Fresenius Medical Care AG & Co. KGaA Sponsored ADR Aktie

Ladies and gentlemen, welcome to the report on First Quarter 2026 Earnings Conference Call. I am Valentina, the Chorus Call operator. [Operator Instructions] The conference is being recorded. [Operator Instructions]. The conference must not be recorded for publication or broadcast.

At this time, it's my pleasure to hand over to Dr. Dominik Heger. Please go ahead.

Thank you, Valentina. I would like to welcome everyone to our earnings call for the first quarter 2026. As always, I start out the call by mentioning our cautionary language that is in our safe harbor statement as well as in our presentation and in all the materials that we have distributed earlier today.

For further details concerning risks and uncertainties, please refer to these documents and to our SEC filings. We will have a little bit under an hour for the call. In order to give everyone the chance to ask questions, we would limit the number of questions to 2. Thank you for making this work, as always.

Let me now welcome Helen Giza, CEO and Chair of the Management Board; and Martin Fischer, our Chief Financial Officer. Helen, the floor is yours.

Thank you, Dominik. I'd like to extend a warm welcome to everyone on the call. Thank you for your continued interest in Fresenius Medical Care. I will begin my prepared remarks on Slide 4. I am pleased to report that we began 2026 with continued operational and financial progress. We realized the solid organic revenue growth of 4%, reflecting positive contributions from all segments. We achieved strong operating income growth of 10%, in line with our planned phasing for the year and leading to further margin expansion. This was supported by continued execution of our FME25+ saving program, which delivered EUR 50 million in sustainable savings in the quarter.

On 30th of April, we successfully completed our initial share buyback program of EUR 1 billion in a significantly accelerated way. It was done in less than 1 year instead of within 2 years as originally announced. We bought back 24.8 million shares or 8.5% of share capital. At the same time, our net leverage ratio of 2.6x remains around the lower end of our target corridor.

Let me now turn to key first quarter highlights across our operating segments on Slide 5. Beginning with Care Delivery in the U.S., same market treatment growth declined by 37 basis points as volumes were impacted by missed treatments. We had flagged during the quarter that we experienced severe U.S. weather events in January and February. As we focus on core operational improvements with clinic closures and insurance verification, this likely had a small impact on patient inflows at the start of the year. This was further complicated by the unclear situation for many patients with their insurance coverage due to the expiry of the extended tax subsidies for ACA.

Volumes also continue to face pressure from mortality remaining above prepandemic levels. We are maintaining our assumption of flat U.S.A. market treatment growth in 2026, which includes the expectation for improving volumes over the course of the year. Our Care Delivery International markets delivered 1.3% same market treatment growth. Whilst TDAPA provided a benefit to our care delivery performance, Martin will address that in his remarks. What really stands out to me is the successful execution of our FME reignite strategy and the actions we are taking to strengthen our Care Delivery business while driving profitable growth.

We understand the sense of urgency as well as the pace and momentum needed to deliver growth in our underlying business, and there are several proof points demonstrating progress already. While mortality levels are still above prepandemic level, we have seen a reduction in catheter-related bloodstream infections, with now around 90% of all eligible patients using an antimicrobial catheter lock solution. This is part of our FME reignite strategic priority to increase patient quality and safety.

We expect the progress we have made on increased usage of catheter lock solutions to begin to have a positive impact on miss treatments and mortality in the near future. The 5008X rollout and introduction of HighVolumeHDF therapy represents the biggest operational and clinical change in our company's history.

With the start of the large-scale launch in January, we have achieved a clear step-up change in rollout speed and are well on track. We surpassed 100,000 treatments on the 5008x in the first week of April and around 100 clinics have been converted to the new care system with more conversions underway as we speak.

In February, as part of FME25+, we announced the biggest U.S. clinical restructuring in recent history with plans to close up to 100 clinics. Here, we are also moving at speed with 64 clinics already exited in the first quarter and the remainder expected within Q2.

And finally, we have realized improvements in revenue cycle management, providing further evidence of our strategic execution.

Turning to value-based care. We delivered positive operating income driven by favorable savings rate, and we realized an increase in member months from future contracting growth.

Leveraging data and analytics to improve quality and coordination of care is a central component of our FME reignite strategy. We have expanded adoption of AI-driven interventions for imminent hospital admissions of ESRD patients. Where employed, these programs have shown a reduction in hospitalizations by as much as 15% and missed dialysis treatments per member per month by up to 26% for the highest risk patients. We will continue to scale this across our VBC population.

I'm also proud to report that we continue to be recognized for quality leadership in the United States Government CKCC program for multiple consecutive years. We delivered over $270 million in shared savings and achieved an 88% average quality score over the first 3 years of the program. In the most recent publicly available data, we earned over 40% of the program's high performer pool driven by our industry-leading quality.

Care Enablement realized favorable business growth as sales of the 5008x in the U.S. ramp up. This is a tremendous opportunity to bring new innovation to the U.S. market and we are on track with production to supply both machines and consumables according to our targets for the year.

In the first quarter, we achieved positive pricing and volume development in our markets outside of China. We faced continued pressure in China, especially from volume-based procurement and stricter tender requirements. We continue to closely monitor developments in China and assess the implications on our product portfolio and strategy as part of FME reignite. We also continue to strengthen our core care enablement business with further FME25+ progress in streamlining our manufacturing and supply chain.

I will now hand over to Martin to walk you through the first quarter financials in more detail.

Thank you, Helen, and welcome to everyone on the call also from my side. I will pick up on Slide 7. In the first quarter, we achieved solid organic revenue growth of 4%, supported by growth in all 3 operating segments. At constant currency, revenue increased by 3%. Care Enablement revenue development continues to face headwinds from regulatory pressure in China.

Divestitures negatively impacted revenue development by 50 basis points. We delivered strong operating income growth of 10% at constant currency. This increase was supported by contributions from all operating segments and is in line with our expected phasing for our '26 outlook. Special items in the first quarter amounted to a net negative EUR 181 million, mainly reflecting costs associated with FME25+ as we accelerated our U.S. clinic closures.

In line with expectations, FME25+ costs are planned to come down over the course of the year as costs related to U.S. clinic closures are first half loaded. Turning to Slide 8. This chart illustrates the year-over-year improvement of the group operating income margin, highlighting a further increase of 70 basis points. With 10.1%, this is a solid start toward achieving our projected group operating income margin of 10.5% to 12% for the full year. Care Delivery was the main driver of improved profitability with a small contribution from value-based care. The higher intersegment elimination reflects the 5008X CAREsystem sales in the United States.

Corporate costs increased by EUR 37 million. This was mainly driven by the planned cost of strategic IT platform investments, including preparation for the transition to SAP S/4HANA. FX translation effects were unfavorable this quarter and stood at negative EUR 34 million. The average U.S. dollar exchange rate in the first quarter was $1.17 compared to $1.16 in the fourth quarter and compared to $1.05 in the first quarter of 2025.

I will now walk you briefly through the business development in each segment, starting with Care Delivery on Slide 9. Care Delivery achieved organic revenue growth of 6%, driven by both Care Delivery U.S. despite muted U.S. volumes and Care Delivery International. At constant currency, revenue increased by 5%. In the U.S., growth was driven by a positive impact from the TDAPA reimbursement regulations as well as favorable rate and payer mix effects.

Our U.S. payer mix remained strong in the quarter with relatively low attrition in the exchange patient population. We expect that attrition to increase over the course of 2026 as rate periods expire and affordability pressures grow around higher premium and out-of-pocket costs. We continue to expect an impact of around EUR 50 million for full year 2026. The impact from divestitures as part of our portfolio optimization plan reduced revenue growth by about 80 basis points.

The main driver here was the prior year divestment of our clinics in Brazil. Care Delivery realized strong operating income growth of 26%. This resulted in a margin improvement to 12.1%. Benefits from TDAPA reimbursement regulation for phosphate binders and catheter lock solutions were, as expected, a meaningful driver of the earnings development. We continue to assume a significant headwind from TDAPA reimbursement regulation in the second half of the year.

Importantly, excluding TDAPA benefit, the underlying business realized around 6% earnings growth on a constant currency basis. This includes favorable rate and mix effects, lower implicit price concession, thanks to our revenue cycle management initiatives and partially offset planned strategic investments for the 5008X rollout in our U.S. clinics. Savings from the FME25+ program contributed positively. The anticipated labor cost increase as well as currency translation effects had a negative impact in the development.

Turning to Value-Based Care on Slide 10. Value-Based Care realized 3% revenue growth on both an organic and constant currency basis. This was driven by a higher number of member months from contract expansion and positive effects from premium rates. Prior period contract true-ups also created positive growth in the first quarter. This was partially offset by the change of risk type for a large contract resulting in a different accounting treatment and lower revenue recognition.

We expect revenue growth will turn negative throughout the year, primarily due to the change in accounting treatment. Operating income for Value-Based Care increased significantly in relative terms and the margin was enhanced by 100 basis points. Value-Based Care was profitable for the second consecutive quarter. The increase in business growth was mainly driven by an enhanced savings rate. FME25+ program-related savings resulted from the reorganization of the team to take advantage of integration with Fresenius Medical Care and becoming more efficient while aligning staffing with our strategic priorities. Higher inflation and currency translation effects were offsetting factors.

I will turn to Care Enablement on Slide 11. Revenue in Care Enablement increased by 1% on an organic and constant currency basis. Organic revenue development reflects continued positive volumes and pricing, excluding adverse regulatory impacts in China, which include volume-based procurement and switcher tender requirements. Revenue was also supported by strong sales of the 5008X CAREsystems in the United States.

Care Enablement earnings slightly increased on a constant currency basis, leading to a 40 basis point margin improvement. Business growth was impacted by adverse regulatory impacts in China and negative currency translation effects. Positive volume and price effect outside of China contributed positively to business growth. Additional, FME25+ savings from continued progress in manufacturing and supply chain initiatives supported margin expansion. Inflationary costs increased and had a negative effect.

Next, I will look at the cash flow growth on Slide 12. As always in the first quarter, we have a seasonality effect in invoicing, which is why the quarter typically represents a relatively low share of the full year operating cash flow. This year, while on the typically lower quarter 1 level, we realized a strong increase in operating cash flow by 39%. The main driver was favorable working capital management. Free cash flow increased by 94% to EUR 40 million. Total debt and lease liabilities as well as total net debt and lease liabilities were broadly stable compared to the prior year period.

As part of our share buyback program, we repurchased a total of 23.3 million shares for EUR 941 million by the end of the first quarter. This represents 7.9% of share capital. On April 30, we successfully completed our initial share buyback program of EUR 1 billion. We bought back in an accelerated way, 24.8 million shares or 8.5% of share capital. With 2.6x, our net leverage ratio continued to be around the lower end of our self-imposed target corridor of 2.5 to 3x. I will now hand back to Helen.

Thanks, Martin. I will pick up with the outlook slide on Slide 14. Given our strong first quarter performance and current expectations for the remainder of 2026, we are confirming our full year outlook. We continue to expect a broadly flat revenue development.

For earnings, we assume operating income will remain on a consistently high level as 2025 with an upside downside range of a mid-single-digit percentage change. We clearly target to maintain our enhanced profitability. Unchanged to our assumptions, we do expect a positive earnings growth in the first half of 2026.

Due to the phasing of the regulatory TDAPA effects, which should present a significant headwind in the second half of the year, we assume a negative earnings growth in the back half of 2026. As you will be asking about the impacts from the Middle East crisis, I want to say that we are closely monitoring inflationary impacts from higher oil prices, raw material costs and other supply chain and transportation cost-related topics. So far, there were no meaningful interruptions of our local operations during the first quarter and the financial impacts are currently absorbed within our range of inflation assumptions for our 2026 outlook.

We are closely monitoring this, have implemented mitigation measures, and we'll keep you updated. This concludes my prepared remarks, and I now hand back to Dominik to begin the Q&A session.

Thank you, Helen. Thank you, Martin. Before I hand over for the Q&A, as always, I would like to remind you please start with 2 questions only and if you have time left, we'll go a second round. And with that, I hand it over to Valentina to open the Q&A, please.

[Operator Instructions] Back over to you, Dominik, for the first question.

The first question comes from Graham from UBS.

Obviously, congratulations on the 5008X rollout, that's obviously an update and big undertaking. I was hoping you might be able to contextualize that and some of the other growth drivers that you expect to build through the year. It's just when I look at the underlying growth for Q1, if you adjust the TDAPA, it looks like there's quite a bit of work to do as we go through the year when we think of the kind of mid-teens implied growth in consensus for 2027.

So I sort of just thinking how do you get there? How you get to that sort of mid-teens growth for next year when you exit that TDAPA piece? So is it more cost savings? Is there another TDAPA coming? Presumably the volume uplift won't start just yet from HVHDF. But if we could get a sense as to which of those drivers are making you confident on that?

Thanks, Graham. I'll take that. Obviously, we outlined a lot of the drivers for reignite and how we get to those mid-teens margins. Kind of the specific building blocks clearly are ongoing FME25, as you rightly said. The 5008X obviously, is expected to ramp up, not just over this year, but over those next couple of years as well.

The work that we are doing and have constantly spoke to about improving inflows and outflows is quite multifactorial there. We're obviously working on improving our internal processes and even the work that we are doing on the catheter lock solutions in improving patient safety, patient quality will have a positive effect as will HDF on treatment volumes, reduced hospitalizations, reduced missed treatments and, of course, longer mortality or improved mortality, I should say. As we think about the rev cycle management, we've got some nice contribution coming in for that. That will continue to ramp up over the course of the year.

And then as you can appreciate, the clinic closures, which is a big part of the onetime cost in Q1, we'll start to get those savings continuing to compound over the course of the year. So a lot of building blocks there, not new building blocks, but ones that we're continuing to work through. I think the other piece, as we go then specific and maybe most of those are specific to Care Delivery. As we think about Care Enablement, obviously, there's FME25 there. And I think the China piece, and I'm sure there'll be questions on that, we've sized that for the year, knew that we'd have a bigger impact in Q1. That should also be behind us or kind of the full number more heavy loaded in the first half.

And then that ongoing work on good contracting, pricing, reimbursement and volume. So I'm confident in the plans. We've really underscored and underpinned the initiatives across all 3 segments, and we're executing against that to crystal clear on the aspiration to be at mid-teens margins for all segment. I shouldn't say all segments in [ VBC ]. Time will tell me, but that Care Delivery and Care Enablement. And I think that's why it's important we understand the TDAPA piece. We understand the cliff that will happen. We are really focused on that underlying improvement and personally really encouraged by that 6% underlying improvement in Care Delivery in the quarter. So recognize a lot of moving parts, a lot of good initiatives, and I think we're really starting to see them come through, but the clear building blocks of how we get there.

Also maybe just a quick follow-up on DefenCath, are you guys seeing the benefits fairly quickly? It seems like something you might see a little bit of a tailwind relatively quickly.

For which Graham, did you say HDF?

For DefenCath. So for the [Technical Difficulty] products..

Yes, for sure. With having more than 90% of our patients on that, we are really starting to see a real improvement and reduction in bloodstream-related infections. So really encouraged by that work. Of course, we know with the DefenCath, should know that's a TDAPA period, but the underlying catheter lock solution really good for the patient safety, patient quality. So outside the financial impact of that, clear improvement that should be expected to translate into reduced hospitalizations and reduced missed treatments with the patients over time.

The next question comes from Hassan from Barclays.

Firstly, on the TDAPA benefit in the quarter, can you talk to the split of the EUR 80 million, be it phosphate binders versus catheter lock in the quarter and how you see Q2 and H2? And if this is consistent with the expectations that you set out in February? And then secondly, on same market treatment growth, if you could help unpack some of the underlying dynamics and if possible, how much of the headwind you think you may have seen from weather in Q1?

And with no second flu spike, do you expect growth to swing quite meaningfully in the second quarter, all else equal? And perhaps into positive territory? Or is there something else in Q1 that should constrain that improvement that you might be seeing, be it inflow or mortality?

Thanks, Hassan. Martin, do you want to unpack the financials on TDAPA? I suspect many have the same questions. So why don't you walk through that, and I'll take the same market treatment growth question.

Got it. So the contribution of TDAPA for the first half -- for the first quarter, as you said, Hassan, was about EUR 80 million on a constant currency basis. We have also told you and shared with you that the catheter lock solution contribution from '25 to '26 would be in equal size, meaning EUR 90 million for the first half year. And we saw about half of that come through in the first quarter as well. And the remainder between that and the EUR 80 million is a binder contribution.

Overall, our TDAPA contribution has developed as expected. And we have, as a reminder, positive contributions for the first half of 2026, and we expect negative headwinds in the second half. And that's why we also have -- when we talk about operating income improvement for the first half, a positive growth and for the second half, a negative growth expectation year-over-year.

Thanks, Martin. And I'll take the same market treatment growth because I expect people have a similar question here, too. Look, it's -- we all know we're in small numbers on small numbers here. We know that we had weather in January and February that did result in missed treatments. Flu was similar in Q1 '26 to what it was in Q1 '25. We are kind of unpacking. We did see slightly lower referrals in the first part of the year. And obviously, we know we've got a lot of clinic closures and restructuring underway.

We also know that the ACA piece did cause a lot of uncertainty on patients, and we're also refining our own patient insurance verification processes. So look, our guide is unchanged. We do still expect to be flat full year -- not -- I haven't even seen April numbers yet, so not in a position clearly to give insights into Q2. We do expect to continue to improve over the course of the year. And obviously, the other impacts that I spoke to on Graham's question about things like bloodstream-related infections, HDF and the ongoing work we're doing across the operation on improving inflows and outflows is important.

I think the other thing worth noting is mortality is still elevated. So that is something that we continue to try anytime impact through some of these other measures. All in all, I would say it's small numbers. Obviously, I know we're all looking for that to turn positive. But because of a small number, it's not really impacting OI as we have kind of maybe consistently said, but really feeling good about the work that's underway. And obviously, we'll continue to see more as Q2 develops.

The next question comes from Veronika from Citi.

Can you guys hear me?

We can hear.

Two for me, please. The first one is sort of a slightly bigger question, I guess, Helen. I know we're early in the HDF rollout, but just curious to get some feedback from you both in terms of operationally how that rollout is going out, going on in your own clinics, how you're feeling about some of the early signs of mortality benefits that you're seeing, if any, I know it's very early, but to the extent that you could talk about it. And I guess some of the training costs that you've budgeted for in the year, how you're tracking against those? And then I have a bigger picture follow-up question, but maybe we can get this out of the way first.

Sure. And as you know, it's my favorite topic. So we can spend the rest of the call talking about HDF, if you like. [indiscernible] leave aside, really, really happy and excited about how it's going and the progress we're making. We are accelerating at speed now. I mean if you look at our website, you'll see clinics coming soon, and we're already passed the 100 that we were at by the end of the quarter.

So training is going well. Those costs are incurred and being incurred as we had forecast. So that's all fine. The adoption in the clinics is really, really positive. It's easier to train. The staff are loving it. It's less noisy, less disruptive with alarms and beats and things going off. But more importantly, the feedback from our patients is terrific.

We're clearly seeing the immediate benefits of patients feeling better on these treatments, feeling less tired, et cetera. Now I've been pretty consistent on this and kind of maybe just a caution. Obviously, we are tracking the data set from patient 1. We've had -- we've got 100,000 treatments here and over 100 clinics. We are starting to get that data set into a form that we can kind of start to tease out some KPIs and report out on it. But obviously, we want to get a little bit more of the data set under our belt.

So we have kind of said we'll start to -- once we're maybe through half 1 here, start to give more color on those KPIs. But everything so far is in real-world evidence is supporting what we had seen through the studies. So yes, obviously, it's big. It's the biggest thing we've ever done, but the level of excitement and engagement and adoption by our teams, our physicians and our patients is terrific. So very, very happy with how that's going.

That's super helpful, Helen. And I think maybe just to sort of bleed it into my second question. I guess we're all anxiously awaiting that return of the same market to a positive territory. I know you can't predict when that happens. But I guess just fundamentally, we're here again in 12 to 18 months' time, and we haven't seen any progress on same market treatment growth. How will you think differently about operating the business or running the business? We're seeing more clinic closures this year. Just curious kind of high-level thoughts. I know that's not your working assumption, but to the extent that we're there in 2027, what should we be expecting from you in response to that?

Yes. Look, I -- first of all, my expectation is 12 to 18 months, we wouldn't be at negative same market treatment growth. I do expect this to continue to improve. I feel really good about the work the SKC and CG team are doing in addressing a lot of these operational improvements and efficiencies and both addressing inflows and outflows.

Look, I think if we -- if -- and it's a big, big if, we are in a situation where even with -- you have to think about 18 months from now, Veronika, we would have technically also converted about 40% of our machines. So we should also be seeing the real nice impact coming through on HDF. As we have shown this year, where we know we have underutilized capacity or we don't have profitable growth, clearly, we would trim the network accordingly, but that is not our working assumption.

But obviously, every month, every data point gives us a new insight. And I think what we're seeing in the work that we're doing, both on the patient safety, patient quality initiatives as well as HDF, I think all the signs are pointing to that improving mortality, improving missed treatments, improving hospitalizations. And as always, we know that we would have to flex a different cost muscle if need be along the way. And I think what I'm also would commend the team on is as we were looking at this 100 that we've teed up on clinic closures, not just 64 through the first quarter, but that should be done sometime in May. We've already got, I think, close to 90 done through April. So that's also a good proof point that we can move at speed should we need to go deeper here.

The next question comes from Hugo from BNPP.

I have 2, please. First, on the EUR 200 million to EUR 300 million inflation headwind that's in the guide. Could you maybe give us an indication of how you track against that guide and given macro uncertainties, what room do you have with either the top or the low end of that guidance.

Martin you mentioned ACA subsidies expiring, all of you or will you account for patients that are signed up in ACA marketplaces, I think generally, but at least 1, 3 months grace period for the first event, I guess. In other words, would there be a stronger impact in Q2 from your EUR 50 million savings or some type of reversal that we...

Martin, do you want to take the inflation question?

Thank you. So far for the first quarter, we are tracking in line with our assumptions on the inflation side. We also saw only minimal impact from the conflict and from the macro environment. We are closely monitoring that, as Helen outlined. And we are also taking mitigating actions. But for quarter 1, this is well in line with the development. And as we see it as of today, this is also something that is within the band of our assumptions for inflation as well.

Yes. And then maybe on the ACA subsidies, you know that we had guided this impact of around EUR 50 million. Obviously, what we're watching closely is what happened through open enrollment, what the uptake of patients or where patients are getting their insurance coverage since open enrollment closed.

We always said it would take Q1 to play out to see how that was. What we've actually seen in Q1 is maybe lower than planned or lower than thought patient attrition. Some of that -- the mechanics of how it worked was they're also enrolled. They've got -- and they had to make their first payment for their first month of coverage.

We don't know after that first month, whether they stayed on or didn't. There is this grace period that is happening. And then we don't know from an affordability standpoint, whether they will stay on an exchange or move to Medicare or Medicare Advantage after that. So we're roughly at the point where they should be making their first premium. And I think that's a real kind of test point for us.

So while we didn't see much impact in Q1, our expectation is affordability will become an issue. So right now, we believe our assumption of EUR 50 million for the year is still a good estimate, but we would not necessarily start to see that impact until Q2 and obviously then compounded Q3, Q4. So something we're watching closely, but holding the assumption for now.

The next question comes from Aisyah from Morgan Stanley.

My first one is hopefully a quick one on China. Could you quantify the impact from VBP and the tender exclusion in the quarter versus the guidance of, I think, EUR 50 million or a bit less than EUR 50 million that you saw last year? And do you have a clearer view on when you could reenter the tender this year? And then the second question, also hopefully quick is on Value-Based Care. So your performance in the quarter was clearly ahead of your expectations of a decline for the full year. Would this mean that we just see a steeper decline for the remainder of the year? Or does this drive a bit of upside to the original guidance? And at what point do you think you'll have better visibility on the margin side of things?

Martin, do you want to take those 2 financial questions?

Yes, more than happy to. So Aisyah, on China, yes, we gave an expectation that we would see a little bit of below EUR 50 million for the full year. We did see also in quarter 1, about half of that come through as we expected. And this is in line with how we looked at China for the full year. And obviously, also then we do see lower effects in the coming quarters to that extent.

When we talk about Value-Based Care, yes, you are right. We had a bit of an uptick in the quarter where we had a mix of revenues being driven also by prior period adjustments, which is helping us to offset the headwinds that we have from the revenue recognition of a differently casted contracts. I think it's too early given the volatility of the Value-Based Care business, quarter 1 being a, let's say, proof point, so to say, the positive to change the outlook for the year. So we have given you a EUR 300 million assumption, and that is still what we currently work with.

And Martin, if I could push a little bit as well on the inflation side, which you talked a bit earlier. You mentioned you're monitoring the situation closely. But if in the extent that the current conflict is prolonged, which areas of your cost base would you see most sensitive to incrementally higher inflation as a result? So would it be energy, freight, plastics, et cetera? I appreciate you're not seeing any impact at the moment, but in a worst-case scenario.

Yes. When we look at different buckets, typically, you look at energy, you look at transportation costs, everything that's exposed to oil price also on the oil price-based materials like plastics and stuff like that. So on the energy side, we are rather well hedged. So 70% of our exposure is hedged. So I would call that a limited exposure. Having said that, when there would be a continued high oil price dependency, obviously, transportation like with everybody else or plastic-based oil dependencies would see a potential inflationary cost increase if this is very much [indiscernible]. But also, as I said, perhaps one last thing here. We are currently, and that's what I answered Hugo in his question, absorbing that in our guidance assumption for the year.

