G&A per treatment was up $1.29 per treatment, primarily driven by compensation expense, including seasonal fluctuations related to fewer treatment days in the quarter and higher payroll tax.

During the quarter, we experienced $7 million in international losses, reflecting improved international performance, with the addition of our operations in Poland and Portugal. Please note, we still continue to expect operating losses in 2013 to be less than $30 million, absent securing any large new contracts that would have associated startup costs.

And now, a comment about HCP's operating performance. HCP's performance was solid in the quarter with operating income of $110 million. Total capitated HCP members (sic) [HCP member months] grew 5.8% sequentially, of which 2.1% was acquisition-related. Year-on-year, member months grew 20.3%, of which 16.2% was acquisition-related. And note that this compares incorporates dates prior to the completion of our merger, which occurred on November 1, 2012.

For the overall enterprise, our debt expense was $106 million in the first quarter. Given the current debt levels, our expectation is that debt expense will be around $430 million for the year, which includes the impact of the interest rate hedges we put in place late in the first quarter.

The effective tax rate attributable to DaVita HealthCare Partners, excluding the loss contingency reserve, was 40.7% in the quarter. And we continue to expect an effective tax rate of 40% to 41% for 2013, excluding the impact of a loss contingency reserve.

Now turning to cash flow. Operating cash flow was $379 million in the first quarter. And our 2013 operating cash flow guidance remains at $1.35 billion to $1.5 billion. This guidance excludes the impact of any legal settlement we may reach. And with that, operator, let's go ahead and open it up for Q&A.

Question-and-Answer Session

Operator

[Operator Instructions] Your first question comes from the line of Matthew Borsch from Goldman Sachs.

Brian Zimmerman - Goldman Sachs Group Inc., Research Division

This is Brian Zimmerman in for Matt. With the rebasing in mind, can you talk a little bit about what levers you could pull to mitigate some of the potential cuts on the cost side?

Kent J. Thiry

Sure. This is Kent. We have always tried, as everyone does, to run themselves pretty efficiently. So while we will be taking a second and look -- second and third look at everything on both sides of the house, right now, we can't offer up any material number with the degree of confidence that would warrant publicly mentioning it. So we're going to do the best we can, but right now we can't attach a number to that for you.

Brian Zimmerman - Goldman Sachs Group Inc., Research Division

Okay. And then regarding the CMMI pilot program, you said that you've had some positive discussions. I was hoping you could give us a bit more color on that? And then when would you expect to see any changes to the program, because May 15 is coming up pretty quickly?

Kent J. Thiry

Yes, you are right. Although, in many respects, it's the later date that's more relevant because that's the binding proposal. And I should correct the mistake I made earlier. Evidently, I said 2014 when I was talking about outlook and guidance going forward and I should have said 2013, so I apologize for that. With respect to CMMI, the positive interaction is a commentary, unfortunately, just on the quality of the process and the fact that they're listening, it is not that they have told us that they're going to change anything specifically or generally, so we have high hopes and we're just glad that they listen to us and we've got a quality dialogue. But they haven't given us any indication that they actually will make material changes.

Brian Zimmerman - Goldman Sachs Group Inc., Research Division

Okay. And then my last question is, you mentioned that you saw a bit of a pickup in payor mix this quarter. What percentage of your dialysis volumes were from commercial payers?

James K. Hilger

It's approximately 10% of our patients are commercial.

Brian Zimmerman - Goldman Sachs Group Inc., Research Division

Okay. And it was 10% last quarter, too, is that correct?

James K. Hilger

Yes, it was. It just -- it improved just slightly from that.

Operator

Your next question comes from the line of Darren Lehrich from Deutsche Bank.

Darren Lehrich - Deutsche Bank AG, Research Division

So I just wanted to ask some questions here about MA in your comments, obviously, about 2014. You talked a little bit about some of the contractual pass-throughs that you expect and quantified that. I guess on the other 2 pieces, you said you're working on other offsets and so I'd be curious just to get your thoughts and maybe you can share with us, Bob or Matt, how you might be able to accomplish that? And then as far as the benefit design changes by the plans, at this stage of the game, what kind of visibility do you have into the half of the offset that Tim mentioned from what the plans are going to be doing?