The next question comes from Anna from Bank of America.

I wanted to follow up on what Veronika was asking about the HVHDF rollout and how the costs are unfolding versus your expectations? I think you said you rolled out 200 clinics versus an implied goal of closer to 500. Should we be thinking that the costs accelerate in Q2 and into the back half of the year, maybe compounding the headwind from the TDAPA roll-off? And then I don't want to get ahead of myself, but how are you thinking about that going into 2027, the cost for the ongoing rollout there? I think previously, you've messaged that the savings from the HVHDF rollout would offset the cost. Is that still the right way to think about it? Or maybe will it be more of a similar magnitude?

Yes. So Anna, our plan is obviously to kind of replace about 20% of the machines of the installed base in 2026. As you can appreciate, the costs are front-end loaded because we have to train. We train, we get installed, we run them and obviously, the benefits lag. So as you can appreciate, the costs will continue to accelerate as we continue to accelerate the clinic closure.

But it's more just kind of linear to the number of machines that we install over the course of the year. I think the piece that you're maybe trying to tease out is we have costs and then the benefits lag, but they'll come a point where the benefits will be absorbing some of those costs in the later years. So that lag kind of sorts itself out on an annualized basis. But nothing -- I don't think anything remarkable to comment on the costs outside of what we had originally guided. And now it's in line with the number of machines that we deploy.

The next question comes from Oliver from ODDO.

The first one is on the payer mix. So over the last quarters, we have seen or you have reported some progress. This was also again confirmed now. Up from now, how you think about further improvements in the payer mix? Is it still some source for additional profitability or at one point of time, it's basically it's becoming more neutral?

And the second question is about Value-Based Care. So in your report, it has also shown a solid increase, I think, 5% of enrollment of new patients. Can you provide some data whether the growth now comes more from CKCC or from commercial programs? And how do you think about further patient growth in VBC?

I can take both of those. In the payer mix improvement, we are very pleased with how we continue to improve that mix. Obviously, that right now, there's no ACA headwinds in that because we're still holding on to those patients. So there is an expectation that depending on what happens with ACA, that might change. The other thing I would say is clearly, we are focused on improving that reach and be focus on profitable growth.

So as we close clinics, we don't hold on to 100% of the patients. We know that. But obviously, the focus here is on the kind of the profitable mix there. And I think also the opportunity to be talking to payers as well about some of these new initiatives that we're focused on, notwithstanding HDF and some of the other piece. So we are pleased with how that is developing and the conversations there and continues to slightly tick up each quarter.

On VBC, obviously, in the quarter, Martin spoke to this already, there was a prior year true-up. But I would say we are -- we've got a new leader in there. We've kind of got a really good strategic focus here on finding the growth in both the contracts and better contracting and premiums as well as member months. So I would say that improvement is coming more from commercial than it is from CKCC. And obviously, we are really focused on improving the contract status that we have there and have had some nice wins and some nice discussions and new relationships with some of the larger payers.

The next question comes from James from Jefferies.

Just a couple, please. Firstly, on operating cash flow. I noticed EUR 227 million in the quarter, up 40%. I guess there is a summary on Slide 12. But just wondering what goes into the other working capital and noncash items. That was a positive inflow of EUR 133 million or nearly 60% of the operating cash flow. Because if one adjust for that line, I appreciate there might be some other stuff that goes in there, it implies a 50% reduction in operating cash flow. So I just wondering if you can give some color what goes into that line and also just confirm if there's any factoring.

And then my second question is on full year, and there was the slide on the outlook assumptions just because that was missing in the deck this time, can you confirm that all of those are still valid?

James, why don't I take the full year outlook assumptions while I'll let Martin maybe have a look at the cash flow question, and we may have a follow back up on that.

Yes, look, we don't include that headwinds and tailwinds slide every quarter. We generally talk about it in full year about what we're mapping and then maybe half year or speak to any major variations. I would say is we look at that internally, that classification that, that is really developing in line with expectations. So nothing significant to point out there. The headwinds and tailwinds are very much from what we've seen in Q1 and our outlook for the year developing in line with as we expected.

What I can say, and I might come back to you, we are driving operating working capital improvements for the underlying cash performance. And on that other piece that you referred to, I would have to understand exactly what you referred to and come back.

The next question comes from David from JPMorgan.

Sorry to rebang on the both ACA and cost inflation. Maybe first on ACA. I just wanted to double check. So have you recognized all the revenues from patients coming through? And then if they fall off sort of going forward from here, will you have to go back and readjust numbers or take provision where we could make some sort of provision through the first quarter just in case those guys do come off and then you might be able to write it back later if they don't? And the second question is on cost inflation maybe for Martin. Just wonder what percentage of your COGS in Care Enablement is particularly associated with plastics and actually what you're seeing in terms of plastic inflation there?

Yes. David, on the ACA question, obviously, we have a patient, we would be billing for that treatment for that patient. So there's no kind of -- it's just particularly it's billed. I think our concern is more if they fall off insurance or they go out of the system that we lose that patient. And obviously, that revenue that comes from that. So I think that's why we can say there's not really an impact in Q1 because our patient census didn't have the attrition that we first thought.

Now obviously, we're also looking pretty hard at the front-end process on insurance verification and things like that. So there shouldn't be an impact. We just take it as the patient is there and then doing the insurance verification to make sure we're billing accordingly. So I think that's why we're saying we'll hold the assumption because we don't know if these patients will fall off once they make their first premium payment in Q2, Q3 or rest of the year. They do have to be covered. If they're on, they will get covered by the insurance company in what we call this grace period, but it's after that, that is the risk for the patient coming off the exchange. Martin, maybe you can talk about the inflation?

So David, regarding the inflation question, as I said, we are monitoring the situation closely. There is multiple buckets where oil dependency impacting transportation cost is one, plastics are another one. I don't want to give you a number of our costs because we have a supply chain that has different exposures.

Obviously, we are manufacturing also our plastic parts like the blood lines or like also other consumables in different locations. And as such, it is not a simple extrapolation. We are working on this. We are mitigating the effect. We have it inside our inflation guidance that we gave for the market. And I think that is from our perspective, the right way to look at it.

The next question comes from Falko from Deutsche Bank.

Two questions, please. The first one, can you remind us how much of your Care Enablement sales are coming from China? And how was growth excluding China in the first quarter for the segment? And then secondly, on Care Delivery, the organic growth in the international business was a tad softer than in previous quarters. Was there any particular reason for that? Or was that just normal quarterly volatility?

Yes. On the China one, Falko, we said it's about 7% to 10% of the revenues that we have in Care Enablement. It is a relevant market. It's also an attractive market, and we have not disclosed for the quarter what the top line impact is overall?

Yes. And then your question on CDI, as you know, we are -- we're kind of continuing to refine that portfolio on kind of where that treatment growth is coming. It was -- it does look a little bit lower, but don't forget last year, we had Brazil in the base. So as we look at this market by market, we're not concerned with what we're seeing. So I think it's just maybe a tough comp because of Brazil.

And the last question comes from Richard from Goldman Sachs.

Just a follow-up on China for Care Enablement. Between the stricter tender requirements and VBP, how are you seeing competitive dynamics in that market change, if at all? And Martin just referenced China as being an attractive market. What kind of scenario is embedded in your medium-term plans for Care Enablement in China, please?

Yes. Richard, look, China is an attractive market for us. It's a large market. The profitability is there despite some of the challenges that we've already experienced. I think we're eyes wide open of what it takes to succeed in China. Obviously, we're hearing this across med tech, the competitive dynamics are changing.

I think for us, it's about having the right strategy and the right go-to-market approach in China and the right portfolio of what is local for local and what is really premium. So we have some good assumptions into our mid-range plans. We are obviously getting under the current environment and what the future portfolio should look like for China. And obviously, if these dynamics continue to evolve, we will strategically adjust accordingly on the portfolio.

We know we were -- we had -- we were later into China than some med tech companies. So we learned a lot. Even with that, we obviously had some impact, and you saw that hit us last year. But a lot of the focus is on what is the right portfolio to have in China for the China market, what can we do local, what can we partner. And I think then we have to look at China in relation to the global portfolio that we're developing and see what it is that we need to have offered there for continued success. But then I think there's more to come here as we continue to look at that strategy and the portfolio in light of these changing regulations that are happening in real time.

Thank you. So with that, we have answered all questions. The time is up, so perfect combination. And with that, thank you for being so interested that we filled more than an hour. And with that, I'll say thank you. See you on the route on conferences and around the world.

Thanks, everybody. Have a good day. Bye-bye.

Ladies and gentlemen, the conference is now over. Thank you for choosing Chorus Call, and thank you for participating in the conference. You may now disconnect your lines. Goodbye.

Ladies and gentlemen, welcome to the report on the Fourth Quarter and Financial Year 2025 Conference Call. I'm Moritz, the Chorus Call operator. [Operator Instructions] The conference is being recorded. The presentation will be followed by a question-and-answer session. [Operator Instructions] The conference must not be recorded for publication or broadcast.

At this time, it's my pleasure to hand over to Dr. Dominik Heger. Please go ahead, sir.

Thank you, Moritz. Welcome, everyone, to our earnings call for the fourth quarter and the financial year 2025. As always, I start out the call by mentioning our cautionary language that is in our safe harbor statement as well as in our presentation and in all the materials that we have distributed earlier today. For further details concerning risks and uncertainties, please refer to these documents and to our SEC filings.

We will have 1 hour for the call. In order to give everyone the chance to ask questions, we would limit the number of questions to 2. Thank you for making this work as always. We will begin our full year financial results by reviewing key strategic milestones achieved in 2025, which mark the end of our midterm strategy. Next, we will analyze fourth quarter outcomes and present our outlook for 2026 and different horizons beyond.

Let me now welcome Helen Giza, CEO and Chair of the Management Board; and Martin Fischer, our Chief Financial Officer. Helen, the floor is yours.

Thank you, Dominik, and welcome, everyone. It's great to have you with us today. We appreciate your continued interest in Fresenius Medical Care.

2025 was a milestone year for Fresenius Medical Care. We delivered an outstanding step-up in profitability, having achieved the upper end of our 2025 financial outlook and closing the year with an exceptional fourth quarter performance.

The progress we realized in 2025 and the momentum we have built over the past 3 years reflects the consistent focus and dedication of our employees around the world. Their commitment is the foundation to our success as we strive to lead kidney care through exceptional care and innovation, and I'm extremely appreciative of the progress we made for our patients and the exciting path we have ahead of us.

Before we delve into the fourth quarter specifically, I would like to take a few minutes to reflect on the key highlights of the past year and how we are positioning Fresenius Medical Care for the next phase of value creation. Beginning on Slide 4. At our Capital Markets Day last June, we officially launched our new 2030 strategy, FME Reignite. This strategy is designed to accelerate growth and drive ambitious profitability improvements aiming for industry-leading margins. FME Reignite represents a pivotal step forward for us as we shift our focus towards accelerated innovation and growth. As part of our FME Reignite, we carved out our value-based care business, establishing our third operating segment. This strategic decision further enhances our reporting transparency and reflects the continued growth in value-based care, which generated over EUR 2 billion in revenue in 2025. We not only initiated but accelerated a EUR 1 billion share buyback program, reflecting our strengthened financial profile, further reduced net debt and commitment to regularly returning excess cash to shareholders.

In 2025, we marked an important milestone with the successful soft launch of our 5008X CAREsystem in select FME clinics in the U.S. to accelerate to the large-scale clinic conversion in 2026. As we speak, we are rolling out at speed the 5008X CAREsystem to our U.S. clinics and are setting a new standard of care in the U.S. with high-volume HDF therapy.

We accelerated our FME25+ savings program through the end of 2025, achieving sustainable savings above our already increased target. This supported a significant step-up in profitability with a group margin of 11.3%, driven by all 3 operating segments and landing well within our target margin band for 2025.

Turning to Slide 5. For 2025, we delivered revenue growth at the upper end of our outlook leveraging our vertically integrated business model to overcome a difficult market environment and unanticipated headwinds from lower volumes and elevated medical benefit costs. Supported by an exceptional fourth quarter performance, the 2025 operating income growth of 27%, reached the top end of our ambitious outlook for the year.

Next on Slide 6. At the beginning of 2023, we set demanding midterm profitability targets to 2025 as we began a 3-year journey to build a stronger and more resilient company while committing to significant operational improvements. I am proud to say that we have delivered on that commitment. We increased our Care Delivery margin to 13.1%, achieving the middle of our target band for the segment. We more than quadrupled our Care Enablement margin from nearly 2% to just over 8%. If you recall, at the time of setting the targets, we had just 2 operating segments with value-based care still part of Care Delivery. This is why there was not a specific target for value-based care. However, the improved performance in that segment is reflected in the group development.

While returning capital to shareholders in the form of dividends and share buyback, we are in a significantly stronger financial position as we have reduced net debt and improved our net leverage ratio from 3.4x at the end of 2022 to 2.5x at the end of 2025.

Turning to Slide 7. We also delivered on the committed key strategic initiatives. This execution supported our improved operational performance to date and, importantly, has positioned us well as we transition towards the next phase of growth and innovation. With our FME25+ transformation program, we committed and over-delivered, exceeding our already upgraded sustainable savings target with EUR 804 million in realized sustainable savings to date.

We executed our portfolio optimization program at pace, focusing our international clinic footprint to 25 core markets across 34 countries, considerably down from 49 in 2023. A key pillar of our strategic plan announced in 2023 was to unlock value as the leading kidney care company. The launch of our 5008X machine in the U.S. and leadership in renal value-based care are powerful examples of how we are delivering on that ambition while raising the standard of care for patients.

Next on Slide 8. Cash generation is an inherent strength of our business model. In 2025, we generated EUR 2.7 billion in operating cash flow, clearly demonstrating this capability. This strong cash performance supported by disciplined capital allocation provided the flexibility to invest in our core business for profitable growth while returning excess capital to shareholders. Through our accelerated share buyback program, we repurchased shares for a total amount of EUR 586 million in 2025 completing the first tranche of our initial EUR 1 billion program, which supported our EPS growth. In January of this year, we initiated the next tranche with around EUR 414 million, further accelerating the share buyback program. For the 2025 financial year, we plan to propose a dividend of EUR 1.49, representing a 3% increase to 2024 and corresponding to a payout of 33% of adjusted net income, well aligned with our target payout ratio of 30% to 40%.

Let us now look at our fourth quarter performance, specifically, beginning on Slide 10. The cap off a strong 2025, we delivered a truly exceptional fourth quarter financial performance. We realized strong organic revenue growth of 8% and earnings growth of 53%, resulting in a margin of 13.9%, a remarkable 430 basis point increase over the prior year. This was supported by our FME25+ savings program with EUR 63 million in additional sustainable savings in the fourth quarter alone. We recorded exceptional EPS growth of 68%, driven by our accelerated share buyback program. And in parallel, we further improved our net leverage ratio to the low end of our target corridor.

Let's review some fourth quarter highlights from each of the operating segments on Slide 11. Beginning with Care Delivery in the U.S., same market treatment growth was broadly flat as volumes remained under pressure from the follow-on effects of the flu-related elevated mortality in the first half of the year and a high level of missed treatments in December. Our Care Delivery international markets delivered solid 1.7% same-market treatment growth. Underlying performance in Care Delivery was positively supported by favorable U.S. rate and payer mix development. In addition to the underlying trends, Care Delivery performance was boosted by around EUR 40 million higher-than-expected benefit from phosphate binders that fall into the TDAPA regulation, bringing it to around EUR 220 million contribution in 2025.

We shared in our third quarter earnings call our quality initiative on bloodstream infection prevention by using different types of catheter-related bloodstream infection interventions. In the fourth quarter, we made significantly faster progress on the initiative than assumed. Both interventions require a physician prescription, and one of those solutions prescribed by physicians falls under the TDAPA regulation until the middle of 2026. It has contributed around EUR 90 million in 2025, and it will be a year-over-year neutral effect for 2026. This has helped us in 2025 to offset around EUR 80 million higher medical benefit costs in the year that we had not anticipated at the beginning of the year. Of course, the higher-than-expected TDAPA contribution in 2025 raises the outlook base for 2026 even higher, and I will address the impact in the outlook section.

As I highlighted earlier, we started with the launch of our 5008X machine in select clinics in preparation for the large-scale expansion of access to high-volume hemodiafiltration in 2026.

Turning to Value-Based Care. We realized positive operating income in the quarter, driven by favorable savings rates, which was partially offset by an unfavorable effect from CKCC programs. This development brings our 2025 value-based care performance to breakeven, a notable achievement from a historically loss-making position. In the fourth quarter, we realized an increase in member months from further contracting growth as well as the continued growth of our provider network.

The fourth quarter in Care Enablement saw continued positive pricing contributions. However, in China, we faced negative impacts from volume-based procurement as well as other regulatory policies, resulting in stricter tender requirements and delayed tenders. This weighed on our revenue and earnings development in the quarter and is also expected to impact 2026.

We continue to capture sustainable savings as part of FME25+ driven by disciplined execution of the next level of footprint optimization across both manufacturing and supply chain. And also in Care Enablement, preparation for the large-scale launch of the 5008X and shipments of new consumables continue to advance as planned.

I'll now hand over to Martin to walk you through the fourth quarter financials in more detail.

Thank you, Helen, and welcome to everyone on the call also from my side. I will begin on Slide 12. In the fourth quarter, we achieved organic revenue growth of 8%, supported by Value-Based Care and Care Delivery. At constant currency, revenue increased by 7%. Care Enablement revenue development was negatively impacted by regulatory pressure in China. Divestitures executed as part of our portfolio optimization plan, negatively impacted revenue development by 70 basis points. Adjusted operating income increased by an impressive 53% on a constant currency basis. This increase drove a clear step change in our group margin to 13.9%. Special items negatively affected operating income by EUR 111 million. This comprises costs related to FME25+ and our continued portfolio optimization as well as effects from the remeasurement of our investment in Humacyte.

Turning to Slide 13. This slide highlights the remarkable 430 basis point margin improvement, driven by especially strong contributions from Care Delivery due to significant higher contributions from TDAPA regulation than we had expected and Value-Based Care contributed positively as well. Net corporate costs improved by EUR 5 million. This includes a favorable EUR 2 million development in virtual purchase power agreements -- power purchase agreements compared to the prior year period. Foreign exchange rates developed unfavorably with a negative EUR 43 million translational impact. The average U.S. dollar exchange rate in the fourth quarter was 1.16 compared to 1.17 in the third quarter.

I will now walk you through the financial developments in each segment, starting with Care Delivery on Slide 14. Care Delivery realized 7% organic revenue growth and 6% revenue growth at constant currency. In the U.S., organic revenue growth of 8% was driven by positive impact from TDAPA regulations, favorable rate and mix effects and reduced implicit price concessions, demonstrating progress in our revenue cycle management initiatives.

Care Delivery International delivered 3% organic growth. Divestitures negatively impacted Care Delivery revenue growth approximately by 120 basis points overall. Care Delivery achieved 45% earnings growth and 440 basis points margin improvement to 16.4%. Business growth benefited from higher-than-anticipated contributions from phosphate binders. The significantly higher prescription and adoption rate of one of the antimicrobial catheter solutions that falls under TDAPA regulation also contributed around EUR 70 million in the quarter, helping us to offset the not anticipated around EUR 80 million higher medical benefit costs in the fiscal year.

Business growth also supported by positive rate and mix effects in the underlying clinic business as well as the phasing of a content agreement on certain pharmaceuticals. Increased labor costs, which include a significantly elevated medical benefit costs, were partially offset by FME25+ savings.

Turning to Value-Based Care on Slide 15. Value-Based Care again accelerated revenue growth, achieving 42% organic growth. This significant increase was driven by further growth in the number of member months largely attributable to further contract expansion. Value-Based Care realized positive EUR 29 million in operating income, driven by improved savings rate, FME25+ savings and partially offset by an unfavorable effect from CKCC programs.

For the full year, Value-Based Care was positive EUR 3 million compared to a loss of EUR 28 million in 2024, marking the first year of breakeven earnings development for our Value-Based Care business.

I will next turn to Care Enablement on Slide 16. Revenue for the segment decreased by 3%. Lower volumes driven by negative impacts from value-based procurement and other regulatory policies in China were partially offset by overall continued positive pricing momentum. Care Enablement earnings declined by 6%, primarily due to unfavorable business development in China and currency transaction effects. This was partially offset by positive pricing. Further sustainable savings from the FME25+ program, primarily driven by improvements in supply chain and manufacturing compensated for the expected inflationary cost increases.

Next, I will look at cash flow development on Slide 17. In the fourth quarter, operating cash flow strongly increased versus the prior year, mainly driven by higher net income, improvement in cash collection and prior year phasing of income tax payments. Our disciplined use of cash fully aligned with the priorities set out in our capital allocation framework. In the quarter, we purchased existing production sites in Germany that had previously been leased for a total of EUR 181 million. We reduced our net debt and lease liabilities compared to the prior period by 6%. We accelerated our share buyback program, repurchasing over 14 million shares for a total amount of EUR 585 million, representing 4.8% of share capital in 2025. Since the end of the quarter, we have repurchased an additional 4.2 million shares for EUR 163 million. We ended the quarter with a further strengthened net leverage ratio of 2.5x, improving to the lower end of our target band. We reconfirm our target band of 2.5x to 3x.

I will now hand back to Helen.

Thanks, Martin. I will pick up with FME25+ on Slide 18. In 2025, the FME25+ transformation program further accelerated its positive momentum, delivering EUR 238 million in additional sustainable savings for 2025, ahead of the upgraded target of around EUR 220 million. Accumulated savings of the entire program reached EUR 804 million. The successful execution of FME25+ and the strengthened foundation we have established as a result has allowed us to identify additional opportunities to unlock sustainable savings that were not necessarily visible or accessible before.

Also, the flat same-market treatment growth of the last years triggered the decision to further adjust the clinic footprint in the United States while balancing at the same time, the capacity for the expected future growth of 2% plus once mortality has normalized. We have again structurally assessed changes to developing and attractive growth areas across the country and decided to close the least promising clinics in the United States. This results in a footprint rationalization affecting around 100 clinics in 2026. Building on the momentum, we will further accelerate and expand FME25+. We expect costs and savings of EUR 400 million for the years '26 and 2027 for a total of EUR 1.2 billion of sustainable savings by the end of 2027.

Let me now move to our outlook section on Slide 20. To frame our 2026 outlook, I will begin with our most important operational priority, the 5008X rollout in the U.S. This represents the largest transition of clinic infrastructure in Fresenius Medical Care's history. Our large-scale launch of the 5008X is now underway with the target of replacing around 20% of the installed base in our own clinics this year. Importantly, this replacement strategy will deliver substantial benefits, including reduced mortality and improved outcomes for patients, increased operational efficiencies and a stronger competitive position for our U.S. clinic network. However, in the first year of the large-scale rollout, our Care Delivery U.S. business will face an OpEx headwind from rollout-related costs.

In 2026, we will train over 7,200 nurses and technicians and transition about 36,000 patients to the 5008X machine across 28 states. This requires significant training effort, but we expect to improve efficiency as the rollout progresses. We will start to see operational efficiency benefits in converted clinics ramping up as machines are converted. As a reminder, eligible patient can typically be transitioned from HD to HDF within a few weeks. And once patients are on high-volume HDF for 3 months, the improved outcomes, including lower mortality, will start to ramp up over the following 2.5 years. Therefore, we would expect that the positive effects will only start to become visible later in the year with greater benefit to increasingly supporting results in 2027 and beyond.

Still early days, but our rollout is well on track and it's exciting to start to see more and more clinics converted every week. And by the time we get to half year results, I would expect to have a more detailed update on how the rollout is progressing.

I now move on to our outlook for 2026 on Slide 21. Following a significant step-up in profitability in 2025, we are comparing against a very high base in 2026, while significant temporary benefits from TDAPA regulations start to phase out in 2026. Our 2026 outlook underscores our disciplined focus on sustaining this higher baseline. While we expect Care Delivery and Care Enablement to grow, we are assuming broadly flat revenue growth, largely reflecting changes in Value-Based Care's risk contracting and related revenue reductions. For earnings, we assume operating income will remain on a consistent level with an upside/downside range of a mid-single-digit percent change. We clearly target to maintain our enhanced profitability while investing for future value creation and navigating regulatory headwinds. This implies a margin range of 10.5% to 12% at group level.

I'll now hand you back to Martin to walk you through the assumptions between our 2026 outlook on Slide 22.

Thank you, Helen. Starting with revenue. For Care Delivery, we carefully assume flat same market treatment growth in the United States, including a normal flu season similar to the '23-'24 season. This does not change our expectations of returning to 2%-plus as mortality normalizes and patient outflows improve. We are excited about the opportunity to reduce missed treatment and patient outflow by further enhancing the quality and patient outcomes as part of our FME Reignite strategy.

Increasing penetration of high-volume HDF and antimicrobial catheter solutions, further expansion of Value-Based Care as well as benefits from ESRD patients using GLP-1 are supporting this path to 2-plus percent growth. Internationally, we are assuming solid same market treatment growth in 2026, and we assume the usual moderate reimbursement rate increases. Following a significantly greater than anticipated benefit from TDAPA regulation in 2025, we assume a headwind for the starting phase out in 2026, also on the revenue side.