Robert J. Margolis

Bob Margolis here. I'll try to answer it pretty similar to actually Kent's answer about the rebasing, and that is, we always to try to run a very efficient operation. There'll be opportunities, we think, to be more efficient in some areas and to really look hard at our cost structure going forward. You did mention that there's a pass-through of about 10% of it. And as to the benefit question, as you've heard in other analysts' analyses, it's a fairly significant $34 per member per month that CMS has allowed to be shared with the beneficiaries. And there's still an enormous gap of better benefits in Medicare Advantage versus Medicare fee for service. Whether or not the plans will choose to pass some or all of that $34 on to beneficiaries is out of our control. They do inquire and discuss with us benefit in many of our markets. But ultimately, they make the determination, not us. I think it's relevant to point out that we are in relatively rich benefit markets, none of which have Medicare Advantage premiums. And so there is a fair amount of room and some expectation on our part that there will be movement in that direction. But again, it's something the plans will make -- independently make that decision in their initial filings in May.

Darren Lehrich - Deutsche Bank AG, Research Division

Sure. And then, Bob, maybe just a bigger-picture question for you. You've seen lots of MA cycles over time. We'd love to just get your view on enrollment and how you think enrollment in your 3 core markets might be disrupted by some of this?

Robert J. Margolis

Again, it's not possible to be very precise on that. We believe that the MA program is still strong, as we've seen over the last couple of years, despite some projections of some of the people in the administration that the program would shrink. It's actually grown pretty robustly. We've seen a good new membership this past year as was reflected in the numbers that Kent offered up. And it really is still a strong program, so we're hopeful to see. But, of course, if you move more of the cost to the beneficiaries, it's less of an incentive than it had -- they had before to join the program. So we don't expect it to be dramatically bad. But we don't have any way to project accurately what it will be.

Darren Lehrich - Deutsche Bank AG, Research Division

Okay, that's great. And just one last question. Just as it relates to the joint venture model, Kent, you -- we've all thought about it as sort of a time-tested model, given that JVs have been around for so long. Can you just maybe confirm for us whether part of your settlement offer is to stop doing JVs in the future? And maybe just help us think about the status of the JVs that you currently have overall, whether the structure would need to change?

Kent J. Thiry

None of the specifics have been worked out at this point, Darren. And for us, the strategic imperative is a level-playing field.

Darren Lehrich - Deutsche Bank AG, Research Division

Okay. So we should assume then that JVs will still continue to be part of your operating model?

Kent J. Thiry

At this point, I'm afraid I just can't give you a definite prediction in either direction. The government has agreed that non-Safe Harbor joint ventures can be legal, and we're still discussing exactly what structures qualify and which ones they think do not. We, of course, have been under the impression for a decade that the way we've been doing them is fine. And so we're having to do a lot of sorting through with them. And right now, there has been no resolution.

James K. Hilger

This is Jim Hilger. I just wanted to correct a statement I made earlier. When I was discussing HCP's operating performance and describing the growth of total capitated HCP member months, I believe I just said total capitated HCP members, and I intended to say member months.

Operator

Your next question comes from line of Justin Lake from JPMorgan.

Michael A. Newshel - JP Morgan Chase & Co, Research Division

Mike Newshel in for Justin. Another question on the settlement. Can you just clarify whether you're negotiating with the Colorado AG and the federal attorneys separately or are they negotiating together with you?

Kent J. Thiry

It's one set of multipart negotiations.

Michael A. Newshel - JP Morgan Chase & Co, Research Division

And since you sort of put a dollar estimate on there, I mean is the major point of the sessions going forward more in terms of oversight or the structure of JVs, how -- what they think is acceptable? Or is still like the dollar amount still a big part of the discussions?

Kent J. Thiry

Dollars are still under discussion as well.

Operator

Your next question comes from the line of Matt Weight from Feltl and Co.

Matthew J. Weight - Feltl and Company, Inc., Research Division

Jim, I think you were talking about the non-acquired growth of dialysis. How many centers are actually operating at a loss?

James K. Hilger

Well, it varies from time to time. But it is a minority of our centers, clearly. But more than a handful.

Matthew J. Weight - Feltl and Company, Inc., Research Division

Okay. And then, okay, fair enough...

Kent J. Thiry

Could you repeat the question, please? I didn't catch it.

Matthew J. Weight - Feltl and Company, Inc., Research Division

Yes, I was -- Jim, I believe, unless I misunderstood it, had referenced that some of your centers are operating at a loss. And I was interested how many actually are.

Kent J. Thiry

Yes, the number varies somewhat. But it's -- it varies between 140 and 200, somewhere in that range.

Matthew J. Weight - Feltl and Company, Inc., Research Division

Okay. And how many members did HCP gain during the annual enrollment period this year on the MA side?

James K. Hilger

We don't break out the membership for HCP on a quarterly basis.

Matthew J. Weight - Feltl and Company, Inc., Research Division

Okay, all right. And then just kind of a more big picture here on HCP. When you guys bring on new members, I'm assuming they come on at lower margins than what you currently -- more mature members have -- are, is that correct?

Kent J. Thiry

Yes, that's correct. We expect that over time, best practices and so on of all the years of our experience will diffuse to the new membership that we bring on.

Matthew J. Weight - Feltl and Company, Inc., Research Division

Okay. And in regards to that, and I'm sure it's a combination of both, I'm wondering if you could kind of maybe tell me or directionally point to us which one is more important in terms of maturing those margins. Is it understanding kind of the disease profile and diagnosis which then can be correctly used to code that patient properly? Or is it more towards the implementation of kind of the care coordination and clinical initiatives that you have?

Kent J. Thiry

As been stated before, it's a complex set of integrated care expertise that we and others like us that involves improving the coding and diagnosis and documentation as you mentioned. The utilization by focusing on health, wellness and prevention and avoidable admissions and readmissions, excellent post-acute care management and training doctors, care managers, disease managers, social workers and the like into total integrated care, so it's a complex of all of those aspects that has to occur over time.

Matthew J. Weight - Feltl and Company, Inc., Research Division

How much do you feel that risk coding and properly risk coding contributes historically kind of to your PMPM growth?

Kent J. Thiry

You can't really break it out and -- because you're always coding the entire population that you have, the ones who have been with you for a long time, as well as the new ones. And so perhaps, ask the question again and see if we can be more helpful.

Matthew J. Weight - Feltl and Company, Inc., Research Division

I was just -- because you probably -- I'm assuming you get the 2 risk code adjustments per year from CMS. And so I'm curious what that does as an impact of kind of the overall growth in the revenue PMPM side? How much does that contribute?

Kent J. Thiry

Well, the adjustments have been positive and nontrivial. But I don't think -- they move around enough that giving you a single number I don't think would be that helpful. And, of course, they all are absorbed on a delayed basis into the aggregate business economics. And so on a year-over-year basis, these things tend to even out absent the big step function decisions, like the ones the government just made. So I don't think there is any helpful analysis in there for you beyond what we've said. Matthew, would you amend that?

Matthew Mazdyasni

No, I think what -- the other thing about coding, which is important, there's always a year delay because you have to code this, as you know, this year and you get paid next year. So as Bob Margolis said, we try to focus on more diagnosing the patient so we can have the appropriate treatment plan for those patients and disease management program. That's more important to us at the beginning than trying to maximize the coding.

Matthew J. Weight - Feltl and Company, Inc., Research Division

Okay. And last question, then I'll jump off. Last time you faced significant MA rate pressure is probably, I'm assuming, 2010. Now there's this accumulation effect, I understand that. But is there anything you can look back in terms of what you learned that may help you manage the pressures that you're facing in 2014?

Kent J. Thiry

We all learn from history. You're probably not old enough to remember the balanced budget amendment. We learned from that. We did learn that MA cycles, we believe that it's an excellent program that provides tremendous care to sick and fragile seniors and that it has a benefit structure significantly better than Medicare fee-for-service. And that there will be fluctuations in membership growth and in margins as the government adjusts from time to time.

Operator

Your next question comes from the line of Gary Lieberman from Wells Fargo Securities.

Gary Lieberman - Wells Fargo Securities, LLC, Research Division

Question, just going back to some of the prepared comments in terms of the ability to mitigate part of the 6% to 9% rate reduction. I just want to make sure I heard the components correctly. So I think you said 10% of -- should be offset through contract pass-throughs and then I guess 50% could be offset through potential benefit designs. Were there any other pieces that you've discussed or mentioned there that could help offset the rate reduction?