In Value-Based Care, we are assuming negative revenue growth of around EUR 300 million due to changes in risk contracting that result in lower revenue recognition. We do not expect this to impact earnings development.

In Care Enablement, we assume a continuation of the solid organic volume growth. China remains challenging, and we are assuming moderately negative impact as we address regulatory policy changes and review our portfolio and strategy accordingly. At the group level, we are assuming a negative 30 basis point impact from portfolio optimization realized in '25 and '26. Our currency assumptions are based on euro-U.S. dollar rate of 1.18.

Turning to the earnings side. We are assuming EUR 250 million to EUR 350 million of business growth, driven by favorable pricing developments and revenue cycle management initiatives. We expect incremental FME25+ savings of EUR 250 million with related onetime cost of EUR 350 million. We are assuming inflationary pressure of EUR 200 million to EUR 300 million, which includes a typical 3% net labor cost increase as well as the usual cost inflation across all of our operating segments. We are facing regulatory impacts that we assume will impact earnings development by EUR 150 million to EUR 200 million. In Care Delivery, we assume regulatory headwinds from phasing out of phosphate binder, TDAPA contributions and the negative effect from the expiry of the extended tax subsidies for ACA contracts.

Strategic investments of EUR 100 million to EUR 150 million include 5008X rollout costs, mostly in Care Delivery as well as investments in our IT platforms such as the required transition to SAP S/4HANA, supporting the harmonization and standardization of core business processes across our organization. The costs related to the IT platform investment, making up about half of the EUR 100 million to EUR 150 million, will be reflected in our Corporate line. We will continue to further optimize our portfolio in 2026 and assume costs of around EUR 50 million.

To help with your modeling, we are assuming Corporate costs of EUR 200 million to EUR 220 million, a net financial result negative EUR 340 million to EUR 360 million and an effective tax rate of 22% to 24%. And driven by our 5008X rollout, we assume an increased operating income intersegment elimination of around minus EUR 100 million. While we do not provide quarterly guidance, from a high-level phasing perspective, we expect a stronger first half of 2026 before TDAPA benefits begin to phase out in the second half of 2026. This phasing is different to normal patterns for our underlying business and industry.

I will now hand over to Helen for Slide 23.

Thanks, Martin. We knew 2026 will be a transition year, which does not change our aspiration to achieve industry-leading growth and margins. This aspiration remains firmly intact. The year 2026 will serve as a pivotal milestone as we continue to strategically position ourselves for sustained value creation.

During our Capital Markets Day in June, we communicated that margin development in Care Delivery is expected to be more weighted towards the later part of the period, whereas Care Enablement demonstrates a steadier pattern of improvement. To enhance transparency regarding the group's future trajectory, we have added an aspiration for 2028. We see a clear path toward operating income growth, targeting a compound annual growth rate of 3% to 7% through 2028. This growth will be driven by the focused execution of our FME Reignite strategy, which includes the 5008X rollout and our quality strategy to reduce missed treatments and mortality as well as continued progress in revenue cycle management.

In addition, increased sustainable savings from our FME25+ program will contribute to this earnings growth. If we exclude the noise resulting from the interim TDAPA tail and headwinds throughout this period, our implied earnings growth trajectory through 2028 would be in the low teens on a CAGR basis. This shows how strongly the underlying operational performance is unfolding. Our 2030 aspirations are fully underpinned by the strategic priorities and momentum of FME Reignite. At the time of the Capital Markets Day, we have not given explicit revenue growth aspirations to 2030 as the Value-Based Care segment has an inherent volatility from changes in risk contracting, which makes top line forecasting less predictable. Therefore, we have excluded Value-Based Care from our revenue growth aspirations.

For Care Delivery, we anticipate a lower to mid-single-digit revenue growth CAGR. And for Care Enablement, we expect a mid-single-digit revenue growth CAGR.

Our 2030 margin aspirations to achieve industry-leading margins in all of our operating segments remain unchanged. At the group level, we maintain our aspiration to deliver an operating income margin in the mid-teens. We maintain the same 2030 margin aspiration for both Care Delivery and Care Enablement. Recognizing that Value-Based Care is a structurally lower margin business in a relatively nascent industry, we have a low single-digit operating income margin aspiration to 2030. We are well positioned for continued value creation in the years ahead.

That concludes my prepared remarks. And now I'll hand it back to Dominik to begin the Q&A session.

Thank you, Helen. Thank you, Martin. Before I hand over for the Q&A, I would like to remind everyone to limit your questions to 2, please. And with that, I hand it over to Moritz to open the Q&A session, please.

[Operator Instructions] And the first question comes from Hassan from Barclays.

Firstly, if you could please talk about some of the key drivers of the acceleration of EBIT growth from flat at the midpoint of guidance this year to propel you to the midpoint of the '25 to '28 -- 2028 range of 5%? And how much of this is reliant, if at all, on an acceleration in same market treatment growth?

And then secondly, on Care Enablement, could you quantify the drag from China tender modifications and delays in the quarter? And how you're thinking about this persisting throughout 2026?

Thanks, Hassan. I think I'll take both of those and make sure I've got your first question covered. So we'll maybe tag teammate if you need more here. Obviously, what you can see is that we have a flat 2026 versus the midterm growth CAGR of 3 to 7. Obviously, you can hear from the talk outline that we have -- in fact, 2026 is a year of investment both in HDF and in systems platforms. And of course, we're calling out quite explicitly, deliberately the impact from the regulatory pieces of TDAPA and ACA.

I think the way to think about it is as you look at the headwinds and tailwinds slide that we know was quite detailed this year deliberately that you can kind of see the levers of the pluses and minuses and the range that is there. Obviously, there's a lot of underlying operational work that we're focused on. So once you kind of get past the TDAPA and binders piece, the business growth on rate and mix and kind of the business growth and revenue cycle improvements start to come through.

As always, we have the ongoing -- sorry, headwinds of labor and inflation. So kind of -- I think you kind of got the building pieces -- building blocks there. And of course, the accelerated FME25 just adds to all of that. We -- in Care Enablement, that margin improvement is kind of constant over time, both from the top line levers that they're pulling as well as the FME25 levers that they're pulling there. In terms of the kind of the same market treatment growth and what impact, obviously, we're calling it flat. We know where we've been. We kind of obviously have been coming out of December, missed treatments from weather and flu. We haven't seen flu data yet. So we just felt it was safe to call that flat.

And then gradually improve over time to get back to that 2% plus by pulling the levers of the mortality improvement that we outlined on the call, not just our antimicrobial measures, but also HDF as well as all of our quality safety measures as well. So kind of a lot going on there for sure.

In terms of the China drag, clearly, that's been -- let me just maybe frame up China. For Care Enablement, China is about 7% to 10% of the revenue. It's a great market. We like the market. We like the profile. Obviously, with the change in regulatory policies as well as tendering delays, we did have about a 50 million EBIT impact in 2025. We are expecting an impact in '26, but lower than that. But obviously, at the same time, we are looking at how can we maximize. I'll go to kind of our local China by China policies there. So the team is kind of working on that as well. So while there is an impact, it's a lower impact than what it was in 2025. I think I covered everything.

The next question comes from Veronika from Citi.

Two questions for me, please. And apologies they're both focused on the headwinds, I guess, but just trying to understand the moving parts. Helen, thank you for the phosphate binder comment. I just want to confirm that the number there is EUR 220 million and what your expectation is for '26 and '27, as that sort of unwinds? And then related to that, this catheter -- the antimicrobial catheter benefit, I think I caught you saying something along the lines of it should be neutral year-on-year, if you can elaborate on that. I'm very sorry, I'm missing that sort of link how it flows from '25 to '26.

And then my second question is just your thoughts on the ACA subsidy headwinds as we move to '27 and '28. Obviously, your closest competitor has outlined figures for that? Should we use those as a baseline? Or are you expecting the shape of the headwind to look differently either?

Veronika, I'm more than happy to talk about the headwinds. So we have called out regulatory effects of EUR 150 million to EUR 200 million. And that includes the headwinds from both binders as well as ACA. We have also quantified ACA before at around EUR 50 million. We also said we're going to see how it plays out. So we have only quantified 2026. We have not given a further outlook. And we'll see how that plays out in the next weeks and then we might update our assessment in that.

Also in that EUR 150 million to EUR 200 million is the year-over-year decline that we see for binders. To your point, yes, we had about EUR 220 million of positive contribution in 2025. And we have also called out before that we see about EUR 50 million staying in our clinics and another EUR 50 million staying out of our pharmacy business. So there is a headwind or a total positive contribution that stays in '26 for EUR 100 million, leading to a reduction of -- bigger than EUR 100 million from '25 to '26. And those 2 effects combined are the EUR 150 million to EUR 200 million that we have there.

To the catheter lock solution, yes, you heard correctly, there's no year-over-year effect. We do not have an effect because it is still under a limited half for the first half. I hope that clarifies the question.

Veronika, I'm glad you're not the only one to pronounce that. The capital piece is half, half 2 '25 versus half 1 '26 impact. So just to put a finer point on that. That's why the impact is because of the short TDAPA period on one of the solutions. We got a benefit in half 2, mostly towards back end of the year and we're expecting a benefit in half 1 before that TDAPA period expires. So that's why year-over-year, it is neutral, but it will add one key phasing for sure.

The next question comes from Oliver from ODDO BHF.

The first one is on patient volumes. So can you comment on the impact of higher insurance requirements on your patient volume development?

And second question is also on your outlook for the patient volume growth. So you mentioned that missed treatments have stayed at an elevated level, but that's also not really new. Right now, we see flu season is very mild. It's not over yet, but I would say there's a high probability that it's not as goo as it was last year. And later this year, there should also come some of this annualization effect from the higher insurance requirements and as well as slightly improving mortality due to the HVHDF introductions. So if I put all together, it looks for me that the patient volume development must be better than it was in '25. So is it really only, let's say, a conservative stance? Or have I missed anything in this Q&A?

So look, I deliberately used the word careful in terms of our assumption. We're assuming a normal flu season. We saw it go up. We've seen it come back down. I think we can -- looking at what we've seen today, we're saying a normal flu season, not like last year. I think we also know that when you go pick up the headlines this week to see the weather. So we do have elevated missed treatments, whether that be weather, illness, flu. Obviously, as you know we've been pretty consistent on the data lag that we see in 6 to 8 weeks. So by the time we get through Q1, we'll have a better sense.

As we get through Q1, we're also going to have a better read on what open enrollment look like and how the ACA kind of choices actually develop. Open enrollment, why you could say it was the end of the year and you should start to see it in first quarter. Actually, it's not until they enroll and pay the first month premium, do you even know what they talked. So that's going to give us a lag as well. So I think we're watching that closely. Obviously, you'll see the headlines on what the overall enrollment looked like. And obviously, if it didn't drop as much as we expected, then we'll be able to reconcile that accordingly.

And then, as you say, with HDF, we're full steam ahead, converting clinics, converting patients. And while it's too early to see results, we should get the benefits kicking in there. And in fairness, along with the overall underlying improvements that we're working on in -- on mortality, including the catheter lock solutions and just kind of the patient outflows. But we felt with where we are, the right thing to do was to call this flat for 2026. We know we're talking small numbers on small numbers and the small number piece were plus 0.1 or minus 0.1. We know that doesn't make a difference on the kind of on this EBIT range. So we feel like that is the right place to call it for 2026, and we'll update accordingly.

Okay. Can you also comment on the higher insurance requirements, please?

Maybe I'm not understanding the higher insurance requirements question. Are you talking about those people that maybe didn't enroll in ACA and then had to go to a different insurance policy?

Yes. Or let's say, I'm speaking about the active improving -- actively steered improving patient mix, choosing your patients more selectively.

Okay. I think our -- sorry, thank you. There's a lot happening on insurance and enrollment. So thank you for clarifying that. So yes. Look, I think on mix, we're feeling good about our patient mix. I think the only piece that we're watching is -- and that's why it maybe does come back to the ACA comment is how did open enrollment really end up? And did that change -- did we change anything when -- once we see that kind of first month payment come through, but nothing else. I think that nothing else there.

The next question comes from Hugo from BNP.

I have 2. First on U.S. volumes. Helen, if I can push you a bit further. One of your competitors mentioned that they expect a very slow start into the year in negative territory. So just the question is like whether or not you expect to see the same trends at play? And as a result, and assuming that you would also agree with the statement of getting back to 2% volume growth by 2029, how much of U.S. dialysis volume recovery is a prerequisite to achieve the mid-single-digit growth CAGR in Care Enablement? So I guess, how much of the Care Enablement growth is intertwined with the volume recovery in the U.S.?

And second, on FME2025. Historically, you guys had a balanced recognition of both benefits and costs from the efficiency program in FY '26. It seems that you have a bit more of one-off costs that you recognize. So just curious about where exactly the lag between the cost and the benefits comes from.

Thanks, Hugo. I'll take the volume question, and Martin can give a bit more color on the benefits and costs. We touched on some of it.

Look, I -- Q1 is always a tough quarter to know where your volumes are going to be, both with the weather and the flu-related effect. So look, I know where we ended up and you see where we ended up in Q4. I think we just got to wait to see the data to know how Q1 is going to play out. I'm not going to comment on a quarterly phasing here. We kind of really need to kind of see what that first quarter is going to look like with this -- with some of the messiness that we're seeing, particularly on weather. Look, I -- and I'll say market treatment growth, I think all the efforts that we are doing, and I think particularly the excitement around 5008X and all of our patient safety and patient quality initiatives that all go toward reducing hospitalization, improving mortality, reducing missed treatments, all of that will continue to give benefit over time. So I'm not time stamping it, but clearly, we have improvement built into our 3-year and 5-year outlook.

Martin, you want to do FME25?

More than happy to cover the FME25. So you're right, we are front-loading 2026 a bit. And also, we have then in '27 a higher savings contribution. And as you would expect, at the end of the program, a lower onetime cost because we want to have savings effectiveness in 2027 as well.

On the '26 front-loading, you see that a lot of the measures are tilted of the remaining EUR 400 million also towards Care Delivery with 40% contribution. And there, the clinic footprint optimization that Helen referred to as well as efficiencies that we drive in real estate are more front-loaded on the onetime cost and then they will contribute subsequently to the savings. I hope that gives a bit more color.

The next question comes from Graham from UBS.

It's just on the Q4 point around what was obviously a really strong beat, particularly in Care Delivery. I'm just trying to work out the phosphate binder and then this TDAPA catheter contribution. It just looks to me like that was pretty much all of the growth, I suppose, effectively year-over-year. Is that TDAPA payment, does that -- is that like more than half of the EUR 90-odd million that you categorized for the full year '25?

And then just a follow-on. When we think about whatever about '26, when we think about '27, it looks to me that there's still like a further EUR 250-maybe million to come out from TDAPA plus phosphate binders into '27. Is that overstating it? Or how do you think about that in terms of your ability to grow then in '27?

Yes. So Graham, let me tackle the TDAPA contribution and because I outlined in quarter 4 that, yes, there was a contribution from the catheter lock solution of about EUR 70 million in the quarter, and that was due to the much higher than anticipated adoption and prescription that we saw for one of those 2 dilutions that was under TDAPA and the other one is not. So that was something that drove some of the higher contribution, so to say. We outlined that, that solution will be year-over-year, not a head or a tailwind because we expect that it's a similar contribution for 2026. In wholesale in '25, we had EUR 90 million and it was Q3 and Q4 and then in Q1 and Q2 '26. So it will be a non-year-over-year effect, yes.

To the earlier point, I think I was very clear on binders where we ended the year with EUR 220 million, and I outlined how that is. So I'm not going to repeat and dig into that again. But I think with the EUR 150 million to EUR 200 million regulatory headwinds, we have provided also a very clear building block.

Yes, Graham. And maybe I'll just pick up on your -- go ahead.

I was going to say just the relevance for '27, like it just feels like this TDAPA piece was a bit of a -- obviously, a great positive surprise. But just when we think about modeling it going forward, what's going to happen in '27?

Yes. So look, on the -- on both actually, expectation is that TDAPA period ends in 2026, and there will be a payment that then goes into the bundle. So we don't know what that bundle payment will be in 2027 yet or actually even halfway through 2026 for the catheter lock solution. So obviously, we know that some of that's going to stay in the business. And on our pharma business, it doesn't go to 0. What we're going to have to see is go through 2026, so we have an assumption is how the pricing -- how the generic -- sorry, how the branded pricing erodes as the kind of the move towards these products going into bundle develops. So we're not breaking this out year-by-year. It's why we've given the 3-year CAGR. And you also heard me speak to the low teens CAGR we get past all of this binder piece.

So I think there's obviously positive benefit in '25 and '26. It starts to erode in '26, and we have to see how much it erodes that doesn't stay in the bundle in '27. But on the back of that, we've got all the other initiatives taking hold, particularly in Care Delivery, where we start to see a significant benefit from the back-end load of HDF and all the other initiatives. So look, I think what we were trying to do, we've been very explicit on trying to size the TDAPA piece because we recognize -- agree, it's great, always wonderful to have that benefit. But we also recognize how high a base it is giving in 2025. And our goal here is to maintain that high base in '26, regardless of the tail off of these issues -- I shouldn't call it issues, the TDAPA regulations. And we're investing in the future. So we've got this front-end loading for the training costs for HDF and we're investing in systems platforms that will also drive efficiencies in the future.

And our last question comes from James from Jefferies.

Two, if I can, please. And just first one, just a clarification. Can you confirm you said Corporate costs were EUR 200 million to EUR 220 million and intercompany were EUR 100 million for this year. I understand you're prioritizing your own clinics in Care Enablement, so we should see higher eliminations. But why such a large increase in Corporate costs? And is this a permanent step-up as part of your '28 growth outlook? And then I'll come back for a follow-up.

So on the intercompany profit elimination, yes, you're right. We called it out EUR 100 million, and it has to do with the prioritization of the rollout of high volume HDF and that is something on the Corporate line that is being eliminated. So confirming that.

On the Corporate cost, the EUR 200 million to EUR 220 million. I did call out that we have in the Corporate line, the IT platform investments that we included in the investment line that drives a year-over-year increase. That's why the assumption is higher. And in addition, you know that we have that FX impacts that we normally have from the gross charge out of the Corporate line and the global functions, and that is also contributing a low double-digit million in the increase year-over-year. So those 2 effects are explaining the year-over-year.

That's great. And then my follow-up question is, if you could just talk a little bit more about the number of missed treatments in the U.S. At least like the treatment numbers, I think they were lower by 150,000, which I know includes some divestments. And you talked about weather and flu, I think, in some of the comments earlier, but just wondering if you could comment on the perspective, this actually might be a structural headwind because we do understand if patients are entering dialysis, they're increasingly older perhaps kind of post COVID. Maybe they've got more co-morbidities, so they require more hospitalizations and they're missing treatments. And if so, like how can this trend reverse, which does seem to be key to unlocking the same market treatment growth if the funnel is slowing?

Yes. Look, we don't believe it's a structural issue. We do see elevated missed treatments, and we also see specific targeted initiatives that we are targeting that can help bring that down, whether that be the improving mortality, the hospitalization days, the kind of the things that we've talked about.

We do have kind of -- and if anybody has picked this up, but we do have 1 treatment day less in 2025 compared to 2024. That's just a function of how the end of year Christmas holidays and New Year in particular fell. So that's obviously playing into the '25 number. But we feel good about the work that we have ahead of us, and we have line of sight into all these initiatives that will help improve the outflows and kind of confident in that, that will turn to 2% plus same market treatment growth. And we'll start to see that progress as we obviously continue with HDF as well. Thank you for the question.

Thank you. Good. We do have no further questions in the call. So thank you for your patience. Thank you for your interest. Thank you for your good questions. And we'll see all of you or many of you on the road, I hope, in the next 2 months.

Yes. Thanks, everyone.

Thank you.

Great dialogue. Thank you. Bye-bye.

Ladies and gentlemen, the conference is now over. Thank you for choosing Chorus Call, and thank you for participating in the conference. You may now disconnect your lines. Goodbye.

Good morning, everybody. I'm David Adlington. I head up the med tech research group for JPM London.

It's my pleasure this morning to introduce Helen Giza, CEO of Fresenius Medical. There will be a Q&A afterwards. Thank you.

Thank you, David. Good morning, everybody. It's great to be back in San Francisco with you all. The JPMorgan Conference marks an important opportunity each year to reflect on progress as well as to look ahead, and I'm encouraged that the direction we have been setting continues to drive meaningful results.

Today, Fresenius Medical Care is stronger, more resilient and has set a very clear strategy to drive profitable growth and long-term value creation and has already embarked on this strategy. 2026 will be an important transition year on that journey with setting a new standard of care in the United States by starting the large-scale conversion of our clinics with a new therapy. I presented this a year ago at this conference, and today the execution is in full swing.

I won't read the safe harbor statement, you'll be glad to hear, but it applies here.

What gets lost in all the noise on the different topics is that the fundamentals of the kidney care industry remain intact, largely independent of the broader macroeconomic cycles. Structural drivers, including the aging population, chronic conditions like hypertension and diabetes globally, greater recognition of chronic kidney disease as a significant public health crisis continue to support the global demand for life-sustaining kidney replacement therapies. We continue to experience higher elevated mortality, especially here in the United States. However, once this normalizes, we see no reason why we would not return to historic growth levels.

There's also exciting advancements in pharmaceuticals as well as their availability, as well as new technologies enabling patients to live longer, healthier lives. The introduction of high-volume HDF therapy in the United States and the support from expansion in Value-Based Care will drive improved patient outcomes, lower mortality and patient outflow and will reduce missed treatments.

We are excited about the possibility of uptake in some new drugs such as GLP-1s. While they are not a cure for chronic kidney disease and only slow down kidney progression towards end-state renal disease by 6 to 7 months -- months, not years, as a reminder -- they do offer significant cardiovascular protection and reduce mortality in the CKD population. A recent study has also shown a significant benefit for dialysis patients. By using GLP-1s while on dialysis, a 23% improvement in mortality for patients has been seen.

As the need for kidney care continues to grow, the ability to deliver high-quality, innovative care at scale now matters more than ever. This is what sets Fresenius Medical Care apart. We lead kidney care through exceptional patient care and innovation.

We are uniquely positioned as a vertically integrated business with all 3 of our operating segments distinguished by market-leading positions and industry-defining assets. In Care Delivery, we are the global leading provider of kidney care services with over 290,000 patients and over 3,600 clinics around the world. In Value-Based Care, we manage the largest renal value-based care network with over $7 billion in medical costs under management, a network of 2,200-plus nephrologists and over 160,000 patient lives.

In Care Enablement, we have an industry-leading renal med tech portfolio with a diverse international footprint and commanding global market positions. One out of every 2 dialysis patients around the world uses our products. In the important in-center HD market, we have a 40% market share for in-center HD products. And in specific markets, we have a market share north of 80%. This reflects our commitment to both quality and innovation.

Individually, each of our operating segment is a market leader in its own right with compelling scale and market share. But the real value is unlocked when they come together. Care Delivery provides Care Enablement with direct insights into patient needs, which can then be efficiently incorporated into the product development cycle. New technologies can then be implemented by Care Delivery to enhance patient care and drive improved patient outcomes.

The importance of Value-Based Care, which meaningfully increases the uptake of best practices that improves patient outcomes, is a key strategic component and an important source of innovation in patient care. These outcomes directly benefit our patients through extending patient lifespan. They serve to increase the number of lifetime treatments per treatment and per patient, a key lever of growth.

I'm incredibly proud of our track record in execution and ability to deliver on the ambitious strategic commitments that we set for ourselves. Since 2022, we have seen a meaningful improvement in our operating performance. Our operating margin increased each year, from 7.9% at the end of 2022 to 10.3% through the first 9 months of 2025. This was supported by strong momentum in our FME25+ transformation program that should deliver EUR 790 million in sustainable savings in 2025.

We have not just executed, but we have accelerated and enhanced this program. You may remember that we initially targeted EUR 500 million in sustainable savings through 2025 and increased it to EUR 790 million. Through 2027, we have now targeted EUR 1.050 billion for this program, and I'm confident that we can go even faster here.

We have also been increasing shareholder returns. Our 2024 dividend payment was the highest in the company history and reflects a 13% growth CAGR since 2022. In June of last year, we announced an initial EUR 1 billion share buyback program over 2 years. We started in August of 2025 with the first tranche. By the end of December, we had successfully completed the first tranche, repurchasing 4.8% of total share capital for EUR 585 million buying back.

Our strong cash flow generation on the back of continued business momentum has enabled us to accelerate the initial EUR 1 billion share buyback from 2 years to less than 1 year, with the completion expected in May of this year. This demonstrates our consistent execution against our FME Reignite strategy with a focus on value creation for shareholders, in line with our new capital allocation framework.

In parallel, we continue to strengthen our financial profile. We have reduced our target net leverage ratio from -- band to 2.5x to 3x. And since 2022, we have meaningfully reduced our net leverage ratio from 3.4x to 2.6x at the end of the third quarter of 2025.

So while the early January timing of this conference means we have not yet published our Q4 results, there's still a lot to talk about for the first 9 months of 2025. I'm sure you can all appreciate it's this time of year where this year and last year can sometimes get confused. But at our Capital Markets Day in June, we officially launched our new strategy, FME Reignite.