Kent J. Thiry

Those are the 2 sources of offset that are directly related to the issue itself, of the decision the government made. Anything else would have to be operating improvements of the normal business variety, either finding additional efficiencies, driving additional acquisitions, driving additional same-store growth, things like that. So everything else is normal business and trying to do more of it than usual.

Gary Lieberman - Wells Fargo Securities, LLC, Research Division

And have you had a chance to look and see how doable it would be to achieve other efficiencies to offset part of the rest of it?

Robert J. Margolis

Yes, we'd be very disappointed if the number was 0. But at the same time, no way right now to give you any assurance that the additional number is certain enough or large enough to mention.

Gary Lieberman - Wells Fargo Securities, LLC, Research Division

Okay. And then on -- I guess, on the JVs and the discussions, I appreciate that you probably can't share too much with us. But is there any other detail, is there a sort of a specific piece of it that seems to be at issue in terms of what -- where they think the JVs might have violated the Safe Harbor?

Robert J. Margolis

It's a very reasonable question, and I'm afraid we can't just go there. The -- to go into more detail on the live conversations would just not be a good idea. It wouldn't be constructive. And since the conversations are still going on and we don't know where they're going to end up, we might very well tell you something that's wrong, which would be really dysfunctional.

Gary Lieberman - Wells Fargo Securities, LLC, Research Division

Okay. And what's the timing or your best guess for the timing of when if it sort of continues down the path that it's going, when it might be resolved?

Robert J. Margolis

It's a guess only because we're not the primary determinant of the pace. And these are complicated areas, and we're dealing with multiple parties. So very, very difficult to venture forth for the guess. But in the spirit of trying to be useful, if we get to a point of a successful conclusion before it's entirely paper and consummated, my guess is it would be a few months. But again, the operative word is, that's a guess, there's a lot of variables.

Gary Lieberman - Wells Fargo Securities, LLC, Research Division

Okay. And then going to the rebasing, have you had any incremental conversations or any conversations at all with CMS around the rebasing and the framework for the rebasing and how they're thinking about it and your input into that?

Robert J. Margolis

Do the question again so I don't ramble, please?

Gary Lieberman - Wells Fargo Securities, LLC, Research Division

So I guess the question is in terms of discussing the rebasing with CMS, have you had any discussions with CMS around the rebasing? And where, I guess, do you think their head is at with regards to some of the comments you made, maybe last quarter about your thoughts on what the rebasing should be based on, changes in utilization and changes on price, et cetera?

Robert J. Margolis

Yes. Okay, a very fair question. The -- we have had high-quality conversations and we have made the analytical point that the drop in utilization has been totally offset by increases in price of the subject drugs themselves. In other words, the same ones that got used less had higher and higher prices, which offset a majority of the decline. And then the other revenue leakage that was not intended to be a part of putting in a bundle, but in fact happened because of the case-mix adjusters and other variables, means that in aggregate, our economics have not changed on the Medicare side, which means we still lose money on average on every Medicare treatment we do across America. And so we've gone in and made that point, and we would love to have the government take us up on our offer to come in and do additional audits. So they see that the data from the industry is absolutely spot on and timely because so many of their data sources lag in terms of timing. And so the good news is they've had the meetings with us. They've listened. They've asked good questions. On the other hand, they're staring at the legislation, which targets very selectively and unfairly the one part of the cost structure that did in fact go down. They, however, retain the right and, in fact, the legal responsibility to take into account the entire picture with respect to ESRD economics. So put all that together and you end up not knowing where they will come out, but we have had an opportunity to make a whole lot of accurate, analytical, real-world community-wide points.

Gary Lieberman - Wells Fargo Securities, LLC, Research Division

Okay. And so I guess the timing is still around the beginning of July for the proposed rule?

Robert J. Margolis

That's my understanding of the current predictions. And I don't know if there'd be any reason to think that it would slip, given the magnitude of the work. But that's what people are saying right now.

Gary Lieberman - Wells Fargo Securities, LLC, Research Division

Okay. And then maybe my last question on the 8-K regarding the agreement with Berkshire. I haven't had a chance, I sort of skimmed through it. But it seems that they are agreeing not to purchase more than 25% of DaVita shares. Was -- is there something that you're giving them in return for that or is that just sort of something they were willing to enter into?