As part of our FME Reignite, we carved out Value-Based Care as our third operating segment, recognizing the growth in that business to nearly EUR 2 billion in revenue and to further enhance our reporting transparency. As I mentioned earlier, we initiated the mentioned EUR 1 billion share buyback program, reflecting our strengthened financial profile and commitment to delivering shareholder value. And in a historical moment, we kicked off the soft launch of our 5008X rollout, introducing high-volume HDF therapy as the new standard of care for the United States.

We accelerated our FME25+ savings program with EUR 187 million in incremental savings through the first 9 months of 2025, putting us well on track to achieve the increased target of EUR 790 million in sustainable savings by the end of 2025. And this supported an improved operating performance with group margin increasing to 10.3% through the first 9 months of the year, driven by all 3 operating segments.

FME Reignite marks the start of a new chapter for Fresenius Medical Care as we transition beyond the phase of turnaround and transformation into a period of accelerated innovation and growth. The word reignite embodies how we will accelerate the realization of the potential of this iconic company. We will reignite kidney care. We will shape and define the future of kidney care.

Our strategy comes to life through 3 strategic elements. One, reignite the core by strengthening our core operations to improve performance. Two, reignite growth and innovation with a focus on profitable growth and bringing new innovative solutions to the market. And three, reignite our culture, to develop together and strengthen our culture.

These 3 strategic elements do not only enable us to lead kidney care into the future, but more importantly, also reignite value creation. This is our path forward designed to achieve our 2030 aspiration of reaching industry-leading mid-teen margins and reigniting value creation with enhancing returns for our shareholders. Our new dividend policy targets a 30% to 40% payout ratio, and we are already delivering on our commitment of a regular share buyback program.

But what matters now is how FME Reignite translates into execution. A lot is underway already, and I would like to share some highlights. At the group level, we will start investing in 2026 in IT platforms to enable the efficient execution of our FME Reignite strategy. And of course, there is the 5008X rollout strategy, which I will highlight in more detail later on.

For Care Delivery, we're advancing to industry-leading margins. This includes driving improvements to realized dialysis rates, and we are beginning to see benefits from our revenue cycle management initiatives. Volume growth and improving patient inflow and outflow within our control is a key focus. And one way we look to reduce patient outflow is by raising the bar on quality even higher, further enhancing clinical outcomes and patient safety.

These initiatives are gaining traction with encouraging early examples from the U.S., such as reducing controllable missed treatments by supporting patient treatment adherence and increasing antimicrobial interventions to reduce infection rates in patients with central venous catheters.

High-volume HDF will be another game changer in improving clinical outcomes and reducing patient outflow. For 2026, the 5008X rollout and major conversion of clinics means that Care Delivery will face in an initial transition period, and as a consequence, a more back-end loaded margin improvement towards 2030.

In Value-Based Care, we are taking responsibility for the integrated health care of our patients and creating mutual value through key quality and outcome initiatives. One example of this is Value-Based Care's strong results driving optimal starts for CKD patients transitioning to ESRD, with an optimal start rate of 2.5x the national average.

Overall for the segment, we are progressing on a path to profitable growth and an aspiration of a low single-digit margin by 2030. It's important to remember that revenue growth is largely a function of contract risk type and whether it increases or even decreases due to a change in contractual risk. That does not necessarily impact operating income contribution. While quarterly volatility remains a factor in this still nascent industry, we do expect more of a continuous margin improvement on an annual basis out to 2030 for Value-Based Care.

And in Care Enablement, we are focused on accelerating profitable growth towards a mid-teens margin aspiration, leveraging our strong global presence and market share. To enable robust growth and margin expansion, we are driving momentum in commercial excellence and operational efficiencies. We are also focused on driving innovation, and the 5008X is just one example of our innovation pipeline. For Care Enablement, we generally expect more of a continuous margin improvement.

HDF is not a new topic for me at JPMorgan, but the difference today is that we are not only talking about it, but we are in full swing with the launch of the 5008X machine in the United States. And HDF might be the best example today of how we leverage our vertically integrated business model to transform the standard of care.

This is incredibly exciting for FME as well as the entire industry, including patients, nephrologists and other providers. It is proven that high-volume HDF treatments result in improved mortality and quality of life for patients. The CONVINCE study demonstrated a 23% lower risk of death, with survival benefits emerging after only 3 months. This is great news for patients and also supportive of our own volumes and reducing patient outflow given the reduction in mortality as well as missed treatments.

The feedback from the first converted clinics is extremely encouraging and rewarding to hear. Patients report feeling significantly better with increased energy levels and improved sleep quality and reduced post-treatment recovery time. Clinic staff have highlighted the benefits of quieter, less stressful workflows, thanks to the enhanced automation of the machine, which supports more efficient and patient-focused care.

And as we look forward to significantly ramping up our launch, it's important to remember that we are executing this rollout from a position of strength already. In the United States, we have a 90% market share for in-center machines. Of the entire installed base of 160,000 machines, 145,000 are FME machines, including 56,000 in our own clinics. For the machines in external clinics, we have only a 66% consumable attachment rate today. And with the introduction of the new machine, we have an aspiration for that to grow to 100% by 2030.

For 2026 specifically, we expect production capacity of up to 15,000 machines available. In our own clinics, we are targeting to convert around 20% of our machines, with the ultimate goal of converting 100% by 2030.

I am confident in our ability to successfully execute this launch. However, this is the biggest transition of clinic infrastructure in the history of the company and it is important that we get it right early on. This is why we took a very controlled and measured approach with our soft launch in 2025, limiting it to a handful of clinics, which has provided us with valuable learnings and insights, allowing us to further enhance and refine the clinic training and conversion process.

In 2026, we are now targeting around 20% of the installed base in our clinics to be replaced with the 5008X. And although the replacement strategy for FME clinics is CapEx-light, the first year comes with an OpEx headwind for the rollout costs of a mid to high double-digit million euro, depending on the amount of speed of implementation.

This is why I'm calling 2026 a transition year. In 2026, we will train over 7,200 nurses and technicians and transition about 36,000 patients to the 5008X machine across 28 states. This requires significant training efforts, but we expect to improve efficiency as the rollout progresses.

We will also start to see operational efficiency benefits in converted clinics ramping up after conversion. Additionally, we can then start to transition eligible patients over a couple of weeks from HD to HDF to high-volume HDF therapy. And once they are 3 months on high-volume HDF therapy, the medical benefits of lower mortality will start to ramp up over the following 2.5 years.

In 2026, the positive effects will ramp up only towards the end of the year, hence, the benefits of 2026 rollout will be helping in 2027. And as we proceed with a significant transition in 2027, the efficiencies and improvements in mortality and utilization realized from the 2026 rollout will help mitigate associated costs in 2027. The year 2026 remains designated as our transition period within the broader multiyear infrastructure upgrade plan.

An important dimension of our business that is underestimated is the strength of our cash generation. Through 2030, we expect to deliver operating cash flow above EUR 2.5 billion annually. As mentioned before, in alignment with our FME strategy, we introduced a new capital allocation framework designed to reignite value creation by driving enhanced shareholder returns. This includes our updated dividend policy and the regular share buyback program.

Through September reporting, we are well on track to deliver our outlook for 2025. We expect to be at the very top end of our revenue growth range for 2025. We've also confirmed our operating income guidance of high-teens to high 20s percent growth, which reflects a meaningful step change in our earnings base. Through the first 9 months of the year, we were already at 18% earnings growth, and expect further acceleration in the fourth quarter.

In any business there's puts and takes, and in Care Delivery, reimbursement for phosphate binders has been a strong benefit supporting growth in that business in 2025. In Care Enablement, we are facing additional headwinds in China from modifications in tender requirements, along with delays in the tendering process.

And as you all know by now, we won't provide our outlook and assumptions for 2026 until our full year results on February 24. However, I do want to give you a sense of the additional moving pieces that we are considering for 2026.

As I just described, the 5008X launch is a major undertaking with OpEx headwinds, and 2026 will be more of a transition year for Care Delivery, with rollout costs of mid to high double-digit million euro depending on the speed of implementation. We are still unpacking underlying volume development through the end of '25, obviously tracking the current flu season, all of which will help inform our 2026 assumption.

Phosphate binders provided an unanticipated benefit of our pharma business in 2025. On our Q3 earnings call, we shared that this additional advantage to be about EUR 80 million, bringing the total benefit to EUR 180 million for the full year. We do not anticipate this additional EUR 80 million benefit to recur in 2026. However, the remaining EUR 100 million is expected to continue into 2026.

As previously communicated, we are assuming a headwind of around EUR 50 million from the expiration of ACA enhanced tax subsidies. And for our Care Enablement business in China, we are currently evaluating the consequences and potential impacts of the modifications in tender requirements for 2026, while further developing our strategic approach in that market.

At the same time, we plan to continue with full speed on our FME25+ savings program and are looking into further potential. Having accelerated by EUR 40 million in 2025 does not impact our EUR 150 million target for 2026.

At its core, Fresenius Medical Care is a highly cash-generative business. We have demonstrated strict financial discipline and a clear prioritization of shareholder returns while maintaining an investment-grade credit rating. We operate in a structurally growing market globally driven by a chronic disease with long-term demand.

What really sets Fresenius Medical Care apart is our vertically integrated business model with market-leading assets and strong competitive positioning across Care Delivery, Value-Based Care and Care Enablement. Innovation is embedded in our DNA, and we are on track to once again set a new standard of care with high-volume HDF in the United States, which creates meaningful benefits for patients and a tremendous opportunity for our business. All of this underpins a clear path to industry-leading profitability on our aspiration of a mid-teens margins profile by 2030.

While we have indicated that 2026 will be a necessary transition year as we scale up our 5008X rollout, our execution track record gives us confidence in our ability to deliver. Taken together, this is why we believe Fresenius Medical Care is clearly positioned to drive long-term value creation.

With that, I hand back to you, David, for questions.

Great. Thanks, Helen. So one of the discussions we've been having over several years now is just the volume impact on the industry. Obviously, we had the COVID impacts, and we've not really seen a recovery to pre-COVID levels. Both you and DaVita pointed towards an expectation at this conference last year and the year before of recovery. We still haven't seen it. I think the number of patients coming in has recovered, it's just you were seeing a higher level of mortality. I just wondered if there's any sort of further color around that and what might change that going forward.

Yes. Look -- am I -- you can hear me, right? Yes. Obviously, in the peak of COVID, we were hit with about 300 basis points of negative volume growth. And obviously, in the last few quarters, we are sitting here now with pretty much flat volume growth. And we're increasingly trying to put the narrative less about that net number, but really focusing on the inflows and the outflows, inflows being new patients coming in, outflows keeping patients on therapy or kind of reducing mortality.

And you're absolutely right, we don't have an inflow problem. We are seeing new patients coming in. What we have is an outflow problem. Mortality has still remained elevated post-COVID. And at the same time, we have an increasing missed treatments, not mistreatments, missed treatments phenomena happening with our patients.

So the work that we are doing, and we have clear line of sight into the work that we need to do in the operations that's really focused on reducing hospitalizations. We've got an increasing catheter usage in our patients. So work is focused on reducing catheter-related bloodstream infections, reducing hospitalizations. High engagement with patients to kind of reinforce that, while you think you might get away with coming 2 times a week instead of 3 on any given week, that is not good for your survival outcomes. So all that work is starting to take hold and pay dividends.

As you saw from the very first slide, we don't believe that the underlying fundamentals of this business are broken. We're actually encouraged by the uptake in the new class of drugs and the cardiovascular benefit that that provides. So I think it's just a question of time all the measures taking hold. And there's no reason for us to believe that we get back to the 2% plus that we saw pre-COVID. It's just been one of time.

And what's changed the dynamics in terms of the patients trying to reduce their number of visits to the clinic?

Yes. As you can appreciate, we have the world's largest renal database, we have a lot of information and data on our patients. And we have been constantly trying to unpack that, what's happening. When we look at our data, what we are seeing is those patients who have been on dialysis for longer and maybe survived the COVID period, somehow in COVID, many of those patients learned that while optimal treatment is 3 times a week, every week, we are seeing them skip treatments every now and again.

Obviously, that is part of the reason likely for the elevated mortality. Obviously, mortality is still elevated from the severe flu season that we saw in Q2 last year. But people can miss treatments from a whole host of reasons. Some of those haven't changed, David, as you know, over the years, whether that be transportation, they don't feel well, they just don't feel like coming.

So what we're learning is that this has to be one on the local ground, clinic by clinic. And the intimate patient knowledge that a clinic manager has of the patients that are scheduled in the clinic, we need to be on top of those patients' treatment behaviors right away. If somebody is missing a treatment today, we need to be calling them today. We need to get them rescheduled for tomorrow.

So we, through the Care Delivery kind of fixing of many things that needed to be fixing, we're also realigning that structure within the clinic manager process as well. So we're chipping away at a clinic by clinic, patient by patient, but it is definitely a changing paradigm since COVID.

Okay. Perfect. And then you mentioned flu there. Obviously, it's a strange season last year, it was very late. This year it's early.

Right. I know. Since I've been here, in 6 years, I don't think I've had 2 flu seasons in the same year. So this one is a first. Obviously, in 2025, we saw flu season start in February and go through February, March and April. And now we've got flu season starting in December.

What I was encouraged by, and I gave that narrative on the Q3 call, was with the current kind of narrative or rhetoric from the U.S. government on vaccinations, I was honestly concerned that our vaccination levels were going to be lower. Obviously, we have a very vulnerable patient population, so them not getting vaccinated is a problem. I was really encouraged by -- on Q3, that we saw the vaccination numbers high, like in the mid-70s, by Q3. That has continued through December. We see now a similar level of vaccinations in our patients by December.

What I can also see is a higher number of missed treatments in December. What I can't do yet, until I get the 6 to 8-week data lag that we have on mortality, is what impact that really had on patients and whether it was just a missed treatment or did it add to mortality. I don't know how much more color we have on that by the time we get to earnings on February 24. But obviously, we're tracking the season closely.

Okay. Perfect. And then one of the other things you actually called out in the slides, which is helpful, in terms of the change in ACA subsidies and what sort of headwinds they might present this year, there's a lot of uncertainty around what might actually happen there. But as we stand today, they've gone. Has that actually impacted patient behavior already?

Yes. I mean, gosh, you're going to change those subsidies right in the middle of open enrollment and it's -- it couldn't have -- all that narrative couldn't have happened at a worse time in the -- kind of in the insurance system. So we are assuming that the subsidies are gone. While it's still in the Senate, we're not hopeful that that is going to pass. So we're assuming it's gone.

What is going to be really difficult is all of these patients through the open enrollment period at the end of last year had to make a choice. And what we don't know yet are those patients who are already in an exchange, did they stay in exchange hoping a subsidy might come through? Or did they make a shift so that they could be in control of what their outcomes were for insurance?

We know our patient population likes to be insured. And we've seen that all through COVID, they're sticky. So we have made an assumption of where we think those patients will go in line with our current patient mix. Enrollment is still open for the exchanges, believe it or not, until January 15. We won't know what happens till it closes. And there's a further wrinkle that until they pay their first premium or first month of premium, they won't actually get coverage. So we really won't know what's going to happen here, I'm thinking, until end of Q1, of where we really see how our patient mix kind of shook out.

So yes, it's a nice one to try and predict. But I think we're holding to our assumption of around a EUR 50 million headwind. We'll see once we get the open enrollment numbers.

Perfect. And then one of the tailwinds you had in recent years is that shift to Medicare Advantage as well.

Yes.

How are you feeling about that? Is it a bit further than you expected originally?

Don't quote me.

But do you see that plateauing here? Or is there a risk that actually moves the other way?

Yes. I'm smiling because with the Cures Act in '21, we were sitting about 16% or 17% of MA. And if you remember, David, I was like, there's no reason to believe that this MA book business can't get to 35% in 3 to 5 years. And yes, we were there, what, in 2 years? Yes.

So now we're sitting with a Medicare Advantage book of business that's mid-40s. I -- from what we can see, it looks like that will hold. We're not expecting any major changes up or down. We feel pretty good about the stickiness of that MA book of business. But again, it will be interesting to see if the exchange shakeout has any implication on that too. But we're feeling good about the mid-40s.

Perfect. And then obviously, a lot of focus in this presentation and through last year on HDF.

My favorite topic.

Obviously, it's been approved in Europe for a long time.

Yes.

It's taken a lot -- unusually, it's taken longer to come to the U.S. Maybe you could just, for the people in the room, remind us why that is the case.

Yes. Am I allowed to say, before my time? Yes. No, look, you're right, this technology has been available in Europe for a decade. In Europe, about 75% of the patients are on HDF therapy. And the mortality levels in Europe are around 12%. The CONVINCE study shows that HDF moves mortality by 23%, which directly translate to mortality in the U.S. being around 17%. So we can all see the benefits.

Look, I think this machine when it was kind of maybe first available for the U.S., was pre-COVID, where volumes weren't an issue, where nobody, I can say before my time, nobody felt like they needed to buy a new, more expensive machine, or incur significant cost for training on that new machine. Obviously, that was before the CONVINCE study.

So when we think about innovation and connecting the dots on innovation and outcomes for patients, clearly, it all came together at a perfect time. When I was reevaluating the portfolio, I'd say I inherited when I became CEO, and it was very -- it was clear that this was a significant opportunity for us. So obviously, the CONVINCE study and the FDA approval all at the same time and then really shaping the future strategy for this has all happened in the last, I guess, last 2 years.

And you mentioned there that last year you've had a relatively conservative rollout and you wanted to learn a lot of things about that rollout. What were the key learnings that you took away?

Yes. Look, we got approval from the FDA for the base guts of the machine, for want of a better word, in May of last year. We also knew that we had this opportunity to upgrade the connectivity on the system side. And rather than rolling it out and then upgrading later, we did make the conscious decision to roll out the version 2.0, if you will, later in the year.

We have not had any innovation in this industry in 40 years. This is, as I mentioned in my comments, this will be a significant undertaking, and we wanted to make sure that while it's a similar machine to Europe, it's not exactly the same. It is U.S. specific. And we wanted to make sure that we could iron out any kinks that might exist sooner rather than later. So we have -- our learnings are kind of getting used to the machine, the training. I mean it's not just a new machine, it's new consumables that are integrated. And then making sure that we could track and see the patient experience and the benefits.

So it was deliberate on our part to get it right. As you know, we also plan to sell this to other third-party providers. We want to be the testing ground for that before we sell it. But in all honesty, it's been incredible. I mean the color that I mentioned in my comments from our patients is real. I mean if you and I are sitting in 2 dialysis chairs and you're on HDF and I'm not, I am saying, "I want what you're having." It's very, very visible benefit. So we're all systems go. I mean we have -- we soft-launched last year with a handful of clinics. As you say, we've got about, whatever, I think just under 12,000 teams, and we're off, off and running.

We also have to minimize disruption, right? So we wanted to make sure we weren't doing too much too soon. And if something did go wrong, and touch wood it doesn't, that we didn't have kind of massive disruption. I know what that felt like in the summer of '22. We won't go through that again in this company's history.

And is the plan to convert an entire clinic to the new machines that's...

Yes, exactly. So we've been very targeted in the strategy of the launch plan. We've got 2,600 clinics in the U.S. We are stratifying them by the clinics that are performing well, that they're growing, that they have a high degree of commercial mix. Ideally, they already have an almost fully depreciated current installed base. And then obviously, if we have an opportunity to gain market share in that particular area, that's our sweet spot.

So we won't go region by region, we won't go state by state. We will absolutely go clinic by clinic based on that criteria. And that's why we're in Massachusetts, we're in Florida, we're in Minnesota. We are going top clinic to bottom clinic.

Perfect. And do you have evidence that it's actually being used as a way of gaining patients for those clinics?

Maybe too early to tell, but we expect that to be the case. Once we've got a clinic fully operational on this -- big part of the strategy has been the nephrologists' engagements, making sure that they are supportive so that they can refer the patients. And if I'm a nephrologist who is all in on HDF, our belief they will refer to us versus a clinic that doesn't have it.

Okay. And so at what point do you switch supplying only your own clinics to -- there will hopefully be some decent demand from some of your competitor clinics.

Indeed. And there's definitely -- Katarzyna is retired now, but Katarzyna would tell you demand isn't our problem. So obviously, the advantage of being vertically integrated is I want to maximize my first mover advantage and I want to get it in my clinics first. We have production capacity for about 15,000 machines a year; we will plan to do about 20% a year in our own clinics. And then the excess that is created through production and our own demand will be allocated to the other providers. And the other providers are welcome to place their purchase orders.

Perfect. I'm afraid we're out of time, but thank you very much.

Thank you. Thanks, everybody.

Ladies and gentlemen, welcome to the report on the Third Quarter 2025 Conference Call. I am Sandra, the Chorus Call operator. [Operator Instructions] The conference is being recorded. The presentation will be followed by a Q&A session. [Operator Instructions] At this time, it's my pleasure to hand over to Dr. Dominik Heger. Please go ahead, sir.

Thank you, Sandra. Welcome, everyone, to our earnings call for the third quarter 2025. As always, I start out the call by mentioning our cautionary language that is in our safe harbor statement as well as in our presentation and in all the materials that we have distributed earlier today. For further details concerning risks and uncertainties, please refer to these documents and to our SEC filings.

We will have roughly 1 hour for the call. In order to give everyone the chance to ask questions, we would limit the number of questions to two. Thank you for making this work. As always, let me now welcome Helen Giza, CEO and Chair of the Management Board; and Martin Fischer, our Chief Financial Officer. Helen, the floor is yours.

Thank you, Dominik. I'd also like to extend a warm welcome to everyone on the call. Thank you for taking the time to join us today and your continued interest in Fresenius Medical Care. As many of you know, the U.S. is in government shutdown since the 1st of October, and many health care policy decisions are open, like the questions of extended tax subsidies for the exchanges and whether they will expire by the end of this year or the publication of final 2026 ESRD PPS rule. This requires us to remain flexible in planning and agile in running our business.

We remain focused on what we can influence. In Q3, we made meaningful progress in advancing our FME Reignite strategy and positioning ourselves for sustained value creation. Our strong third quarter results reflect continued momentum and disciplined execution as we further accelerated top line growth while delivering a clear step-up in earnings growth and profitability. The step-up is in line with our full year planning. I will begin my prepared remarks on Slide 4.

In the third quarter, we realized strong organic revenue growth of 10%, with positive contributions from all 3 operating segments. In the U.S., same market treatment growth was slightly positive. This is in line with our assumption of flat to slightly positive growth for 2025. Operating income growth increased for a third consecutive quarter and accelerated to 28%.

As a result, this drove a step change in profitability with our operating income margin expanding from 9.9% to 11.7%. The improvement in profitability was supported by continued momentum in our FME25+ program, which generated a further EUR 47 million in sustainable savings in the quarter. This brings us already to EUR 174 million of savings for 2025. As part of our new FME Reignite strategy and capital allocation framework, we announced an initial share buyback of EUR 1 billion, in line with our commitment to reignite value creation for shareholders.

The share buyback program officially commenced in August with a first tranche of up to EUR 600 million. Through 30th of September, 3.6 million shares had been repurchased for a total investment amount of EUR 151 million, and until October 31, we have repurchased in total 4.35 million shares for a total investment of EUR 188 million. For full year 2025, we are very well on track to achieve our outlook for the year and therefore reiterate our guidance.

Next, on Slide 5. The American Society of Nephrology's Kidney Week takes place in Houston this week. Already last year, we saw a lot of interest in high-volume HDF and our 5008X machine at the ASN. I do expect a high level of interest and engagement again this year, especially as we start the 5008X rollout. And with that, a new therapy becomes available in the United States. This will set a new standard of care. We submitted around a dozen of clinical abstracts that are specifically focused on high-volume HDF. From the risk reduction resulting from HDF therapy to the implementation of HDF in clinics to AI support for clinicians during implementation.

Besides the scientific side of HDF, it's also great to see how the feedback is from nephrologists that visited one of our clinics that are already run with HDF, and I want to share what they said. Being able to see the human experience of HVHDF firsthand was one of the most pivotal moments for me and given our mission and the potential of the HVHDF therapy, we would love to explore having our clinics serve as index centers for the North American rollout of this modality.

This shows that we are not only excited about the broad rollout in '26, but how well prepared we are in all dimensions and how well received it might be. Next on Slide 6. With the launch of the FME Reignite strategy, we have committed to reignite growth and innovation across our organization. In care delivery, we are supporting overall volume growth by raising the bar on quality even higher, further enhancing clinical outcomes and patient safety. This is especially important to me because it directly reflects our purpose-driven patient-centric approach where the patient is at the heart of everything we do.

We are already seeing encouraging progress on our quality and safety initiatives, and I would like to share some examples from the U.S. market. Treatment adherence is a key focus as patients with chronic illnesses often struggle to adhere to their care plans. This frequently involves helping our patients to understand the importance of sticking to their treatment plan and working with them to remove barriers. Since the beginning of this year, controllable missed treatments have decreased due to improved alignment amongst physicians, patients and clinicians.

Many ESRD patients begin dialysis with a central venous catheter, which while necessary, poses a high infection risk. Although our long-term goal is to transition patients to permanent access, bloodstream infection prevention remains even more critical during this period. Antimicrobial interventions reduce infection rates by 70% compared to conventional care.

In August, we launched a program to further increase antimicrobial catheter treatments to eligible patients. Adoption to date has been strong with 84% of eligible catheter patients now receiving bloodstream infection protection, and we are on track to achieve even greater utilization.