Robert J. Margolis

They were willing to enter into that. Kim, would you like to add anything?

Kim M. Rivera

I'd say we agreed to coordinate the HSR filing with them.

Robert J. Margolis

Could you hear that?

Gary Lieberman - Wells Fargo Securities, LLC, Research Division

I think so. Agreed to file an HSR filing?

Kim M. Rivera

We agreed to coordinate the HSR filing with them, yes.

Operator

Your next question comes from the line of Kevin Fischbeck from BofA Merrill Lynch.

Kevin M. Fischbeck - BofA Merrill Lynch, Research Division

Just a question here on the 6% to 9% MA cut that you announced before. Is that inclusive of the industry fee or would the industry fee be an addition to that? And how do you deal with that in relationship to the managed care companies? Do you [indiscernible] that, that's something they need to pay or is that something that they're going to try to pass on to you?

Kent J. Thiry

That's a fair question, and we -- that's why we gave a range because we're still discussing that with our health plans.

Kevin M. Fischbeck - BofA Merrill Lynch, Research Division

Okay. So that's in the range, but the higher end of the range included it in the lower end of the range or not?

Robert J. Margolis

That's correct.

Kevin M. Fischbeck - BofA Merrill Lynch, Research Division

Okay. And then, Kent, your commentary about the $34 cut and the 75% of the delta received [ph] [indiscernible], is that just a long way of saying that you provide about $130 to $140 of extra benefits today? So unless [ph] you cut $34, you'd still be providing about $100 of extra benefits, is that the way to think about it?

Kent J. Thiry

That's the right way to think about it and, of course, every plan in every market is a little bit different. But if you took a bit of a weighted average, that puts you in the right ballpark in the legacy markets that we're in.

Kevin M. Fischbeck - BofA Merrill Lynch, Research Division

Okay. And then you also said in the prepared comments that the rate cuts that you expect at the time of the deal unfortunately have come to pass. Does that mean that when you look at these rates, you think that this is basically in line with kind of how you thought things would be trending for HCP or is this more front-end loaded? Is this worse? I mean how do you think about these rate cuts in context of how you thought about this as you entered the whole transaction?

Kent J. Thiry

Got it. I'll take 2 cuts at answering, and perhaps other people's answer on our team would be different. On the one hand, it's them doing what they did and when they did it is worse than we thought it would be. Second, on the other hand, HealthCare Partners' operating performance has exceeded what we thought it would be. And so if you look at what we said when we announced the marriage, we are still in a good position to be where we said we would probably be in 2014. We can't guarantee it, so it kind of depends how you look at it. My first answer was sort of no, this is worse than we thought. And second answer is, well, if you look at it in a broader sense, we're about where we thought. Or we still have a shot at being where we thought, maybe that's a more accurate way to put it.

Kevin M. Fischbeck - BofA Merrill Lynch, Research Division

That's certainly more similar to the way that we normally hear things from you anyway, if not, it's more accurate. I guess how does it change your view, if at all, about consolidating the HCP side of the industry? I mean, do you still feel like the opportunity is as robust as it was or do these rate cuts make it more difficult on the margin to make some of these acquisitions that you're evaluating work out?

Kent J. Thiry

Two-part answer. Again, on the one hand, when you take a reimbursement hit and your margins suffer, it's tougher to invest. There's less of a margin for error, and maybe some people even lose some interest that you thought were attractive partners, although we're not seeing any of that since most of the world seems to think that the fundamental trends are inexorable. So that's the bad part where you say, gosh, that hurts us and our probabilities and prospects for what we intended to do and still intend to do. On the other hand, if you're better at something than most people and are more committed, then when you take a rate cut like this, some people are going to check out or fail because there's no longer enough margin to support their learning curve or their efforts. And so we've certainly seen that over 15 years in dialysis that during the better reimbursement periods, of course, when I say better, I mean primarily on the private insurance side which subsidizes Medicare. The good news is you have higher margins. The bad news is you have more competition and you pay more for things. When reimbursement is tougher, you suffer on the margin front. But if you're disciplined over the long term, your return on capital may in fact be superior, as well as your rate of unit growth. So I think time will tell which of those 2 vectors is stronger.

Kevin M. Fischbeck - BofA Merrill Lynch, Research Division

So I guess when I think about that type of dynamic around consolidating an industry during a period of disruption, there's 2 ways I could envision HCP benefiting. One would be if the managed care companies that you're aligned with are gaining share within their respective markets, then you would get some natural follow-through from that. And the other way would be is if other providers are -- other physician groups are actually exiting the market, so you then gain it from the other side of things. I mean, is there one dynamic that you think is more impactful than the other? And then I guess, how do you think about the managed care companies that you're aligned with? Are they generally the larger companies with higher margins and therefore more likely to be consolidating or are they more representative of the industry as a whole? How do you think about that?

Kent J. Thiry

I'll answer the first one and let Bob answer the second. On the first one, the variable of having the payers that you're partnered with gaining share and derivatively enjoying that benefit versus, on the other hand, the driver of the providers against whom you're competing, losing share to you and others, which of those is more powerful, that differs by market by year. And either one can be significantly more powerful than the other in any given period. And we, of course, try to benefit from both as best we can. Although in some of our markets, we work with so many payers, if one's losing share to another, for us the net effect can be 0 because we're on both sides on a Switzerland type of basis. On the second question as to the types of payers we deal with primarily, I'll turn to Bob.

Robert J. Margolis

I'll try to answer in a couple of different ways. First of all, I think we're recognized that the HCP division is having some expertise in some of our payer partners, would like to see us in more of their difficult markets, work with them to coordinate care and to work with the physicians, so that's still a driver. I would say for sure that rate cuts are not pleasant anywhere, but there's a lot of horses driving physician consolidation that are unrelated specifically to these rate cuts. First of all, lot of physician groups have a serious amount of commercial business, so it's not just MA running the whole scenario. And number two, even in the MA program, the need to align with credible partners that can help star rating, which is certainly one of the offsets to these kinds of cuts, is something that's driving it. The need for capital for technology continues to drive it. The advent of pay-for-performance and more and more transparent metrics drives this consolidation, and the frustration that physicians have in a decreasing reimbursement fee-for-service world. So I think that taking MA cuts just in isolation is not as fulsome a way to look at this as perhaps we look at it.

Kevin M. Fischbeck - BofA Merrill Lynch, Research Division

Okay, that's helpful. And then as far as the -- do you guys break out acquisition spending? Do you have a breakout of the acquisition spending by division? How much of that $91 million was spent on dialysis versus HCP?

James K. Hilger

No, we do not break that out.

Kevin M. Fischbeck - BofA Merrill Lynch, Research Division

Okay. And then just looking at these -- the data here around clinicians and IPAs. Obviously, the IPAs are up a lot sequentially, but the full-time clinicians are down sequentially, even though it sounds like you bought some things in Q1. Just wanted to see -- I don't know -- this is the first time we're seeing the data. I don't know if there's any seasonality to that number around year end or what, but I just wanted to see any comments there.

Kent J. Thiry

No, we haven't had any changes on the clinician. As far as employed clinician, our contracted clinician is up. Are we having a disconnect here? Could you say the question again, please, just so we're as helpful as we can be?

Kevin M. Fischbeck - BofA Merrill Lynch, Research Division

Yes, so in the HCP operating metrics, it looks like the number of clinicians are down sequentially from 1,079 to 1,069. The IPAs are up a whole bunch, but it was just down about 1% sequentially. And I wasn't sure why that would be the case if you bought a few things in the quarter, it sounds like?

Robert J. Margolis

From time to time again, for example, if you have a certain specialty that we end up subcontracting, so they're hired by outside specialty group, so that 10 FTE that you see is just a normal business that we go through from quarter-to-quarter.

Kevin M. Fischbeck - BofA Merrill Lynch, Research Division

Okay. And then the last question here, on ESCO, it sounds like CMS actually already has made a couple of changes from the original proposal, reducing the minimum size for each demonstration down from 500 to 350. Also reducing, I think, the minimum savings rate down to 4% to -- from 4.75% (sic) [from 4% to 4.75%] for these non-Large Dialysis Organizations. I -- do you have any comment on the -- do those things really help you at all or those are really meant to help the smaller players participate in this?