Protection against the flu is especially critical for our vulnerable patient population. And because flu strains change yearly, annual vaccination is necessary to maintain protection. Our U.S. clinic network has launched its annual vaccination campaign and vaccination rates are 34% higher than where they were at this point in 2024. We already have more than 72% of our patients vaccinated. And like in previous years, we expect to come to 85% before the end of the year.

These are just a few examples of reducing hospitalization and costs for the health care system and at the same time, increasing the number of treatments, while improving patient outcomes and reducing mortality over time. I'm extremely proud of the work we are doing and the results we are already achieving. It gives me great confidence and excitement for the path ahead.

Turning to Slide 7. This quarter, we saw strong execution across all 3 of our operating segments. I will take you through some of the key highlights by segment. In care delivery, in line with our expectations, U.S. same-market treatment growth was slightly positive with 0.1%. This reflected the carryover effect from elevated mortality, which was driven by the severe flu season earlier in the year and positively offset by improving admissions as well as slight improvements in missed treatments.

In our international markets, same market treatment growth increased to 1.2%. Third quarter care delivery performance benefited from favorable rate and mix development in the U.S. as well as accelerated contributions from phosphate binders in our pharma business. We further executed on our portfolio optimization plan, closing clinic divestitures in Brazil, Malaysia and some other smaller markets. One highlight from me in care delivery, which I'm sure it comes as no surprise, is the availability of high-volume HDF treatments in select U.S. Clinics. We are progressing every day and are very encouraged by the initial feedback we have heard from our patients that have been receiving HDF treatments.

The work we are doing is paying off, and I'm very proud of the team's focus and execution while never wavering on the highest quality of patient care. These patients report feeling significantly better with increased energy levels and improved sleep quality and reduced post-treatment recovery time. Clinic staff have highlighted the benefits of quieter, less stressful workflows, thanks to the enhanced automation of the machine, which supports more efficient and patient-focused care. The excitement is palpable.

While we are not expecting this to be a major driver of operational performance this year, our learnings are rapid from the early rollout of select clinics, which is providing valuable insights allowing us to further enhance and refine the clinic training and conversion process. This will set us up for a seamless large-scale launch in 2026, which will be the start of the broad transition of our clinic network.

Turning to Value-Based Care. As expected, we continue to face a degree of earnings fluctuations. We are also facing delays to 2026 by CMS in providing reporting data for the CKCC program, which adds to these fluctuations as these cannot be planned. In Value-Based Care, we realized a higher number of member months due to continued contracting growth as well as a growing network of providers, and we are further enhancing our care models through increased use of artificial intelligence.

As part of our Reignite Strategy, we took an important step forward by increasing and strengthening our ownership stake in our Value-Based Care asset Interwell Health. This reinforces our leadership position in renal Value-Based Care, which is supported by the vertical integration benefits for our business model offers.

With this step, we are better able to leverage the full scale and size that Fresenius Medical Care as a total company offers. This and the underlying progress we are already making in Value-Based Care is positioning this business for long term, more profitable growth. Care Enablement delivered another strong quarter, supported by volume growth and positive pricing momentum overall.

We continued to capture sustainable savings as part of FME25+, driven by disciplined execution of the next level of footprint optimization across both manufacturing and supply chain. And as a result, our Care Enablement margin further progressed compared to the prior year despite being increasingly challenged by transactional exchange rate impact.

I will now hand over to Martin to take you through the financial performance in more detail.

Thank you, Helen, and welcome to everyone on the call also from my side. I will pick up on Slide 9. In the third quarter, we achieved organic revenue growth of 10%, with all 3 segments contributing to this strong performance. At constant currency, revenue increased by 8%. We continue to divest assets as part of our portfolio optimization plan. Divestitures negatively impacted revenue development by 60 basis points. Operating income, excluding special items, increased by 28% on a constant currency basis. This significant increase led to a clear step change in the group margin to 11.7%, well into the implied range of 11% to 12% for 2025.

Special items negatively affected operating income by around EUR 100 million. This comprises costs relating to FME25+ and our continued portfolio optimization as well as effects from the remeasurement of our investment in Humacyte. Next, on Slide 10. This slide breaks down the significant 180 basis points margin improvement. All 3 segments contributed to the positive margin development with an especially strong contribution from Care Delivery. Net Corporate costs developed favorably by EUR 19 million. This was primarily driven by virtual power purchase agreements with around EUR 20 million and Corporate costs broadly stable otherwise.

Foreign exchange rates developed unfavorably with a negative EUR 24 million translational impact. The average U.S. dollar exchange rate in quarter 3 was 1.17 compared to 1.13 in the second quarter. I will now walk you through the financial developments in each segment, starting with Care Delivery on Page 11. Care Delivery realized organic revenue growth of 6%, supported by both Care Delivery U.S. and International. In the U.S., organic growth of 6% was driven by favorable rate and payer mix development. Positive contributions from phosphate binders as well as reduced implicit price concessions, which demonstrate our progress on active revenue cycle management.

Internationally, we realized strong organic growth of 4%, including 1.2% same market treatment growth. The continued execution of our portfolio optimization plan negatively impacted Care Delivery revenue development by 120 basis points. Care Delivery significantly improved profitability in the third quarter with a margin of 14.5%, it is at the upper end of our 2025 target margin band. While we still saw muted same market treatment growth, the business growth was supported by positive rate and mix effects and additional higher contributions by phosphate binders in our pharma business. These factors compensated for the missing income from the consent agreement on pharmaceuticals, which we had in the third quarter of last year.

The phasing is different this year, and we do expect this to come in the fourth quarter, but at a lower level. Higher sustainable savings through FME25+ helped to partially compensate for higher labor costs, including elevated medical benefit costs. The unfavorable development of exchange rates also had a sizable negative impact on operating income.

Let us move to Slide 12 to review the development in Value-Based Care. Value-Based Care further accelerated revenue growth, realizing 42% organic growth. This significant increase was driven by a high number of member months, mainly due to continued contracting growth. The higher growth in Value-Based Care is also driven by gross revenue recognition instead of net revenue recognition of a major contract. This change does not result in additional earnings growth.

Operating income in Value-Based Care amounted to a loss of EUR 21 million compared to a loss of EUR 37 million in the prior year. This reflects the quarterly earnings fluctuations that are inherent to this business model. As mentioned by Helen, we are also facing delays to 2026 by CMS in providing reporting data for the CKCC program, leading to a delayed revenue recognition. Due to this shift, we assume a slightly more negative operating income contribution from the Value-Based Care segment. I will provide an overview of the financial performance in our Care Enablement segment on Slide 13.

The Care Enablement realized strong revenue and organic growth of 5%. Revenue development was driven by solid volume growth and continued positive price momentum. Care Enablement achieved a 38% increase in operating income, leading to a margin increase of 200 basis points to 7.6%, in line with our expected phasing for the year. Business growth was, as mentioned, driven by volumes and pricing, which was partially offset by higher-than-expected and increasing currency transaction losses. Further sustainable savings from the FME25+ program compensated for the expected inflationary cost increases.

Moving to Slide 14. Due to the cash flow disruptions from the Change Healthcare cyber incident in 2024, it is more useful to assess cash flow development on a 9-month basis. We have realized strong cash flow development through the first 9 months of the year, with operating cash flow increasing 8% year-to-date. In the third quarter, operating cash flow declined compared to an inflated prior year base that benefited from around EUR 400 million in catch-up reimbursement following the Change Healthcare cyber incident.

The negative year-over-year effect was partially offset by favorable working capital developments in this quarter. Our disciplined use of cash reflects the priorities set out in our new capital allocation framework, which is designed to reignite value creation. We reduced our net debt and lease liabilities compared to the prior year period. As highlighted by Helen, our share buyback program is well underway.

By the end of September, we repurchased 3.6 million shares or 1.2% of our share capital with an investment volume of EUR 151 million. In addition, we invested EUR 312 million in the third quarter to strengthen the ownership in our Value-Based Care asset Interwell Health. This is reflected in financing cash flow. In parallel, we ended the quarter with a further strengthened net leverage ratio of 2.6x, well within our target range of 2.5 to 3x.

I will now hand back to Helen to review our outlook.

Thank you, Martin. I will finish my prepared remarks on Slide 16. The strong growth in our Value-Based Care segment due to the type of revenue recognition of one contract results in stronger-than-expected revenue growth in this segment. Therefore, we expect to be at the very top end of our low single-digit percent revenue growth range for 2025. As explained, this growth in Value-Based Care driven purely by contract type related revenue recognition does not drive additional operating income growth.

Looking at operating income growth for the group. We have shown continued progress through the first 9 months with an expected acceleration in the third quarter. This brings us to 18% operating income growth in the first 9 months. We are not only in our target range of high teens to high 20s percent operating income growth already, but also demonstrate with 11.7% a new and improved level of profitability despite a challenging environment and very low same-market treatment growth in the U.S. When I look at the big picture for 2025, we are confident in our continued improvement of our underlying business. With 9 months under our belt, we would like to update you on our latest thinking for the operating income development for the year.

The positive momentum in FME25+ will deliver around EUR 40 million more, delivering around EUR 220 million full year, helping us to directly offset the increasing medical benefit costs. The acceleration in the third quarter of our pharma business contributions from phosphate binders is now estimated to be around EUR 80 million higher than the assumed EUR 100 million. This is helping to offset the full year headwind from lower volumes in the U.S. and the increased foreign exchange transaction headwinds.

As always, the fourth quarter is our strongest quarter. We do expect further acceleration in earnings growth and margin expansion. With all that I just outlined above and our 18% operating income growth in the first 9 months, we are not only already above the bottom end of the range, but we are confident in confirming our full operating income guidance range for 2025. As we approach year-end, I know many of you will want further insight into our outlook and assumptions for 2026.

To manage expectations here, we are currently in our planning process for 2026. And I'm sure you can all appreciate that there are several moving pieces. In addition to the normal headwinds and tailwinds we navigate any given year, we also need to see how mix evolves for phosphate binders and to what extent price erosion will impact our pharma business. What happens to extended ACA tax subsidies, the final CMS pricing for '26 as well as the potential impact of new tariffs and pharmaceuticals pricing. We acknowledge the key KPI is next year's same market treatment growth. Our Q4 volume data will clarify trends in mortality, referrals and overall volume, shaping next year's outlook. Just like every year, we will share our 2026 outlook along with our full year results in February.

With that, I'll hand this back to Dominik to start the Q&A.

Thank you, Helen. Thank you, Martin, for the presentation and the updates. Before I hand over to the Q&A, I would like to remind everyone to limit the questions to 2. If we have time over, we can go another round.

With that, I hand it over to Sandra to open the Q&A, please.

[Operator Instructions]

Our first question comes from Oliver Metzger from ODDO BHF.

First is on your guidance on the margin guidance. So in your slides, you showed that the Care Delivery already stands at the top end of your expectations. And having said this, do you see the stronger progression in Q4 coming over relatively spoken from Care Enablement? Or do you expect due to the timing of payments, a step-up in Value-Based Care.

Second question is on the treatment adherence. So technically, beneath mortality, it's definitely one of the areas where you're not where you want to be. Do you see -- because COVID is already 5 to 6 years or 5 years ago. And you see that you commented that the patients who were -- patients during COVID have a lower adherence than the patients who you recruited afterwards. So do you still this normalization in form of over time patients just passing away due to the normal mortality? Or do you see that there's still some other reasons why this level is elevated?

Look, on your first question regarding guidance, we do expect to see continuous improvement in all segments, but we also see strong support from Care Delivery. On your second question, I'll make sure I unpack all those pieces in there. In terms of -- I think you started with treatment adherence and also kind of wrapped up in their reasons for mortality. There's no question, our mortality levels are still elevated. But where we're focusing on things that we can control are seeing an improvement in missed treatment. Obviously, those areas that we can control, if we can make sure our patients continue to get their treatments, that obviously helps with treatment volume and we are seeing those improvements in referrals. So obviously, we work hard on those missed treatments because that has a double effect on improving the number of treatments, but also ultimately, if the patients keep getting their treatments should help with mortality as well.

And as you saw from one of my opening slides, we're also working on our catheter rates kind of coming down as well. So all of that should help mortality just tied up with our general strategy of the focus on patient quality and patient safety. In terms of your comment on the passing away, maybe reason code. I don't know that we can tease out that if anything different. I mean there was a time in COVID that you could kind of get the COVID piece. And if you remember, we used to report that as excess mortality. Now we just pass it all as the general mortality, and there's nothing in those trends or that data that is telling us it's anything new or different. It's just that it continues to stay -- it continues to be elevated.

I was referring towards the patients who were already on dialysis during COVID that they have a higher average number of missed treatments compared to the patients who came to dialysis afterwards.

Yes, that would have been the case because they were already kind of vulnerable and those that were with us during COVID would have had more missed treatments than that we see in maybe new patients coming in. Sorry, I misunderstood that direct question on COVID.

The next question comes from Veronika from Citibank.

And hopefully, you can hear me okay. I have 2, please. One, I just want to go back, Helen, to your comment on phosphate binders, apologies. There's a lot of numbers, and I probably misunderstood it, but I just want to confirm that you are now expecting EUR 180 million of benefit from phosphate binders this year versus the EUR 100 million that was assumed in the guidance previously? And I guess just to play a little bit of devil's advocate. If I strip that EUR 180 million out of the Care Delivery margin trajectory, obviously I don't know exactly how much you booked in the 3 quarters of the year versus the full year, but it doesn't seem like there is a huge amount of margin improvement underlying in the business.

Tell me if I'm doing that math wrong, I did it very quickly on the slide, but I just kind of would love to understand what you're seeing margin-wise, if you strip out the phosphate binders. And then my second question is just looking to 2026, and Medicare Advantage trends in particular, we are seeing some early signs of reduced enrollment. I'm curious how you're thinking about mix as we head into next year from a Medicare Advantage perspective. And to what extent we should be thinking about this maybe no longer being a tailwind to the business into next year?

Yes. Thanks, Veronica. I think I can tackle both of those. Sorry, I may have stumbled, as I was saying, the phosphate binders number. There was EUR 80 million and EUR 100 million adding up to EUR 180 million. So my apologies if everyone didn't catch that on the call, you're right. We are now seeing that full year number to be EUR 180 million versus the original guide of EUR 100 million through Q2. We are seeing favorability in our pharma business, and Q3 was particularly strong with that uptake.

The FKC side of the house or the piece that we see in the clinics is developing in line with expectations, but we are seeing more favorable pharma and are now expecting that trend to continue that we saw in Q3 into Q4. Obviously, that's something that we are kind of trying to get our arms around for 2026 as well as we think about utilization and pricing for the binders while it's still under the TDAPA period, but it is in line kind of with what we saw in Q3.

Look, I would say on your broader question and why I thought it was important to bucket the moving parts, yes. I mean, I can pick the favorability from binders. I can pick the favorability from FME25, but it shouldn't be lost that we are -- while we do have this softer volume, we are having to overcome the lost margin from our original assumptions on volume as well as the underlying transactional exchange that we are seeing. So -- and the medical costs that are driving the labor cost higher in terms of increased utilization of our employee benefit claims as well as the volume of claims.

So as you can appreciate, we're juggling a big business here. We're trying to keep balancing the pluses and minuses, but there are some underlying negatives that these positives are helping us offset that are all coming through in the year. In terms of your Medicare Advantage question, it's an interesting one because we also started to pick up headlines from the big payers that they were backing off some of the coverage of MA plans.

What we have seen through Q3 and projecting into Q4 is actually no change in that MA mix and that book of business. And actually, it continues to grow episode slightly and is quite sticky. What we are seeing in the market is while some of the big payers might be backing off some plans. It is more of the consolidation of MA plans and the overall enrollment numbers are looking consistent. And that's actually come from the government as well. So we see quite a steady mix as well as similar number on enrollment, but there is consolidation of the number of plans out there that payers are doing at a more local level. So right now, our current assumption is that we wouldn't see a big impact in MA.

Just -- maybe just to kind of put a finer point on the mix and things that we are watching of course, the ACA exchange, whether that does conclude at the end of the year or whether there will be some deals on extending that. So that is the piece that we are watching closely on where those patients may end up during the current open enrollment period, which started, I think, at the weekend. So we'll continue to navigate that. But overall, looking quite steady here on MA.

The next question comes from Hassan from Barclays.

A couple from me, please. Firstly, on EBIT guidance range remains pretty wide as we move into Q4. What is driving the risks here to your mind? And why is the bottom end of the range, not more likely? And what was the phosphate binder benefit in the third quarter, please? Secondly, on treatment growth, can you talk a bit about admissions and missed treatments as you moved through the year? And how you see Q4 growth given the flu impact was obviously quite meaningful in the first half at 60 basis points. I appreciate that you don't have the Q4 detail, but how do you consider the moving parts as you move into 2026 and the confidence around the 2% plus treatment growth that you've previously talked about?

Thanks, Hassan. I'll tackle some of that and maybe, Martin, you can take the phosphate binder Q3 question. But let me unpack what I can and then pass you over to Martin. Yes, look, the EBIT guidance, we always knew that the EBIT range is wide because of the implied margin range that's there as well. As you heard from my commentary, and you can see in the numbers, we're already at the bottom end and we've left the range wide open, which I think you all know me by now. That tells you that I do think that there are opportunities for that top end to also be in play.

As you can appreciate, a slightly bigger number on FME25, slightly less impact from exchange, those numbers can move the needle kind of around that range. So you know I don't shoot for the bottom end. We are still excited about the underlying growth, the momentum we're seeing, and that's why I've left the range wide open. On treatment growth, you know I've been trying to put a lot more color on inflows and outflows rather than orienting around the net number because there's a lot happening there.

Over the course of the year, we have seen improving admissions. If I look at it versus Q3 this year versus Q3 last year, they are improving and 9 months over 9 months is improving. Mortality is down, but still elevated. And missed treatment, we are chipping away at and making improvements. I think the commentary you've seen from the industry is they have been higher, but we are really excited about the work that we've been investing in, taking hold. So that missed treatment number is improving as well, along with all the patient safety and patient quality work we're doing. So we're excited about that.

[indiscernible], I didn't touch there. On your flu. Obviously, we did have a severe flu season in the first part of this year. And you're right. You remember that number correctly, 60 basis points impact. We will have to see how the flu season kind of develops, obviously, in Q4. I'm excited about, as you can probably tell, and encouraged by the high level of vaccinations. That's great despite the narrative maybe catching the headlines in the U.S. Our patients are taking good care of themselves. And we are taking good care of them. So we'll see how that develops. But obviously, that's a year-over-year depending on how we see -- how severe a flu season. If it is a severe flu season is going into next year, which the -- kind of the other question that you have on the 2%.

We're still confident in that 2% once we see mortality normalize. And as we know, mortality is still elevated. And of course, we're in slightly positive territory currently. So the funnel improving obviously helps all the work we're doing on outflows obviously helps. And once that mortality level normalizes, we have no reason to believe we don't get back to 2%. And obviously, we'll give our best stab on that once we kind of finalize our outlook for 2026.

And don't forget, I mean, I know it's -- we're kind of in the early stages of HDF, but our expectation as HDF continues to get traction over the course of 2026 that will also help with kind of mortality, missed treatments, et cetera. So there's a lot in your question. Hopefully, I covered all my pieces.

And Martin, do you want to just take that Q3 phosphate binder question?

Hassan. Let's take the phosphate binder. As Helen outlined, we did see a pickup in the third quarter against the second quarter in our pharma business, whereas the clinic business assumptions are coming in broadly as expected. For the third quarter, the total effect of phosphate binders was a mid-double-digit million amount and to underpin the EUR 180 million that Helen mentioned, we are also assuming a similar dynamic on the pharma side in the fourth quarter, a similar amount in the fourth quarter as well.

Next question comes from Hugo from BNP.

A quick one on FME25, which you upside. Can you maybe point to the reasons for that? Is that production move to Mexico that's finally kicking in or any other things? And second, on the rollout of HVHDF, can you maybe share the number of clinics? Sorry if I missed that. And compared to your plan presented at the Capital Markets Day, given the early learnings that you have from the rollout. Does it change anything in your plan from 2026 in terms of how fast you think you will be able to deploy that instrument?

Martin, do you want to take the FME25 question, I'll pick up with HDF?

Yes. Sure. So as you saw in the third quarter, we had strong momentum and we are already after 9 months almost at the full year original guide that we had for FME25+. And that momentum is continuing. And as Helen outlined, we are pushing to further accelerate our efforts. That is true for Care Enablement, where this also helps us to offset some of the inflation and FX transaction headwinds that we have, but it's also true for the global functions as well as for Care Delivery. So we are making good progress, and we are leveraging that momentum, hence, the upgrade of around EUR 40 million that Helen articulated.

Thanks, Martin. And then Hugo, on HDF, as you can all appreciate, we are in the early rollout, and we are adding it to a very small number of clinics, and we're adding them as we go. In fact, we added 2 more just last week that continues to gain momentum, and we are progressing every day with our kind of installations, training, learnings, getting patients, not just on the new machine, but maybe more importantly on the HDF machine. So that will continue through the rest of the year. And yes, we're fully on track with what we shared for 2026 at our Capital Markets Day. So exciting times for us.

Next question comes from Graham from UBS.

Just in terms of thinking about Care Delivery and sort of the moving parts for next year, I know it just directionally, but just phosphate binders presumably just lapping it becomes a bit tougher and it's been such a big driver of growth this year. Is it not reasonable to think that volume -- like U.S. volume growth becomes more important? And just if I look at the first 9 months of this year, 2024 and 2023, there's not a huge difference. And obviously, next year, we've got the head-to-head of like HDF coming through, but then equally maybe some new drugs for IgA nephropathy. So when you look at it, just like how confident are you that you can generate volume growth, which in turn generates operating leverage rather than phosphate binders and cost savings driving Care Delivery margins, just as we shift away from the cost piece driving growth and more so the actual top line?

Yes. Thanks, Graham. Great question. So obviously, as we're trying to help you guys think about phosphate binders. You can obviously see where we are seeing the benefit is in our pharma business. So that's less of an FKC topic, more of just the pharma volume, which we do supply those projects both within our own clinics, but also to outside customers. So that -- while we're still in this period through 2026 will become a topic of what is the volume, what is the utilization of those drugs and what is the pricing. So obviously, we have to see how that plays out.

And obviously, on your question on volume, while we've got these low volumes and numbers, you can obviously see that the impact on EBIT in itself is not the number that makes or breaks any given year. And as you know, in running this business, it is all about kind of the balance and think about those moving parts for next year, the balance of underlying volume kind of the reimbursement, our operating leverage and utilization in our clinics. So we're kind of taking a hard look at that. And then the efficiencies that we drive and obviously managing labor.

So as we all appreciate, volume is always helpful to drive that operating leverage. And I think the other thing here is that there are parts of our country in places that we operate that we are seeing growth, and we are really pleased with that progress. So we're kind of constantly amongst our 2,600 network of clinics, looking at where we're seeing growth, where there's opportunity to further grow and expand. And obviously, in other areas, look to see if we need to sort of consolidate or exit some clinics. So we are preparing all those scenarios, but obviously, under the assumption that volume is returning, and the work that we are doing, which shouldn't be underestimated on the outflow side that if we can reduce hospitalizations and we can reduce missed treatments that obviously adds to the volume on the patients we already have.

So as you say, when you add in the benefit from HDF and for those that are on GLPs, we like that mortality benefit they get to. I think that overall kind of is giving us some confidence that where we can see outside elevated mortality, the things we can control, we're starting to see some improvement on. So I think it's a combination of all the things that we do and what will make us operationally excellent on balancing the volume, the price, the mix, the operating leverage, the clinic footprint and the cost structure. So it's -- I think we understand all those moving parts and more than ever seeing the benefits of the work we've been doing this past couple of years on the turnaround and transformation.

Maybe just a quick one on the HDF benefit. Should we -- just based on what we saw in CONVINCE should we see kind of a benefit in the actual headline U.S. treatment number next year? Or should we think about it maybe more like a phasing into the first half of, say, '27?

Look, I think the expectation is once patients are on it, the CONVINCE trial did show that after 3 months, we got benefit. So as we ramp up for those patients that are on it, we should start to see improvement. Now obviously, as it ramps up, we -- I would say, maybe this time next year, we can start to say, hey, this is what benefit we're getting from those patients on HDF, but we're going to need to kind of get that data behind us.

Obviously, '26 being the ramp-up year, you won't feel or see the full effect. But we are -- as you can appreciate, this is an opportunity for us to track patient 0, if you will, and really start to kind of see the data of those patients that are on HDF and what their performance is on that -- on this treatment. So '26 maybe -- not maybe while we're excited, obviously, it is ramping up over the years. So we will tease out the relevant KPIs as we go through next year and report on what seems to be kind of the right insights for you guys.

The next question comes from David from JPMorgan.

Firstly, maybe your key competitor, DaVita quantified the impact on EBIT next year, well, actually the next 3 years, if the subsidies aren't extended. I'm just wondered if you were willing to do the same. And then secondly, just a bit of a specific one. But volumes in Q3, were they impacted negatively by a sales day mix? And does that become a tailwind in the fourth quarter?

Yes. Thanks, David. Let me tackle that first -- the second one first. Spain market treatment growth for us normalizes days. So our 0.1% is like-for-like. Where it would be impacted on mixed days is on the overall treatment numbers. So our same market treatment growth is pure. So just want to dispel any conclusion that the market might have picked up on that one. David, on 2026, as you can appreciate, we're still in, as I've mentioned, still in planning, I'm not prepared to put any number out there while we're still working through that and even reviewing it. We haven't reviewed it with our -- finalized it with our management Board at a known Supervisory Board at this point.

So I think you understand the levers, you understand our usual headwinds and tailwinds, you understand some of the moving parts that we're watching. I think that's all I can say at this point, and you'd be surprised if I said anything different because you know me, but thank you for asking.

So the next question comes from Anna from Bank of America.

Maybe as a follow-up to one of Graham's questions on the impact of the HVHDF rollout for next year. Do you think that could start to positively impact U.S. same market treatment growth from a referral standpoint as soon as next year? Just any color on how you're thinking about that. And then as well on the Care Delivery growth of the 5.6%, those 3 components, the favorable rate mix, phosphate binders and implicit price concessions decreasing, I think you've broken out the phosphate binders pretty clearly, but any other numbers you could give us around those other 2 components and how you expect those to trend into Q4 would be super helpful.

Yes. Thanks, Anna. Let me take the HDF question, and Martin can maybe unpack the CD question that you have. Look, on your referrals number, yes, I would suggest and think that, that is, my pen just fell apart that would help us positively. I deliberately read the quote from one of our nephrologists and we've had a number of nephrologists kind of coming through our clinics to see this.

So yes, we have seen significant interest and positive feedback and we are being -- as you can appreciate, quite deliberate in where we are launching HDF first. So that is, yes, really exciting. And as you kind of -- on the back of Graham's question, that mortality improvement and the kind of the increased treatment improvement, we should see as soon as we get patients moving on this, and that should ramp up over '26. So really exciting to see that, and I can't wait to hear how [ AFN ] goes this week, but the team that's there.

Martin, do you want to take the CD piece?

Sure. And for the implicit price concessions as well as for the rate mix assumptions that we have for CD. You saw this being a positive in quarter 3. This is the work we do in revenue cycle management paying off and us increasing our revenue yield. So we are collecting more for the amounts that we invoice. This is an ongoing effort, and we are seeing the first benefits and we do expect this to also be a positive in the coming quarters for us as well. And that does also impact then on the, let's say, underlying performance improvement and will be a positive [indiscernible].

So we do not have any further questions. I would like to thank you all for listening and for asking questions and being interested and hope to see many of you on the road in the next couple of weeks. Thank you.

Thanks all.

Thank you.

Take care. Bye-bye.

Ladies and gentlemen, the conference is now over. Thank you for choosing Chorus Call, and thank you for participating in the conference. You may now disconnect your lines. Goodbye.

Ladies and gentlemen, welcome to the Report on Second Quarter 2025 Conference Call. I am Sandra, the Chorus Call operator. [Operator Instructions] and the conference is being recorded. [Operator Instructions]

The conference must not be recorded for publication or broadcast.

At this time, it's my pleasure to hand over to Dr. Dominik Heger. Please go ahead, sir.

Thank you, Sandra. I would like to welcome everyone to our earnings call for the second quarter of 2025. As always, I would like to start out the call by mentioning our cautionary language that is in our safe harbor statement as well as in our presentation and in all the materials that we have distributed earlier today. For further details concerning risks and uncertainties, please refer to these documents and to our SEC filings. We will have 60 minutes for the call. To give everyone the chance to ask questions, we would like to limit the number of questions to 2. It would be great if we could make this work, as always.

Let me now welcome Helen Giza, CEO and Chair of the Management Board; and Martin Fischer, our Chief Financial Officer. Helen, the floor is yours.

Thank you, Dominik. I'd also like to welcome everyone to the call. We appreciate you taking the time to join us today and for your continued interest in Fresenius Medical Care.

Our second quarter results reflect continued improvement in our operational performance and disciplined execution as we transform and strengthen our company. Building on this momentum, we are well positioned to embark on our next chapter FME Reignite, which we outlined at our recent Capital Markets Day in June.

Through our clear ambition to lead kidney care through exceptional patient care and innovation, we are ready to unlock our full potential to reignite Fresenius Medical Care and reignite future growth.

I will begin my prepared remarks on Slide 4. In the second quarter, we delivered strong organic revenue growth of 7% with positive contributions from all 3 operating segments. Our FME25+ transformation program continued its momentum, delivering EUR 58 million in additional sustainable savings of our targeted EUR 180 million for the year. We achieved 13% operating income growth, further driving margin expansion. Our operating cash flow development increased by 75% and our net leverage ratio improved to 2.7x, which is well within our new target leverage range of 2.5x to 3x.

The overall phasing of our earnings through the first half of 2025 has developed well in line with our planning, and we continue to expect accelerating earnings development in the second half of the year. Therefore, we are, of course, confirming our full year 2025 outlook.

Given the strength of our cash flow profile and our belief that shareholders should meaningfully benefit in the success of our company, we announced at our Capital Markets Day that we will initiate a share buyback program of EUR 1 billion initially, which will be executed in multiple tranches. We have planned to start with the first tranche already in August. Going forward, our new capital allocation framework provides further opportunity for regular share buybacks. This is a key component of our strategy to reignite value creation and with that, shareholder returns.

Turning to Slide 5. Here I would like to highlight recent developments in each of our now 3 operating segments, beginning with Care Delivery. In the U.S., the stable volume development reflects strong and accelerating patient inflow dynamics, which have been unfortunately offset by higher-than-expected patient outlets, due to the very severe flu season earlier in the year. I will further unpack the U.S. volume development later in my remarks.

Outside the U.S., international same market treatment growth increased to 1.7%. Second quarter Care Delivery performance benefited from favorable weight and mix development in the U.S. as well as a positive impact from phosphate binders.

Our U.S. clinic network is gearing up for the launch of the 5008x and high-volume HDF and we will begin to roll out the 5008x to our clinics beginning later in the third quarter and ramping up further from there.

On this slide, you will notice that Value-Based Care is highlighted as a separate segment for the first time and is no longer included as part of Care Delivery. As announced in June, we have initiated a new reporting segment as part of our ongoing effort to refine our operating model providing greater visibility into the drivers of this growing business and further enhance our financial reporting transparency. This is important as Value-Based Care has a very different financial profile and market dynamics than Care Delivery.

In the second quarter, Value-Based Care benefited from expanded contracting, leading to an increase in member months. With this positive development, the revenue growth in the first half of the year was at the upper end of our expectations.

Turning to Care Enablement. Care Enablement delivered another strong quarter, supported by volume and price increases. As every year, the volume growth is less strong in the second quarter, which is normal phasing. We expect to -- we continue to capture sustainable savings as part of FME25+ driven by disciplined execution of the next level of footprint optimization across both manufacturing and supply chain. As a result, our Care Enablement margin further progressed within the 2025 target band to 8.7%. Care Enablement is also well on track for the 5008x launch in the U.S. following the additional FDA approval of Release 2.0 in May.

Turning to Slide 6. If you were able to follow our Capital Markets Day, you will remember that Dr. Frank Maddux, outlined the dynamics of volume growth and how both patient inflows and outflows play an equal role in shaping overall patient flow. This framework is helpful to understand the components of recent volume development in the U.S. and underscores why we are encouraged about future growth.

In the second quarter, patient inflow accelerated a bit more than expected compared to the prior year supported by a higher number of patient referrals and new patient starts. This is an important trend as it signals strength in the underlying volume recovery and also reflects ongoing operational improvements in our own inflow management process. This positive development in patient inflow, however, was offset by higher-than-expected patient outflow. The severe flu season in the first months of the year in the U.S. resulted in significantly increased mortality compared to the already elevated level of the prior year as well as a greater number of missed treatments.

The impact of higher mortality early in the year carried forward dampening volume growth in subsequent quarters as well. This clearly impacts our assumption of plus -- 0.5% plus same market treatment growth in the U.S. in 2025. We now just carefully assume flat to slightly positive same market treatment growth for 2025.

I will now hand over to Martin to take you through the second quarter financial performance in more detail.

Thank you, Helen, and welcome to everyone on the call also from my side. I will pick up on Slide 8. In the second quarter, we achieved organic revenue growth of 7%, with all 3 segments contributing to this strong performance. Revenue increased by 5% at constant currency. The impact from divestitures executed as part of our portfolio optimization negatively impacted revenue development by 110 basis points. As a reminder, we decided to absorb the revenue and operating income effects from divestitures executed in 2024 and 2025 in our guidance range.

Operating income, excluding special items, increased by 13% on a constant currency basis, primarily driven by growth in Care Enablement. As a result, we realized further margin expansion to 9.9%. Divestitures had a neutral effect on operating income margin development. Special items negatively affected group operating income by EUR 51 million. This mainly includes costs relating to FME25+ and our continued portfolio optimization offset by positive effects from the remeasurement of our investment in Humacyte.

Next, on Slide 9. This slide outlines the year-over-year margin development for the second quarter. At the group level, we realized a margin increase of 80 basis points. This increase was driven by positive contributions from both Care Enablement and Care Delivery with particularly strong results from Care Enablement and was partially offset by a slightly negative impact from Value-Based Care.

Net corporate costs increased by EUR 14 million from the prior year, including a positive EUR 9 million contribution from virtual power purchase agreements. In addition, foreign exchange rates development unfavorably with a negative EUR 16 million impact. The average U.S. dollar exchange rate in quarter 2 was EUR 1.13 compared to EUR 1.05 in the first quarter.

Let us now have a closer look of the drivers of each segment starting with Care Delivery on Slide 10. Care Delivery showed strong organic revenue growth of 3.6%, supported by both Care Delivery U.S. and international. In the U.S., organic growth of 3.4% was driven by favorable rate and payer mix development, which offset the volume impact from a severe flu season in the first month of the year.

Internationally, we realized robust organic growth of 4.5%, driven by 1.7% same-market treatment growth and continued rate increases. The execution of our portfolio optimization negatively impacted revenue development by 190 basis points. Operating income further improved and the margin expanded to 11.2%.

On the earnings side, business growth in the quarter was supported by positive rate and mix effects as well as contributions from phosphate binders. Further sustainable savings from FME25+ helped compensate higher inflation costs and higher labor costs. The labor costs were impacted by increasing medical benefit expenses for our U.S. employees. The increase in medical benefit expenses is partially attributable to higher insurance utilization observed across the industry and partially due to the timing of offsetting initiatives. Consistent with broader industry trends, we expect these costs to moderate in the second half of the year. The unfavorable translation exchange rate development also had a sizable negative impact.

Slide 11 will provide an overview of the development in our newly reported segment Value-Based Care. Value-Based Care realized continued strong organic revenue growth with 28% in the quarter. This was mainly driven by significant higher volumes in the form of a higher number of member months mainly due to contract expansion early in the year.

On the earnings side, operating income declined to a loss of EUR 9 million due to an unfavorable savings rate and inflation, offsetting positive effects from increased member months. While revenue growth of this operating segment is ahead of expectations, we continue to assume a slightly negative to breakeven earnings development for the year.

I will conclude the detailed segment review with Care Enablement on Slide 12. In the second quarter, Care Enablement continued to show strong revenue growth of 3%, supported by 3% organic growth. Revenue development was driven by volume increases for our products overall and continued positive pricing momentum despite volume-based procurement in China. Care Enablement showed a significant 79% increase in operating income, leading to a margin increase of 380 basis points. With 8.7%, the operating segment is further advancing into its 2025 target margin band.

Earnings growth reflected strong business growth supported by volume growth and pricing as well as savings from FME25+. These positive effects more than offset the anticipated inflationary pressures and the unfavorable impact from foreign exchange translation.

Moving on to Slide 13. In the second quarter, we realized a 75% increase in operating cash flow, mainly driven by favorable working capital development. This reflects the recovery against prior year headwinds from the cyber incident at Change Healthcare and the phasing of federal income tax payments in the United States. The strong cash flow additionally absorbed and expected seasonality in invoicing compared to last year. Consistent with our strict financial discipline, we further reduced both our total debt and lease liabilities and our total net debt and lease liabilities compared to the first half of last year.

As a reminder, at our Capital Markets Day, we announced our decision to lower our self-imposed target range for our net financial leverage as part of our new capital allocation framework. We are now targeting a net financial leverage ratio of 2.5 to 3x net debt to EBITDA. In the second quarter, our net leverage ratio further improved to 2.7x, well within this new lower range.

More recently, in July, we redeemed the EUR 500 million bond that had matured. As Helen mentioned, our commitment is to return excess cash to shareholders as part of our new capital allocation framework. We are planning to initiate the first tranche of our announced share buyback already this month.

I will now hand back to Helen to review our outlook.

Thank you, Martin. I will finish my prepared remarks on Slide 15. Given our performance through the first half of the year and our expectations for growth acceleration in the second half of 2025, we are confirming our full year outlook. With the strong growth in Value-Based Care in the first half of the year, which is driven by the contracted risk types, we expect to be at the upper end of our positive to low single-digit percent revenue growth range. This revenue growth in Value-Based Care is not impacting the operating income growth.

Therefore, we continue to expect to grow operating income by a high teens to high 20s percent rate compared to prior year. We are also confirming our operating income guidance range. This also includes the upper end of our guidance range, which also tells you that we continue to consider this to be a viable outcome for earnings growth. With the planned margin improvements by all 3 operating segments, including benefits from revenue cycle management, we are fully on track to accelerate our earnings growth in the second half of the year.

With that, I will now hand back to Dominik to start the Q&A.

Thank you, Helen. Thank you, Martin. [Operator Instructions] And with that, I hand it back to Sandra to open the Q&A. Sandra, please.

[Operator Instructions]

And the first question comes from Hugo from BNP.

I have 2, please. Maybe in terms of U.S. volume growth and if we think about 2026, obviously we have a low base in H1? Or are you confident to grow volumes in 2026 in the U.S.? That would be my first question.

And second on Care Enablement, you have very strong margin expansion, 250 basis points in Q1, close to 400 basis points in Q2. How should we think about the back half of the year and the level of comfort to it probably the high end of the 2025 margin band here.

Hugo, I'll take both of those. With regards to U.S. volume growth, obviously, what we are seeing right now is this continued elevated mortality. And that's why as we've kind of concluded the first half flat, we are calling the back half flat to slightly positive.

So I know it's a lot of small numbers at this point, but that does assume that the growth continues. We are really encouraged by the referral trends and the inflows, and we have seen improving trends there for 5 months in a row now. So that is really encouraging on the front-end funnel. And that comes back to what we've always said that once mortality normalizes, we see the inflows returning, the underlying fundamentals of this business, there's no reason to suggest that, that 2% plus is unchanged.

So yes, we will expect to see growth going into 2026. And obviously, as we look at the development over the next few quarters, the rate of that slope will be determined in time. So I think that follows the consistent messaging we've been giving there.

With Care Enablement, we're really, really pleased and encouraged with what we are seeing there. And as you rightly point out, nice progression in the margin band. We -- clearly, we still have the margin band out there for Care Enablement of 8% to 12%, and we haven't changed that but we do see H2 stronger than H1. And then we usually see the back end of the year stronger for Care Enablement, particularly in Q4 because of the sales volume. So -- it is a little bit seasonal, but the band overall, we're still confirming and really, really pleased with the progress that the Care Enablement team is making.

The next question comes from Veronika from Citibank.

Hopefully, you can hear me okay. I will also keep it to 2, if I can. The first one is just on the patient inflow dynamics, Helen, that you alluded to. Can you maybe talk to sort of how you're thinking about that in terms of the market getting better versus some of the processes that you have in the business? And I don't know if you can quantify it and also quantify maybe the mortality that you saw in the quarter just to help us with the math as we think about how things accelerate.

And then I'm sorry to be on the -- to stay on the same topic, but obviously, you do have that guidance for 2% plus starting next year. So just curious how you're thinking about the ability to get into that 2% plus already in 2026? So given the dynamics that we're seeing at the moment, is that more a 2027 question? Sorry to stick to the same market, but those are the 2 most important things.

Thanks, Veronika. We'll see how many times we get asked, a different flavor of that question, but we recognize how important it is and for us to share what we are seeing in real time. Look, I think on the patient inflows, as I've mentioned, they are encouraging and positive, and it's the best too we've seen in years, but not just the fact that this quarter is strong, but as I mentioned, 5 months in a row of improving patient inflows and new patient starts I think it's a bit of both. And I think we're still, obviously, with our data trying to tease that out on -- we're doing a lot of things all at the same time, but we are definitely seeing new referrals coming in.

But of course, it is helped by our improved processes to get those patients in and scheduled into treatment. So I think it's a bit of both. And I can't tease out how much is one or the other at the moment other than the inflows are positive.

I think we -- on your second part of that question on the 2%, we've definitely said that, that 2% plus is based on normalized mortality. It is still somewhat elevated coming out of this flu season and with the positive inflow that helped. So I think if we had normalized mortality and the same trend of inflow that we've been seeing, that 2% obviously is unchanged. And I think like we said, it's kind of the weight of the slope as we go through 2026 will be key. But we're kind of encouraged by what we're seeing in this last quarter.

The next question comes from Hassan from Barclays.

A couple from me. Firstly, on the margins, you continue to expect an accelerating earnings development in the second half. And I wonder if the persistent weaker volume dynamics and lowered expectations here has an impact on your H2 expectations and where you expect to land in the range?

And then secondly, on VBC, your guidance assumes EUR 100 million of incremental revenue year-over-year, yet you've banked EUR 200 million already in the first half. So if you could talk about the strength here and how we should think about the evolution in the second half as well as any dilution at the margin level?

Thanks, Hassan. Why don't I tackle the half 2 trend? And then Martin, maybe you can take the VBC trend. So yes, Hassan, clearly, the softer volume for half 2 does have an impact. However, we've always said that it's the volume number alone with small numbers, it's quite small.

So it was never going to make or break the year. We just recognize the underlying metric is obviously important for future growth. So it doesn't have that significant or big impact at all in the back half. What we know is half 2 is always stronger than half 1. And you always -- you kind of -- you've seen this historically, as you followed us and Q4 is always stronger than Q3, but half 2 always stronger.

So clearly, we have that built in. And then in the back half for H2 development, we will see continued benefits from rate and mix. The work that we are doing on rev cycle improvement, as we already touched on the talk outline, will also hit in. And then we're really pleased with the momentum we're seeing on FME25. And of course, all the work that we are doing on continuing operational improvements will continue to have that momentum.

So it is a little bit of seasonal and also the ramping up of the work that's underway and the programs and initiatives that we are already executing on. Martin?

Yes, I'm more than happy to take the VBC one. We are very pleased with what we saw in the first half. Also, we have expanded contracting activities in the meantime, have about 148,000 patients under programs. And we will expect more than EUR 1.9 billion to your point in the full year when we look at it. When it comes to the operating margin, we always said that it is slightly negative to neutral. And as we also said, there's a certain dynamic when it comes to gross revenue recognition. And we expect that we still are within that operating margin corridor.

So there is a limited conversion that comes from the additional volume to our operating income.

The question comes from Oliver Metzger from ODDO.

The first one is also that beneath mortality, you talked also about the missed treatments to a flu season. So is this an area where you already see a return to the normal baseline or it's still also at an elevated level?

The second one is in addition to Hassan's question on Value-Based Care. As it's now a separate business unit, we have got, thanks to Dominik's team, some historic data. But eventually not enough to identify some patterns. So can you give us an indication of when you see some more of this typical pay days? And also whether we should think rather in years and quarters about the progress on the bottom line.

Yes. Thanks, Oliver. I think I'll snag those questions. So mortality -- the flu effect obviously impacted mortality and missed treatment. So it's kind of a double effect on outflows, if you will. That is still elevated over last year. And as we were kind of quantifying that the flu effect through half 1, it is around that 40 to 60 basis points still of elevation over what is already a higher mortality from last year.

So I think that it's fair to say that there's still that elevation. And I think as we come into quarter 3, seeing how that develops kind of bringing down the mortality level. Obviously, the work that we are doing ourselves on [missed] treatments that are in our control, we're tackling as well with the operational improvement. So they are elevated, and we continue to work on those to improve that post-pandemic and post-flu season.

Martin give you a nice outline on how we're thinking about Value-Based Care numbers. Of course, it is a new segment. We are getting under what the right KPIs are. And I think you can expect us to continue to give more transparency on the KPIs as we move forward. Martin talked about the number of lives that we're covering, but we're also talking about membership and membership months because I think that's an important metric for us to continue to track as well in terms of how many months of members we are covering.

So I think more to come, Oliver, as we kind of get more mature in our reporting here, as you can appreciate pulling it all out and having the historical data was a good step in the right direction. So for this year, you can see member months and memberships. And obviously, that varies too. And I think as we continue to progress with this segment, we'll figure out if there's more metrics to provide next year.

So next question comes from Richard from Goldman Sachs.

2, please. So the first one is how much benefit was there from phosphate binders in H1? And how should we think about the remaining benefit into the second half?

And then the second one is another one on treatment volume dynamics. But could you help us put the 5 months of better inflow into historical context? I mean, is it fair to say that that's the first time since COVID that you've seen that consistency in patient inflows. That would be really helpful just to sort of frame that shift.

Martin, do you want to take binders half 1?

Yes. So regarding phosphate binders, we did see quarter 2 develop in line on how we expected the quarter to develop. We did see a double-digit million positive contribution for Care Delivery. As we pointed out, we also had highlighted in the first half that in quarter 1, we had a bit of a stronger development. And then in quarter 2, it came in, in line with what we assumed. So we are, for the first half in line with our expectations.

Thanks, Martin. And Richard, on treatment, yes, I think it's fair to say that this has been our strongest quarter 2 since 2020 from an inflow perspective, and that not just that it's the strongest quarter we've seen but also the monthly improvement we have seen over the last 5 months consistently is a new trend for us as well.

So for us, we can kind of see that, that work has clearly started at the back. Even though we had few we could see this inflow in referrals improving Q1 into Q2 and the work that we are doing is clearly paying off there.

The next question comes from James from Jefferies.

2, if I may, please. Confirming the guidance range, including the upper end, I'm just kind of curious the levers to get you there at the upper end of the margin range if volumes are expected to remain flat this year. And then the second question is just again regarding lower volumes. If volumes don't get to the 2% plus as an exit rate next year, how does that impact your thoughts on timing for capital allocation decisions, just given cash flow is so reliant on higher volumes?

James, I'll take the first one, and I'll give the capital allocation question to Martin. Obviously, what we tried to do is lay out the building blocks of the headwinds and tailwinds on guidance. And there's a range for them all. And I think it's fair to say if we hit the bottom end of all those building blocks, we'd be at the bottom end of the range. And if we hit the top end, the converse would be true.

And obviously, we are -- our job as management is to balance all of those to make them all as strong as possible. The building blocks that we gave in -- with 2024 are the same building blocks that hasn't changed, right? So we are continuing to track quite well within those blocks, and we're managing our way through those. I think what maybe we want to reiterate is kind of what I said in an earlier answer, is we know that there is acceleration in the back half.

Some of that is the natural phasing and stronger business performance with the volume seasonality, particularly on CE but H1 was completely in line with our plan. And we always knew that our H1 phasing would look like this. But the continued momentum on rate and mix, the revenue cycle, as we mentioned, the strong momentum in FME25+, the operating improvements, labor. So we obviously touched on the softness on volume.

Labor regular inflation is tracking kind of favorable -- sorry, in line with our expectations, but we did have an unfavorable hit in Q2 for the medical benefit costs. I think, like the whole -- many corporations are seeing, and you saw across the insurance companies, higher claims and higher cost of claims. But I think that is more of a half 1 phenomenon. So I think we're just managing each one of these building blocks with a high degree of rigor, a high degree of focus, pulling through on the programs, and that's what's giving us the confidence for the back half 2 development.

Yes, James. And on capital allocation, we did outline in the Capital Markets Day, the clear prioritization of investment into the core with our CapEx of EUR 500 million to EUR 1 billion with a lower leverage ratio and returns to our shareholders. And we have announced the EUR 1 billion over 2 years. And you saw that we have a strong cash flow generation in quarter 2 and development. And you also see that the first half, as Helen outlined, expected in line with our expectations, and we expect an acceleration for the second half. So we will start with the first tranche of the share buyback in August, and we feel very confident about our ability to execute the program overall as planned.

The next question comes from Graham from UBS.

They kind of the repeat of what we had earlier, but maybe for some slightly different information. In terms of phosphate binders and their contribution to the business growth in Care Delivery, how much more do you think we have to go in the second half? And what do you think makes us takes up differential if that sort of eases in terms of contribution in the second half?

And then you've talked a lot about the inflows, which is super helpful. Could you give us a sense as to what the percentage growth is? So is it like 1%, 2% in terms of year-over-year? And has that been trending like this for quite some time? And then just a quick one.

Is there any way of discerning what is like share gains versus what is just the kind of funnel picking up?

Okay. Martin, do you want to binder and I'll take inflows?

Yes, more than happy to. Graham, as I outlined, the first half developed in our expectation with a double-digit million contribution for the second quarter and starting stronger in the first quarter. But then after the first half, we feel good about what we saw with phosphate binders. There is still certain topics that we are very close to like utilization and certain pricing developments. But so far, we are feeling good about what we saw, and that also gives us confidence for our full year overall assumptions.

Yes, Graham. And then on inflows, look, I think a couple of things to your question. the trend that we're seeing that referral improvement that we have seen these last 5 months equates to just under about 1% improvement in referrals year-to-date. But about a bit more than that in Q2. So it was closer to 2% improvement in that referral improvement in Q2. So that also speaks to the kind of the improving trend since 2020, but also the last 5 months.