Kent J. Thiry

Yes, good point, and you're right that my statement during the early part of the call was technically untrue. LeAnne, do you want to go ahead and comment on those?

LeAnne M. Zumwalt

Yes. Those would be the first signs that there was mean to the community, and we've been working together. But those are both targeted at helping the non-LDO segment.

Operator

Your next question comes from the line of Kevin Ellich from Piper Jaffray.

Kevin K. Ellich - Piper Jaffray Companies, Research Division

A couple of quick follow-up questions. I guess first on HealthCare Partners, will you tell us how many acquisitions you guys did this quarter? And also given, I think there's about 258 ACOs in the country now at -- as of February, are you seeing any increased competition when you guys aren't looking at expansion opportunities?

Kent J. Thiry

Oh, we don't disclose the number of acquisitions typically. And in this particular case, it's such a small number, it's not of any particular consequence. If we ever have some sort of a spurt where there is data you need to understand to avoid misinterpreting our longer-term trends, we would certainly go ahead and do that. But otherwise, we don't since they differ in size and timing. And then your second question, again sir, please? Matthew has got it.

Matthew Mazdyasni

So I think you were referring to ACOs. And we look at the ACOs, Pioneer ACOs, Medicare ACOs and commercial ACOs, what we have seen in commercial ACOs is there are some relationship that the health plan create that's not necessarily ACO but they call it ACO. We don't see that as a competition with us. It is our regular fee-for-service patients that they're more and more on a commercial, the health plan want to move it to a coordinated population management model. On the Pioneer ACO and shared savings ACOs, again, these are your attributed Medicare patients. So we -- that doesn't create any more competition that every day we have for our fee-for-service patients. So we don't look at that. That is a competition for us because it's all about attributed members that our physicians have. Did that cover -- did that answer your question?

Kevin K. Ellich - Piper Jaffray Companies, Research Division

Yes, that definitely clears things up. Then just kind of what's your outlook in terms of expansion opportunities? And Kent, can you remind us in your guidance for HCP's operating income, does that include acquisitions?

Kent J. Thiry

Yes, it does, is the answer to the latter question.

Kevin K. Ellich - Piper Jaffray Companies, Research Division

Okay. The other part was outlook on acquisitions.

James K. Hilger

The robust pipeline.

Kent J. Thiry

The -- we have an awful lot of people calling us and interested. Having said that, exactly when we'll close any deals that will add up to something material, is not an area where we want to put any kind of stake in the ground. So the good news is lots of interest. The bad news is we're not yet certain enough about which ones we're going to be able to and interested in closing and when that will happen and what the economics will be, so we're -- we'd be very nervous about you baking anything significant into your near-term forecast.

Kevin K. Ellich - Piper Jaffray Companies, Research Division

Okay. Did I hear someone say pipeline is still robust pretty much?

Kent J. Thiry

There was one person on the table who contributed that, yes.

Kevin K. Ellich - Piper Jaffray Companies, Research Division

Okay, okay. And then just a question for Hammer. The G&A, it looked like it was a little bit lower this quarter. Was there anything unusual or is 10.3% of revenue kind of a good run rate that we should be looking at?

James K. Hilger

The G&A expense for the quarter is on a combined basis, the 10.3%. I'd just point out that there would be transaction costs in prior quarters that would be impacting that rate. So I think it is -- and also we only had 2 months in Q4 of HCP. But the 10.3% is going to be a good proxy. For now, it may fluctuate plus or minus, but that's a better proxy than the Q4 number.

Operator

Your next question comes from the line of Ben Andrew from William Blair.

Ben Andrew - William Blair & Company L.L.C., Research Division

Quick questions, if I may. You talked about the number of -- you didn't give us a specific number, but the communities in which you -- closing your center or you're running at centers at poor profitability. Can you give us some sense, in your view, what chunk of your centers that are in that kind of condition, if they were to close, would cause a serious problem for patient access?

Kent J. Thiry

I don't know the exact number. And, of course [ph], the answer cannot be precise because the definition of what is -- whatever adjective you use is highly subjective, and we take any sort of disruption to patient access to care pretty seriously and that can be driving distance. It can be the quality of the center, it can be the timing of the shift that's available, et cetera, et cetera. So many ways to define disruption. But it's not a tiny number because even if there are other centers close by, if someone has to move to the night shift, that can be highly disruptive to their lives, which often translates into poor clinical outcomes, which often translates as well into more hospitalizations. So it's not a small percentage. But I don't -- it'd be pretty arbitrary for me to pick a number.