In terms of your question on share gain, we know that the work that we are doing operationally internally is paying off. And I think those improvements are clearly visible in our operation.

We'll, obviously, have to see how the rest of the market kind of reports out this quarter. But I think for us, it's definitely kind of the patient trend and the work that we're doing is supporting that effort kind of the improving that cancellation rate is also kind of adding to our accepted referral growth. So it kind of -- there's a lot -- even when you've kind of got the new patient starts, we have been struggling to get them in and scheduled in time.

The front-end work on improving the scheduling is also a key driver of this. So I think this trend, we have been seeing it for a few quarters now. It's not just the last month or so. It's been a consistent trend that we're encouraged by. And obviously, we had a lot of work to do with the turnaround in Care Delivery. So I think that is speaking for itself. But I also recognize that we're still talking small numbers.

The next question comes from David from JPMorgan .

Slightly different tax. So maybe just first, early thoughts on 2026 and the headwinds you might have from the annualization of phosphate binders and also the expiration of ACA subsidies?

And then second question, it would be good to get your recent thoughts or your thoughts on the recent clinical data out of ProKidney for the impact on progression of their product on CKD?

David, look, I think we're definitely not giving 2026 guidance and kind of sizing out the headwinds and tailwinds today. More to come on that. But what I would say on binders is we've got this half 1 development, and Martin's touched on this already. There's a lot of things at play here. We've got the -- we got the patient numbers, the utilization rates. We've got generics, we've got branded, we've got the impact that's hitting on the clinics business, we've got the impact that is hitting pharma business, we've got the impact that's hitting pharmacy.

So I think we're trying to get our arms around or not arms, we've got our arms around what we see in 2025, and it is progressing quite nicely as planned. Obviously, this utilization and what happens here, every quarter will shape what 2026 looks like. I think the thing that is key to watch for us is obviously post TDAPA period, which is January of 2027. But we're going to learn a lot about the uptake and utilization of these products by then. So I think, David, this is one where it's a quarter-by-quarter through '25. We'll obviously try and size '26, and then see what happens post-TDAPA.

The other thing on this piece as well is obviously the noise on pharma pricing and potential tariffs. So I think it's just such a fluid situation. We've got good line of sight into '25 and obviously will shape '26.

The ACA, I think we had already sized that on the previous call. Of course, we expect for 2026 and I can size this 2026 because we already have that it would be about 2% of U.S. CD EBIT. Obviously, past '26, we also have to see how this plays out. and what happens with the extended tax credits and do these patients end up somewhere else of exchanges in different coverage and what insurance they would take. So I think too early to call that yet, but obviously, we've got our arms around it. And then you had another question on ProKidney...

It's around the ProKidney data? Yes.

Okay. Yes.

Dominik...

Dominik, it's okay. So we'll wait for the ASN. I think they start their clinical study or the next phase of their clinical study. I think pricing -- I think there's rumors what pricing would be. But I think -- our understanding is you have to see what's the long-term effect of those shots. I think they now do 1 shot versus 2 shots. We are not the experts on that, but you have to see how long it actually holds and how long it would improve the outcomes, right? That's the big question.

How it works? I think even the medical people don't fully understand, but it seems to have an effect, and I think we'll have to wait for the long-term impact to see if there's more shots they need and what's then the pricing of it. But yes, I think it's maybe not a very qualified answer, but I think there is not more that we could know by now.

That's fair enough. And maybe just one follow-up. Just in terms of the phosphate binder double-digit impacts. Could you sort of narrow down a bit whether it's low, medium, high because that's 10% to 99% range.

Martin?

Yes. So it's more -- well, to give you an indication for the quarter when we talk double digit, it's more on the lower, below mid, so to say.

And our last caller is Falko from Deutsche Bank.

I'm fine with just my 2 questions. Firstly, could you briefly remind us on the next steps for your new high-volume HDF machine rollout in the U.S.? The things we should be looking out for here and how meaningful this could potentially be for your financials this year and next?

And then secondly, at current spot rates, what is your expected FX headwind on adjusted EBIT for the full year and also on sales?

Thanks, Falko. This is my favorite topic. So I will take the HDF question, and Martin not surprising will take the exchange rate question.

We're continuing to go all systems fast on HDF. As you heard me say, we have all the approvals we need. We already have one clinic fully converted. And the plan is to have 30 clinics and 600 machines converted during Q3 and Q4. So really excited about the traction and the work that is happening around that.

Impact in 2025 somewhat limited, obviously, the big ramp up hits in 2026. But everything going to plan and excited to get our own U.S. real data and hear firsthand from how our patients are feeling and doing after the treatment. So -- we'll continue to update that on that as the year goes to -- as the year goes by, Falko.

Yes. And Falko, for the FX, we do see quite some volatility currently in the markets over the last couple of weeks. So I'll give you a reference rate because it also changed from the last quarter to this quarter where we did see a significant development also of U.S. dollar and euro.

Over the last couple of weeks, we saw a [117-ish]. It now came down a bit. But when you take that as a reference, we would expect a 3% to 4% impact on both revenue as well as earnings if it were to stay for the remainder of the full year on that level, and that effect would also then be a full year effect that we have.

Great. Okay. Perfect. So thank you very much. We will close the call now. Thank you for listening in, in the summer. We do wish you all a great summer break and are looking forward to be in touch after the break and see you on many conferences, roadshows and looking forward to reconnect.

Yes. Thank you, everybody. Enjoy rest of the summer. Take care.

Thank you. Take care.

Ladies and gentlemen, the conference is now over. Thank you for choosing Chorus Call, and thank you for participating in the conference. You may now disconnect your lines. Goodbye.

So good morning everyone, and for those dialing in from different time zones, good whatever-time-it-is wherever you are. Welcome to our Capital Markets Day. I'm Dominik Heger, and today I'm in charge of Investor Relations. And at least for today, I'm also your tour guide through this exciting and hopefully also reigniting day. Before we dive deep into the topics, let me say it is actually a real pleasure to see you all here in the room in person. It's our first physical Capital Market Day in 8 years.

So to all of you joining virtually, thank you for following on stream. You will unfortunately miss the opportunity to see our product show outside the ballroom and miss our deep-dive sessions in the afternoon. However, I hope all of you will find this day as positively exciting as we have planned it to be. Otherwise, I'm not in charge of investor relations afterwards.

Before we get started and a lawyer hits me, let me quickly refer to our safe harbor statement, which you can see onscreen. Our cautionary language that is in our safe harbor statement you will find in our presentation and in all the materials that we have already distributed today. For further details concerning risks and uncertainties, please refer to these documents.

So let's take a quick look at today's agenda. After our press release this morning, you will already have a quite good idea on what we will be talking about today. We start with our FME Reignite session, an energizing start to the day. And with a name like that, you can expect the temperature and the excitement to rise.

In this session, you will hear about the new strategy and the future of this company from our CEO and Chair of the Management Board, Helen Giza. You will hear about the underlying trends from our Global Chief Medical Officer, Dr. Frank Maddux. Our CFO, Martin Fischer, will walk you through the financial heartbeat of Fresenius Medical Care.

After the presentations, we will bring back onstage all 3 of the presenters for a joint Q&A session. For logistical reasons, only the guests here in the room can ask questions. So pressing *1 does not work this time, I'm sorry.

If you have not already visited our showcase, our Care Enablement showcase outside the ballroom, you will have another opportunity to do that during the lunch break and even before the evening reception.

After lunch, we will move on to the deep-dive breakout session. And unfortunately, the deep-dive breakout sessions are not suitable for a webcast. However, we will make those presentations available after the event on our website.

We have 3 breakout sessions. Care delivery with the CEO of Care Delivery, Craig Cordola; Care Enablement with the CEO of Care Enablement, Dr. Katarzyna Mazur-Hofsab; and Joe Turk, who has won the award for the longest title in this company, who is the Global Head of Home Critical Care Therapies and Head of U.S. Commercial Operations. Wow. Then we have artificial intelligence at Fresenius Medical Care, which will be presented by Dr. Frank Maddux and Dr. Len Usvyat, our Head of Renal Research Institute.

These sessions are designed to allow for really ample Q&A time and opportunity to discuss in a smaller group setting. So use this opportunity, please.

At 5:00 p.m., we will all meet back here inside the ballroom for the closing of today's official program. And after a short break, just enough time to check your e-mails, those of you who have registered for the evening reception are warmly invited to join us.

Now I come to the flight attendant part. First, to the physical emergencies. In case of emergency, please follow the clearly marked exit signs and the instructions from our staff. Restrooms are located on both floors. Life vests are not under your seat, but we do not expect rain despite it's London.

Second, to the digital emergencies. The WiFi password was provided with your name badge. You can find the log-in details at the bottom left of your badge. You will also find a QR code on your name badge, simply scan it to access all the presentations later.

Now please put all your devices in silent mode, fasten your seatbelts for the takeoff. Thank you.

[Presentation]

Pandemic, excess mortality, labor shortages culminating in the company's low point in the summer of 2022.

Transformation. Turnaround. This is what you've heard me talking about over the last 3 years. Today marks the start of a new chapter for Fresenius Medical Care.

Welcome, everyone. It is wonderful to see so many of you with us in London and a very good morning to those of you joining online, and thank you for being part of today's event. We have clear ambitions for sustainable, profitable growth with a stronger base and real momentum behind us. We are excited to share what is next, where we are heading, how we will get there and how we will create value for our patients, our customers and you, our shareholders.

Today's FME is stronger, more resilient, more proactive and with a very clear strategy about where it is heading. The last 5 years have been tough externally and internally. And when I took over as CEO at the end of 2022, I set a new 3-year plan with short-term strategic priorities and we have remained laser-focused in executing against them.

Today, I will spend time talking about growth and innovation and continuing to set the standard of care for our industry. This is not new territory for us. Advancing kidney care is our DNA.

Since Fresenius Medical Care's founding almost 30 years ago, the clear vision was to strengthen our position as the dialysis med tech leader, by continuing to reimagine therapy options through innovation. To implement the innovation and to set the standard of care, we forward integrated by moving into the dialysis care business. This was the starting point of our vertical integration journey.

Throughout this time, whether by leading partnering or acquiring we have continuously elevated the standard of care for patients with kidney disease. From championing single-use dialyzers as the standard in the U.S. to launching the 5008 machine platform and creating the leading value-based care organization in the renal space, we have consistently driven and led advancement in our industry. This relentless focus on advancing kidney care has shaped who we are today, and this is what to expect from the market leader in kidney care.

We are the leading kidney care company. Globally, we offer a range of products and services for patients with kidney disease. Our reach extends to around 150 countries with our products and around 25 core markets with our services business. I am very proud of the fact that our teams across functions and across the world are united by a singular enduring purpose: creating a future worth living for patients worldwide every day.

All our businesses are distinguished by market-leading positions and industry-defining assets. In Care Delivery, we not only treat around 300,000 patients, we do so with quality that is consistently recognized as best-in-class. 78% of our patients strongly recommend our service. This is an outstandingly high number.

In Value-Based Care, we manage the largest renal value-based care network and we successfully run all 10 of the top 10 highest scoring entities in the U.S. government CKCC program.

Care Enablement boasts enviable market share with around half of all dialysis patients in the world using Fresenius Medical Care products and about 90% of all U.S. In-Center machines coming from Fresenius Medical Care.

These are not just positions of scale. They are positions of strength.

With the reorganization into global operating segments with end-to-end responsibility, they give us the competitive edge, the resilience, which we have reshaped in the last 3 years and the relevance to continue winning in the markets that matter most.

All of the hard work of the last 3 years to bring the company back on track, our focused core portfolio and leading positions have strengthened our ability to accelerate part and increased cash generation. And you have seen how much progress and performance we have made just last year.

Today is not the first time we have set bold ambitions. At our last Capital Markets Day in 2023, we outlined a comprehensive and necessary turnaround and transformation plan. And as we approach the end of the third and final year of that strategic plan, I am incredibly proud to say that we are delivering on our commitments for 9 quarters in a row.

We executed significant structural, operational and cultural changes translating into accelerated operating income growth and cash flow generation. This strategic focus and execution have made us a stronger, more focused and more resilient company. And today, we are well positioned to drive and capture sustainable profitable growth.

It is one thing to implement change, it's another to execute change that also translates into meaningful, tangible financial progress and increasing value creation. What you see on this slide is exactly that. We have delivered consistent margin improvements supported by accelerated sustainable savings in our FME25 program as well as improved operational performance resulting from our turnaround measures. Alongside this, we strictly adhered to our capital allocation priorities, both improving our operating leverage while increasing dividend payments to our shareholders.

The strength of our recent performance underscores the critical importance of the change in the operating model in 2023. It enabled the transparency and accountability required to deliver results. It is this track record of delivered results and accelerating momentum that gives us the confidence to raise our ambitions for the future. While our execution has been key, it is reinforced by attractive underlying fundamentals that position the industry and our company for sustained growth.

I would now like to invite Dr. Frank Maddux to the stage to give you a scientific view on how we think about the underlying CKD and ESRD patient trends and why we are so encouraged about the growth opportunity ahead for our different businesses.

Thanks, Helen. Good morning, everyone. Let us begin by reaffirming the strength of the underlying drivers of our businesses. The fundamentals of the kidney care industry remain resilient irrespective of changes in the macroeconomic environment. The continued rise in age, chronic conditions like hypertension and diabetes globally, evolving recognition of the public health crisis that chronic kidney disease is and the global demand for life-sustaining kidney replacement therapies all support long-term growth.

We remain focused on high-quality care delivery, strong clinical innovation and operational excellence in this field. It's at the core of Fresenius Medical Care to evolve the standards of care, which promote better access, better delivery and better outcomes in kidney care.

Chronic kidney disease is an incredibly common, affecting up to 15% of the U.S. population yet remains vastly under-diagnosed throughout the world. End-stage kidney disease and early-stage CKD are often silent. Many patients don't get referred until the disease is quite advanced. This gap represents both a clinical imperative and an opportunity to identify patients earlier, slow progression through more proactive care and help people progress to more advanced stages of kidney failure with better health, fewer comorbid conditions helping people live better, more productive lives with this life-threatening condition.

When we consider growth, it's essential to look at patient population flows, which is at the heart of how we model our population trends. Patient inflows and patient outflows equally have impact on our overall population of treated patients. We have opportunities on both ends, identifying and managing at-risk patients before they require dialysis, supporting long-term survival and transitions of care for those already receiving kidney replacement therapy. Better and earlier detection, retention and outcomes mean sustainable volume over time. We aspire to be in the ideal growth zone of high inflow and low outflow.

During COVID-19 pandemic, we saw the inverse of this with lower inflows and greater outflows. This trend is steadily reversing.

To better understand this growth potential, we have a population impact model of patient flows through the United States kidney care continuum. This includes inflow from newly diagnosed patients, internal movement across CKD stages, initiation of dialysis and outflow through mortality or life-saving transplantation. This approach helps us target where intervention can be most impactful and model multiple intervention impacts to long-term growth sensitivities.

Our modeling has been validated with several external authorities and we've had independent assessments with different methodologies. We feel confident that the modeling is a plausible depiction of the environment the field operates within.

Let's dive a little deeper. Patient inflow is shaped by broader health trends: aging, diabetes, hypertension and limited chronic kidney disease awareness. It's influenced by the almost malignant cardiovascular disease that yields a major dropout of patients to death between CKD stages 3 and 5.

Modest improvements in identification, referral rates and survival in this group could dramatically expand the addressable late-stage patient population we treat.

Small improvement in the survival of total CKD Stage 3 population patients would have the potential to double the at-risk for in-stage kidney disease population.

Earlier engagement and effective care in the best interest of a historically underserved patient population. Success in doing so will yield opportunities to expand the late-stage at-risk population for developing a need for all kidney replacement therapies.

Let's look at outflow for a minute. We see ongoing improvements in survival, but mortality remains elevated and higher than any of us would desire. While transplant rates have plateaued and are stable, the need for improved care models and innovations like home dialysis and personalized kidney care are crucial to reestablishing a downward trend in annualized mortality for our patients receiving kidney replacement therapies. These innovations will help reduce attrition from premature death, improve long-term outcomes as well as benefit the quality of life for these patients. For example, hemodiafiltration can reduce mortality and increase patient volumes. And HDF will increase treatment volumes even more due to lower missed treatments from fewer hospitalizations in addition to the lower mortality. Several current interventions will help drive these population dynamics beyond aging.

Cardiovascular disease, obesity and health inequities all contribute to disease progression and treatment gaps. Modeling these interactions simultaneous allows us to better forecast end-stage kidney disease prevalence and plan care delivery capacity and care enablement volumes accordingly.

Let's look a little deeper. Obesity is the leading contributor of both type 2 diabetes and CKD. U.S. trends suggest significant increases in obesity prevalence, which have led to an epidemic of obesity-related illness. The last 2 decades have seen explosive growth in obesity and concomitant disease. It's related closely to the previously mentioned malignant cardiovascular disease that our patients face.

Turning this tide will yield a healthier population in patients with progressive kidney disease that are in better physical health to face the challenges of life-threatening kidney disease and their kidney replacement therapy.

GLP-1 receptor agonist originally for diabetes and most recently approved for weight loss are now showing kidney protective effects. While they may slow chronic kidney disease progression by a few months, the rise in obesity and diabetes still outweighs this benefit. Their more profound effect in our population is on improved cardiovascular health and the opportunity to have healthier patients progress, albeit a bit slower.

It's important to understand that pharmacologic advances will shift, but not eliminate the future burden of kidney failure. These medications are not a cure for these diseases, but can yield a much healthier person living with these diseases by virtue of improving their cardiovascular health.

SGLT2 inhibitors have similarly shown benefits in slowing CKD progression by a number of months, and their use in earlier stages will again yield a healthier advancing population.

For both GLP-1 receptor agonist and SGLT2 inhibitors, the discontinuation rates of these drugs remains exceedingly high. The CONVINCE trial demonstrated an all-cause survival benefit with high-volume hemodiafiltration. This modality, though not yet adopted in the U.S., represents an opportunity to improve mortality outcomes for dialysis patients, their quality of life and reduce complications from their disease. Its broad adoption will reshape survival curves, and by extension, the population of end-stage kidney disease landscape that we see.

One example would be lower hospitalization rates, which in turn would reduce the number of missed treatments in our dialysis clinics and support overall treatment volume growth. Again, with even modest improvements in cardiovascular mortality, especially in the CKD population, this will translate to more patients living long enough to reach end-stage kidney disease. When these patients do reach end-stage disease, they are likely to do so with improved cardiovascular health. Our models suggest this could drive significant growth in the dialysis population, even as therapies slow progression. In other words, slowing one disease may accelerate the burden of another.

Ultimately, we believe the end-stage kidney disease population will grow due to compounding trends: aging, better survival and delayed but inevitable progression. Worldwide growth will exceed growth in mature markets. We forecast that patient volumes will grow by 4% to 5% to 2035. In the United States specifically, we forecast positive 2%-plus for patient volumes. On top of this, we anticipate even further acceleration in treatment growth, driven by increased penetration of high-volume HDF treatments and continued expansion of value-based care that supports fewer missed treatments.

Our care models, technologies and partnerships are positioned to meet this future demand and we view this as both a responsibility we have to the field of kidney care and a business opportunity to profitable growth in kidney care. Our company will continue to do well by doing good for patients with CKD and end-stage kidney disease.

As we look ahead, it's clear that early detection and delivering evidence-based kidney disease care at scale will remain essential, and our role in shaping its future is significant. We're prepared to lead with innovation, scale and a clear focus on improving lives.

With that, I'll now hand it back to Helen to continue our presentation. Thank you.

[Presentation]

I am excited to unveil our new strategy, FME Reignite, an evolutionary, not revolutionary, new strategy with a clear ambition. We lead kidney care through exceptional patient care and innovation. We are ready to unlock our full potential and reignite FME.

The word reignite embodies how we will accelerate the realization of the potential of this iconic company. We will reignite kidney care. We will shape and define the future of kidney care. We will lead kidney care through exceptional patient care and innovation. We are transitioning from a phase of turnaround and transformation into a time of accelerated innovation and growth. This will drive profitability, generate more cash flow and build room for accelerated shareholder value creation and returns.

Our strategy will come to life through 3 strategic elements: one, reignite the core by strengthening our core operations to improve performance; two, reignite growth and innovation with a focus on profitable growth and bringing new innovative solutions to the market; and three, reignite our culture to develop together and strengthen our culture. These 3 strategic elements will not only enable us to lead kidney care into the future, but more importantly, also reignite value creation.

Let us dive deeper into each strategic element. Reignite the core is about being operationally excellent in all we do centered on our focused assets. It's about driving scalable, high-quality care. It means we must further standardize and improve processes in all our operations to boost efficiency and margins. And it is about making focused investments to improve speed, agility and efficiency.

This also includes building on the great momentum of our highly successful FME25 program to deliver an additional EUR 300 million of total sustainable savings through 2027, and Martin will provide additional color on our extended FME25+ program later.

To reignite growth and innovation, we will further enhance clinical outcomes and patient safety. We will increase our R&D efficiency by building a global product platform that allows for a focused enhancement of treatment pathways and quality. And we will launch high-volume HDF in the U.S. and set again a new standard of care in this large and important market. This will positively support the business development in all our operating segments.

We will leverage our leading product positioning to further expand market share and drive volume growth. We will continue to grow our clinic network purposefully internationally. And we will continue to drive an AI-powered transformation, enhancing clinical outcomes, improving operational efficiency and delivering more personalized data-driven care across the continuum of kidney disease. We are leveraging our vertically integrated business model and use of machine data, global footprint and unparalleled clinical and advanced analytics expertise to reignite growth and innovation.

And for those of you here in London, I'm excited for you to get greater insight into the medical and care side of our AI approach and capabilities during a deep-dive session with Frank this afternoon.

Reignite our culture. One of the things I am most proud of here is our patient centricity supported by our powerful purpose. We have people taking care of people, and we have to and definitely want to continue to develop together and further strengthen our culture.

A strong culture is essential to driving lasting impact. It is what embeds sustainability into the way we operate, innovate and lead. And we have a goal to become the employer of choice in health care. We must attract, retain and engage the best talent with a passion to make an impact.

To clearly develop together and strengthen our culture, our culture must reflect our highest aspirations not just in words, but in action. And in parallel, we're defining our new strategy we have worked to ensure our human capital strategy and culture are aligned to where we need to go and what we need to get done.

As such, we have revised our core values to better capture who we are, along with our culture ambition. We have set 3 aspirational core values. We care deeply for our patients, our people and for creating a healthier, more sustainable future for all. We connect with employees, patients, customers and communities to set the standard in renal care. And we commit to delivering industry-leading outcomes, meeting the highest standards and growing our business.

In reigniting FME, we have a distinct advantage: the ability to fully leverage vertical integration to accelerate innovation, to improve quality outcomes, to drive growth while reducing costs and to set the standard of care for the dialysis industry.

You might have noticed an important difference in our business segmentation with the introduction of a third segment, Value-Based Care. We have carved out Value-Based Care, which was previously a part of Care Delivery in the U.S. as a new operating segment. This change is not only a part of the basis for the execution against our Reignite strategy, it also reflects our commitment to drive further financial reporting transparency providing greater insight into our performance and the relevant drivers in each of the reporting segments.

The benefits of vertical integration put us in a unique position, which is the basis of our strategy. The rollout of high-volume HDF technology in the U.S. is a powerful example of where we will benefit from this unique operating model. Across our 3 operating segments, we have a clear ambition to deliver industry-leading outcomes and industry-leading margins with above-market growth. And I will walk you through what this means for each of our segments.

First, starting with Care Delivery in its new simpler form. The turnaround of our core business in Care Delivery is already in full swing. What comes next is accelerating the progress and unlocking the full potential. Driving sustainable financial performance means ensuring productivity and operational excellence through standardizing core processes particularly in our clinics, maximizing performance from the integration of complementary assets, and at the same time, maintaining the momentum of continuous workforce and productivity enhancements.

In parallel, we work on translating more of the opportunity to improve our realized dialysis rates through managing payer and service mix, improved average reimbursement and improving revenue cycle management.

These complementary measures will strengthen revenue and drive cost efficiencies, leading to sustainable margin enhancement.

This slide is a reminder of the core assets that are part of our now focused Care Delivery portfolio following the establishment of Value-Based Care as its own reporting segment. It is also the outcome of the work we have done so far on our portfolio since our last CMD in 2023.

Alongside our strong network of dialysis centers, Care Delivery's ancillary businesses, Azura, renal pharma and FreseniusRx currently drive significant value for our business. Azura plays a pivotal role by providing timely dialysis across procedures, which improve patient outcomes and reduce hospitalizations. Renal pharma and FreseniusRx support patient health by providing access to innovative, clinically beneficial pharmaceutical therapies.

We addressed our core U.S. clinical footprint closure of net 72 clinics from the end of 2022 through 2023 as part of our FME25 program. Since then, we have been focused on optimizing our network, selectively opening clinics in markets with clear growth potential while exiting locations with lower profitability.

In the last 2.5 years, as part of our portfolio optimization, we have also taken significant steps to reshape our overall Care Delivery portfolio focusing on core assets with attractive growth profiles.

In addition to exiting noncore assets such as national cardiovascular partners in the United States and Cura day hospitals in Australia, we have now exited around a dozen dialysis service markets, including our Latin American presence.