Ben Andrew - William Blair & Company L.L.C., Research Division

Okay. And then within the integrated care program for dialysis itself, have you talked anymore about what you would like to see, what changes you would like to see made to the program? Because we see that there's some movement towards the SDOs [ph]. But is anything there enough that would if extended the LDOs be helpful for you all?

Kent J. Thiry

LeAnne, do you want to go ahead and cover that, please?

LeAnne M. Zumwalt

We -- the industry has asked for a number of changes, including some on the calculation of economics. And so this is a first sign that they're taking those considerations seriously. But we really couldn't be specific beyond that because they haven't given us indication.

Ben Andrew - William Blair & Company L.L.C., Research Division

So there's not a threshold or something that we could really think about in terms of what would be enough?

LeAnne M. Zumwalt

Not at this time because there's several areas that they could make some movement that would really help us in how we feel about participation, and so we'll see -- we'll answer that question when we see their complete proposal.

Operator

Your next question comes from Vijay Malik [ph] from Peninsula Equity Advisors.

Unknown Analyst

Could you please provide some more color on the standstill you entered with Berkshire? Specifically, what prompted DaVita to enter into it and do you feel the market is underestimating DaVita's long-term cash-generation ability? Would it be disadvantageous for -- to shareholders to go private?

Kent J. Thiry

With respect to the standstill, Hammer or Kim, would one of you like to respond?

Kim M. Rivera

Can you rephrase that first part of the question?

Unknown Analyst

Sure. Just some more color on the standstill, really what prompted DaVita, what motivated DaVita to enter into it? Was this DaVita going to Berkshire based on management's opinion that the market is undervaluing the company, and even taking out a significant premium would be disadvantageous to shareholders?

Kim M. Rivera

Well, Berkshire recently approached us about the option of increasing their holdings, and we found them to be a supportive investor with a long-term view and we're glad to have them as a significant shareholder. So we entered into a discussion about coordinating an HSR filing in exchange for having an agreement that reflects the fact that they're a passive investor and this is a friendly relationship.

Operator

[Operator Instructions] Your next question comes from the line of Whit Mayo from Robert Baird.

Whit Mayo - Robert W. Baird & Co. Incorporated, Research Division

Just one other question on the Berkshire standstill. Can you disclose what the length of that agreement is?

Kim M. Rivera

I believe the total -- do you mean the timing?

Whit Mayo - Robert W. Baird & Co. Incorporated, Research Division

The timing.

Kim M. Rivera

I believe it's 3 years.

Whit Mayo - Robert W. Baird & Co. Incorporated, Research Division

Three years? Okay. And my second question is just any general update on the California Duals program and your enthusiasm to participate in that program.

Kent J. Thiry

Again, it's a bit of a moving target. As you know, California got permission from CMS to move forward with it. It's still anticipated to move forward. There is still lack of clarity about how the rates will be set and where and how the risk will be apportioned relative to not only the ambulatory and institutional portions, but the post-acute and long-term care. And so, still a lot of moving parts, a big potential opportunity if the economics pan out correctly. But at this point, I can say we're in a continual discussion in both L.A. and Orange counties with the health plans that will be selected or have been selected to administer the program.

Operator

[Operator Instructions]

Kim M. Rivera

This is Kim. I want to make one quick correction about the question regarding the length of the standstill. I would let folks know, the entire agreement is on file with our 8-K so you can look at it, and it is meant to be in place so long as Berkshire is a 15% or above shareholder.

Operator

And we have no further questions at this time. I turn the call over to the presenters.

Kent J. Thiry

Okay. Thank you all very much for your continued interest in DaVita HealthCare Partners. We apologize that we had an unusual amount of difficult news to convey. We do, in fact, hope to reach a satisfactory resolution with the government and put that behind us, which would lead to a lot lower legal expenses and a lot less management time consumed by it. And so we're hoping that we can, in fact, reach a satisfactory resolution there. And thank you all. We'll to talk to you again soon.

Operator

This concludes today's conference call. You may now disconnect.

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