Today, our Care Delivery international portfolio includes around 25 core markets, primarily in EMEA and Asia Pacific. We have completed a majority of planned divestments to date, and from this basis today, we start from a strengthened portfolio as we reignite our core.

How does this now play into our Reignite strategy? Looking forward, as we reignite our core, we are focused on having the right assets in the right markets. We will continue to hone our portfolio to strengthen our positioning for future profitable growth. This will remain a constant focus as the environment we are operating in is constantly changing. And you would not expect less from us than to continuously, diligently and smartly adjust our portfolio accordingly.

With FME25+, we will further optimize our core U.S. clinic network to ensure we are best positioned to capture growth in attractive evolving markets while improving utilization. As you can appreciate, optimizing a large clinic network is a complex undertaking. Rebounding from post-COVID growth, balancing utilization, growing home dialysis, preparing for the positive impacts of HDF growth while taking into account regional patient shifts means we have to be very thoughtful of short- and medium-term decisions in respect to our clinic footprint and capacity.

In our international markets, we will also further optimize our footprint to prioritize profitable growth in attractive markets.

And the announced divestment of select assets of Spectra Laboratories in the U.S. will support the unlock of cost savings.

Our Care Delivery strategy is not just about operational improvement, but it also prioritizes reigniting growth and driving innovation. Earlier, you heard Frank talk about the potential to unlock volume growth by both increasing patient inflow as well as decreasing patient outflow and reducing missed treatments. While we are proud of our consistently high industry quality ratings, we see a clear opportunity to do even more for our patients and we are furthering our targeted quality and patient safety initiatives. We are bringing innovation to the U.S. market with the launch of HDF to support reduced mortality and improved outcomes for patients. And Craig will speak to this in more detail in his deep-dive session this afternoon.

We know that home therapy offers significant advantages from improved patient outcomes to meaningful cost savings for both our businesses and the entire health care system. Although great growth to date has plateaued coming out of the pandemic, we see a clear opportunity to grow our home therapies program.

We can also reduce outflows by delivering exceptional patient experience. This includes seamless patient access and a streamlined admissions process, strengthening patient treatment adherence and retaining patients overall. These complementary approaches will contribute to extended patient survival, reduced patient outflows and thereof above-market volume growth.

Executing against the presented strategy in Care Delivery will also reignite our financial trajectory. The decision to carve out Value-Based Care from Care Delivery provides greater transparency in how the core Care Delivery business performs and accelerates over time. Starting from an 11.4% margin at the end of 2024, we aspire to and achieve an industry-leading mid-teens margin profile by 2030.

Realizing this ambitious aspiration and offsetting ongoing normal headwinds from labor and inflationary pressures will require disciplined execution of all elements of the strategy. This includes, as already outlined, a focus on increasing patient inflow and reducing patient outflow, while at the same time, improving the realized dialysis rate.

Sustaining momentum in our FME25+ program through 2027 and benefiting from sustainable savings thereafter as well as further supporting productivity and efficiency efforts continuously through 2030 will be an important driver on the way to this margin aspiration.

At the same time, we will further advance our portfolio optimization plan with the plan to be largely complete by 2027.

Before I walk through how our strategy translates to our Value-Based Care segment, it is important to understand the current industry backdrop and our favorable positioning here. Value-based care has been a source of innovation in patient care. It is driving real results for patients through different delivery models where we take on risk and then seek to lower the cost of care by improving the quality of treatment and patient well-being. This will ensure optimal starts and reduced hospitalization days as well.

In the U.S., the renal value-based care market is a nascent but rapidly growing industry, having realized a 25% growth in ESRD patient numbers since 2019. Value-based care kidney care emerged as a critical opportunity for payers, and as a result, the kidney services industry attracted over $2 billion in industry investment with an inflow of new entrants. The U.S. government through CMS' Center for Medicare and Medicaid innovation has also been piloting large-scale value-based care programs that we have been a leading participant in.

However, as with many emerging industries, not all entrants have been equipped with the capabilities or models needed for long-term success. Today, we are looking at a period of more stability as growth expectations are normalizing and the industry is focusing on scaling proven models and phasing out unviable ones. This is where our leadership position in this space sets us up to capitalize on future, more profitable growth opportunities.

Our Value-Based Care company, InterWell Health, is the leading player in renal value-based care with 3 sources of differentiation. This includes connectivity to our U.S. clinic network, the largest network of nephrologists with over 2,200 today and up 38% from 2022 and a unique nephrology-specific electronic health record technology.

At the end of 2024, we managed $7 billion in medical costs with roughly half in the U.S. government CKCC program and the remainder split between sub-cap and shared risk arrangements with private payers. We managed over 130,000 patient lives, comprising 58% CKD patients and 42% ESRD dialysis patients.

Revenue in 2024 was EUR 1.8 billion. Medicare Advantage has a disproportionate percentage of revenue relative to its share of medical costs under management. This is the result of the revenue recognition requirements of sub-capitation arrangements.

In addition to its scale, our Value-Based Care segment stands out for its high-quality and meaningful clinical results for patients: 2.5x optimal start rates compared to national U.S. averages, the vast majority of our kidney care entities in the U.S. government's KCC program qualify as high performers and 80% of gross savings in the overall KCC programs were delivered by our entities. These are not only impressive KPIs for our Value-Based Care business, but benefits also Care Delivery in the U.S.

Despite much focus on the current U.S. government health care spending under the new administration, these types of models are here to stay. We are excited to see that the models have been extended and we are working with CMMI to ensure we are supporting the goals of improved outcomes while reducing costs.

Our vertically integrated business model creates an advantage in the success of both the Value-Based Care segment and our overall company. Value-Based Care also directly improves outcomes and survival for dialysis patients, a key growth driver for Care Delivery. With its large nephrology network, it can also be an important driver for the upcoming HDF adoption due to the potential health benefits from that therapy. At the same time, Care Delivery gives our Value-Based Care segment access to patients and clinics to accelerate growth, drive best practices and support with resources.

By initiating a new reporting segment, we are further refining our operating model, taking into account that Value-Based Care has a very different financial profile, and is by the nature of the business, managed in a different way than each of the other 2 operating segments.

Additionally, we are increasing financial reporting transparency and creating greater insight into the drivers of this growing business but also enable you to better see the development in the Care Delivery Business.

As part of our strategy, we will reignite Value-Based Care as well in order to strengthen and reignite our core business. We are creating mutual value for Value-Based Care and Care Delivery through key quality and outcome initiatives including increasing optimal patient starts, coordinated transitions and enhancing quality and patient safety initiatives.

We also have a significant opportunity to reignite growth and innovation with a focus on driving profitable growth. This includes a focus on enhanced patient engagement to impact behavior and drive down medical loss ratio. Having learned a lot in recent years, we will further optimize our go-to-market and contracting strategies and we will accelerate growth through operational and technology levers.

In alignment with care delivery, we will advance the adoption of beneficial therapies and innovations such as HDF and home therapies. And we will leverage the tremendous data and analytics we have access to in order to improve the quality and coordination of care.

While the value-based kidney care market is still a relatively nascent industry with a volatile return profile, we are well positioned to drive improved financial returns given our leading position in both scale and achieving quality outcomes.

In 2024, we had a EUR 28 million operating income loss in Value-Based Care translating into a negative 1.6% margin last year. In 2025, we anticipate a slightly negative to break-even operating income contribution. By 2030, we aspire to achieve low single-digit margins.

We are shifting our contracting mix toward more profitable segments. We will be further reducing medical costs by enhancing patient engagement and we will be driving greater cost efficiencies and synergies between the operating segments. We expect these margin drivers will offset headwinds from pricing pressure by payers and continued elevated Medicare Advantage claims.

This brings us to Care Enablement where our strategy is founded on how commercial excellence, operational efficiency and innovation will drive robust above-market growth and continued margin expansion.

The 4% to 5% growth in dialysis patients worldwide along with our leading market presence positions us well to capture above the market growth in Care Enablement. We will further expand our already market-leading positions in profitable markets, enhancing customer experience to strengthen relationships and continuing to drive excellence in pricing and contracting as the market leader.

At the same time, we are continuing to drive operational excellence. This is based on the new global setting that enables the next level of restructuring of our manufacturing footprint and supply chain within FME25+. But it is also based on strengthening direct procurement and harmonizing our quality systems, all while keeping patient-centric innovation at the core of our product development.

We have a highly attractive industry-leading renal MedTech portfolio with a diverse international footprint. As a point of reference, our U.S. business is around 1/3 of total Care Enablement revenues. Globally, in each region, In-Center represents the majority of revenues with our In-Center mix split broadly 25% machines and 75% consumables.

We benefit from commanding global market positions in Care Enablement. Not only do we have 40% market share for In-Center HD products, but our position is significantly ahead of the next largest competitor, reinforcing the strength and scale of our leadership. In some markets, we have market share north of 80%.

In home products, which includes PD and HHD as well as in Critical Care, we have meaningful #2 market positions. This reflects the depth of our capabilities, the quality and reliability of our products and the trust that we have earned over time. It also positions us to drive continued pricing and contracting excellence.

Leadership today also means staying ahead tomorrow, and we are reshaping the future of kidney care through innovation. It is how we differentiate and lead, and Katarzyna will give you more insights later in her deep-dive session.

For our future strategy, we are shifting from a focus on machines and consumables to a focus on a more integrated offering with a full package of products and service offerings. We are developing digital ecosystems, which will enable us to continue leading the industry in innovation through connected products. This is about providing a complete integrated offering to our customers. We do not only want to hold on to our already impressive market share, but also continue to improve our share of captive consumables, providing connected health care through our technology offerings all at a premium price.

Moving from regional product offerings to full global platforms will also drive R&D efficiency, innovation and cost savings. With the launch of the 5008X in the U.S., for the first time, we have a true global platform to innovate from.

We can meet the patient in any care setting with a differentiated product that leads innovation in kidney care, whether they are in center, in the home or in a critical care setting. Our product innovation in Care Enablement is unparalleled and we will continue to set a new standard of care with our integrated product offering across the world.

We have made remarkable progress in improving our Care Enablement margin from just 2% at the end of 2022 to 6% in 2024 and already over 8% in the first quarter of this year. We always knew that the scale and time lines would be longer in Care Enablement, but we have demonstrated strong execution and delivery against our strategic plan, and we are well poised to further accelerate.

I always said that we were done with 8% to 12%, but wanted to deliver MedTech-like margins. However, we needed to demonstrate first that improving our Care Enablement margin from 2% to 8% was achievable.

We have proven we can transform this business, and we are in a great position to accelerate profitable growth. By 2030, our aspiration is to realize mid-teens operating income margins. We will leverage our innovative product offerings to achieve further pricing excellence and market share expansion. Now we'll speak more about the opportunity, the rollout of HDF in the U.S. will bring to Care Enablement. And there is a pipeline of R&D development and innovation that we have in place for further global platform innovation.

In parallel with FME25+ through 2027, we will continue to optimize our manufacturing footprint and procurement and we will further restructure international commercial operations. At the same time, we are embedding a DNA of driving continuous operational and process efficiencies through 2030 to overcome headwinds from inflation and FX transaction impacts.

One of the key elements of the Reignite strategy is how our operating segments complement each other to enhance value creation. As you might have guessed, I'm incredibly excited to launch of HDF in the U.S. It unlocks the power of vertical integration and is a critical enabler of our growth through innovation. And it is probably the biggest driver of value in our industry in decades.

For patients, we will set a new standard of kidney care in the U.S. through a truly differentiated therapy. We have seen in the real world the potential to reduce hospitalization days, leaving patients feeling better and tolerating their treatment with greater ease. And most significantly, the CONVINCE study showed the potential of steady reductions in all-cause mortality at 23%.

Our clinics will have a first-mover advantage, attracting new patients who want to receive this innovative therapy. Labor efficiencies will improve, thanks to faster setup and takedown times. Supply costs will be reduced, no saline is needed. And this could also positively impact drug usage. It will also allow our caregivers to be trained more easily and spend more time with patients with fewer alarms or interruptions. And as a result, we anticipate an increase in the number of treatments in our clinics and improving operating leverage.

This is also very meaningful for Care Enablement with the opportunity to replace the large installed machine base and gain captive consumables market share, which is expected to translate into strong performance and growth.

At the end of May, we received additional FDA approval for the 5008X interface we plan to bring to market. We now have all approvals in place to launch the machine in the most efficient way.

We will maximize the value that our innovation has created through premium pricing structures and targeted market share gains in the consumable market. And for the midterm, we are exploring ways to reimagine reimbursement for HDF treatments with the 5008X given its differentiated impact to patients and clinics alike.

Through the successful execution of the 5008X rollout in the U.S., we will further solidify FME as the market and innovation leader and enhance profitable growth across all 3 of our segments. This is what you should expect from the market leader in kidney care.

As we prepare for the launch of HDF, we are taking a comprehensive approach to engage key stakeholders from patients to physicians, to service provider peers to payers. We believe this is a key selling point, which is driving strong and lasting adoption. As the clear market leader with 90% market share for In-Center machines in the U.S., we are uniquely positioned to drive adoption of this new standard of care.

As you can appreciate, we will not be disclosing specific pricing or contracting strategies for competitive reasons, but rest assured, our approach is designed to support broad adoption and long-term value creation.

There are 145,000 of our 2008T machines currently installed in the U.S. out of a total of 160,000 In-Center machines. As our 2008 technology is more than 40 years old, our external consumable capture is only 66% today. By 2030, our aspiration is to achieve 100% consumables market share for the 5008X.

On the right-hand side of this slide, we show our annual production capacity. We ramp up from up to 1,000 machines this year up to 15,000 next year and then 20,000 from thereon. Our goal is to strike the right balance between accelerating our initial rollout and sustaining ongoing commercial momentum and manufacturing capacity utilization while minimizing disruption in our clinics and being mindful about the cost base of our installed machines.

Through 2030, we will look to upgrade the machines in our own clinics as well as sell the 5008X to other providers in the U.S. While the internal versus external split is not detailed here, we do give an indication of the planned internal penetration on the next slide. Here, we have outlined the phasing of our 5008X rollout within our own clinics. We plan to have our In-Center machine base fully modernized with the 5008X by the end of 2030. This will be done on a clinic-by-clinic basis upgrading all machines in a clinic at once, so that there is only one standard protocol for patients and employees in each center going forward. The phasing reflects both our enthusiasm for getting the machines in our clinics, balanced by minimizing disruption and the need to ensure proper training of clinic staff and education of nephrologists along the way as well as the resulting impact on CapEx.

We want our patients to realize the benefits of HDF treatments as soon as possible, and it will not take until 2030 to start to see this impact. We will go as fast as practically possible and financially viable while ensuring safety and patient care.

The CONVINCE study showed benefits emerging after just 3 months of the switch to high-volume HDF treatments. And after 2.5 years of high-volume HDF therapy, the study showed 4.4% fewer deaths, reflecting the 23% lower risk of mortality.

This brings us to how our strategy reignites value creation. As I described earlier, we have a clear ambition to deliver industry-leading outcomes and industry-leading margins across our 3 segments. Our aspiration to achieve mid-teens margins for Care Delivery and Care Enablement, along with a positive margin profile for Value-Based Care drives our group aspiration of mid-teens margins by 2030. This is a meaningful step up from the 9.3% margin in 2024, and I have laid out the strategy on how we plan to get there and this will enable us to reignite value creation.

We are a highly cash-generative business, and through 2030, we expect to further increase our operating cash flow to at least EUR 2.5 billion annually. As we promised, in alignment with our Reignite strategy, we are also introducing a new capital allocation framework. It is designed to reignite value creation by driving enhanced shareholder returns.

To reignite the core, we will invest in our core business to drive sustainable, profitable growth. We will further optimize our capital structure to support our financial foundation in a volatile macroeconomic environment. And we will set a new leverage target. And importantly, with the progress already made, we are now in a significantly stronger position to deliver enhanced returns for our shareholders.

We have listened to your feedback and the different capital allocation preferences you all expressed, which we have reflected in a balanced new capital allocation framework. We will provide consistent dividends in line with our new dividend policy that targets a 30% to 40% payout ratio. We will also start this year with an initial share buyback program of EUR 1 billion with obvious opportunities for further regular buybacks. This step underscores our belief that shareholders should meaningfully benefit in the success we are building for the long term.

I will now invite Martin to the stage to provide more details on the capital allocation framework and the financial aspects for our strategy. Thank you.

Thank you, Helen, for introducing our new strategy and capital allocation framework, and a warm welcome from my side to everybody as well.

Before I share further details, let me briefly look back on the development of our financial profile since 2022. I'm very proud to say we have delivered impressive improvements since 2022. This is a track record that we intend to continue. We have significantly improved our transparency, and based on this, our focus on measures that create shareholder value. With the implementation of our new operating model based on the 2 global segments and global G&A functions, in January 2023, we introduced our current financial segment reporting providing improved external transparency. The introduced external reporting was based on a strongly enhanced data availability internally. And with that, it provided management board and business leaders with better information for decision-making as well.

As presented by Helen, we have strongly increased our profitability since then. We lifted our FME25 savings target twice. In total, we increased it by 50% to now EUR 750 million. Total onetime costs are very tightly managed.

We have continuously improved operating income margins toward our 2025 target band.

In the last years, our capital allocation priorities have been governed by a disciplined financial policy that was strictly followed through. This included a stringent CapEx management to support free cash flow generation. Free cash flow proceeds from our divestitures of around EUR 750 million and the Tricare settlement of around EUR 190 million were consistently used to delever our balance sheet from 3.4 to 2.8x net debt-to-EBITDA in quarter 1 2025.

Between 2022 and 2024, dividends grew an average 13%. And the dividend paid in May this year was the highest in our company's history so far.

All along, we have always been committed to a solid investment grade rating and a sound financing strategy. We have strengthened our investment grade ratings and also the rating outlooks were upgraded to stable in 2024.

Finally, we are well established in the bond market has recently demonstrated in our successful bond issuance and tender in April of this year.

Looking forward, we aspire industry-leading margins that further enhance our financial profile.

A couple of minutes ago, Helen shared our 2030 margin aspirations. These aspirations are based on assumptions that apply to all our businesses. We expect average global patient numbers to grow at a CAGR of 4% to 5% until 2030 and U.S. patient numbers to grow at 2-plus percent annually.

Like in past years, we do only plan with moderate reimbursement rate increases as well as continued U.S. payer mix improvements.

We plan with moderate labor cost increases and cost inflation as well, in line with our 2024 expectations. We also do assume a normalized labor situation, which is comparable to what we see today.

Our modeling assumes broadly stable currency exchanges going forward as well.

And beyond what we can know today, we also assume no further escalating geopolitical conflicts, no further tariffs and trade barriers. These assumptions also exclude major disruptions like material changes in the regulatory environment or the reimbursement systems.

To further enhance our reporting transparency, we decided to break out Value-Based Care from the Care Delivery segment. We will share a comprehensive table of our new segment data including revenue, operating income, special items as well as growth rates in reported, at constant currency and organic for full year 2023 and 2024 after the Capital Markets Day on our website with you.

I will share some financial highlights on the 2 segments here. As you already heard, the new Care Delivery segment will consist of all current Care Delivery assets except for Value-Based Care as a business. The key operating drivers for Care Delivery in 2024 you already know from our reporting. Our aspirational margins target of mid-teens percent, as just laid out by Helen, are formulated for operating income, excluding special items as a percentage of revenue.

The new Value-Based Care segment recorded strong organic revenue growth in '24 of 37%. This was mainly driven by membership growth, benchmark growth under contract and additionally signed contracts with payers.

Operating income improved strongly in 2024, lowering the negative contribution significantly. The development was mainly driven by higher CKCC savings and lower operating expenses due to scaled operations.

As shared with our 2025 outlook, we do expect Value-Based Care revenue to grow to around EUR 1.9 billion in '25. And our operating income to further improve to a slightly negative or break-even level this year. We will report in this new segmentation starting with quarter 2 results.

Sustainable savings remain an important component of driving operating income growth. Beyond the EUR 180 million we expect for this year to reach the 2025 target of EUR 750 million of total savings, we will use the strong momentum and generate additional EUR 300 million sustainable savings until the end of 2027. This will further increase the number of total sustained savings to above EUR 1 billion.

Related onetime costs for FME25+ are expected to be around EUR 300 million and will be recorded as special items.

We continue to strive for the industry benchmark of EUR 1 savings for EUR 1 onetime cost, and disciplined cost management clearly remains our focus.

Planned savings to be realized between 2026 and 2027 will come in largely balanced between Care Delivery, Care Enablement and the G&A areas. Our Value-Based Care segment also has savings included, which are accounted for in the G&A section.

So let's look into more detail for the additional EUR 300 million savings contribution. Care Delivery will be contributing about 40% of the additional savings from the program extension. This emphasis on sales underscores both our determination as well as the momentum and initiatives at hand to further improve profitability. We do plan to optimize our supply chain and clinic footprint as well as realize the necessary efficiencies in our real estate operations.

Care Enablement is planned to contribute 25% of the savings. Key drivers will be the continued optimization of manufacturing and supply chain as well as the restructuring of international commercial operations.

Global G&A functions will contribute the remaining 35% of FME25+ savings. Here, we will see the benefits of further expansion of our global business services, process optimization across all 3 reporting segments as well as further optimization of the procurement function.

Across all areas, the application of innovative technology will play a key role to achieve the targeted efficiencies. And this, of course, does also include the application of artificial intelligence.

Operating cash flow between 13% and 15% of revenue translates into an annual available cash amount of north of EUR 2.5 billion in the years until 2030.

In alignment with our Reignite strategy, we have developed a new capital allocation framework with a clear focus on shareholder value generation. Clearly, to reignite our core, we invest in our business to support sustainable, profitable growth. We have earmarked annual capital expenditures between EUR 800 million and EUR 1 billion for the years '25 to 2030.

In parallel, we further optimize our capital structure. A strong balance sheet, financial flexibility are important to us, so is an investment to the investment grade rating. And those are key aspects of our financial policy.

Reflecting the volatile macro environment, we decided to have a lower self-imposed target rate for our net financial leverage going forward.

And to reignite shareholder value creation, we plan for attractive returns of excess capital to our shareholders. By complementing our updated dividend policy with an initial share buyback program, we are excited to introduce an additional way of returning value to our shareholders besides dividends.

I'm going to further elaborate on each of those frameworks components on the next slide. Our new capital allocation framework starts with driving profitable growth by investing in our core. Our plan until 2030 is to annually invest CapEx of EUR 800 million to EUR 1 billion, which translates to a share of revenue of 4% to 5%. This is a very clear commitment to grow our core business where we see sustainable profitable growth opportunities.

In anticipation of the upcoming 5008X rollout, we had slightly reduced our CapEx for purchases of the 2008 machine in our own clinics. Despite the planned slight increase, compared to the past 3 years this future CapEx level is well in line with historic levels.

We want to continue capturing attractive new opportunities based on innovation and equally keep our focus on investments to enhance quality of care levels and our patient care experience. At the same time, we will continuously upgrade technology.

Until 2030, Care Delivery is expected to account for around 55% of CapEx while Care Enablement is expected to account for around 45% of the planned capital expenditures. Planned CapEx for our new segment, Value-Based Care, accounts for a rather lower share. Importantly, this CapEx plan foresees clear priority shifts from old to new products with the 2005X (sic) [ 5008X ] rollout in the United States and investing in R&D to develop the next generation of machine platform.

We are tightly managing the overall spend. This investment approach is a deliberate reprioritization for us. CapEx requirements linked to the 5008X rollout, of course, are included in the future target band.

Like in the past 2 years, we foresee no major growth M&A. We consider selective clinic acquisitions as well as joint venture entries or adjustments as part of our ongoing business.

Optimizing our capital structure is an important component of our new capital allocation framework. As the graph shows, at the peak of the pandemic, which was the low point of our financial performance, our leverage ratio increased to 3.4x. Improving operating income and proceeds from divestitures drove the successful deleveraging to below our former target range. We are now targeting a lower net financial leverage of 2.5 to 3x net debt-to-EBITDA until 2030. And in the first quarter of this year, we were already in the middle of that updated wings.

This new self-imposed target band is reflecting our value creation-focused capital allocation framework going forward. We are committed to a strong balance sheet and a sustainable investment-grade rating. The target band provides us with the necessary flexibility for funding growth opportunities while returning excess capital to our shareholders. In the current market environment, we do regard the leverage at this level to be a good balance between optimizing our financing costs and meeting our financing requirements. The lower target band also takes into consideration the elevated volatility of the current macro environment that we operate in. The chosen target band of 0.5 allows financial flexibility to absorb potential impacts of uncertainties that are not foreseeable today.

So talking about the financing side. We are building on a sound and proven financing strategy. In line with our business profile, targeting both euro as well as U.S. dollar bond market is a cornerstone of our financing strategy. In early April, we took advantage of favorable market conditions and our improved credit rating outlook. We successfully placed 2 Eurobond tranches with an aggregate volume of EUR 1.1 billion. And we used some of the funds for an early buyback of approximately EUR 300 million of bonds maturing in 2026.

We will continue to use attractive market environments in an opportunistic way to early refinancing upcoming maturities. The high oversubscription of our most recent Eurobond transaction proves our strong bond market access. The result of our sound and proven financing approach is a well-balanced maturity profile and a clear strategy to address the upcoming maturities in 2026.

Returning cash to our shareholders is an important component of reigniting our value creation. As part of the new capital allocation framework, attractive dividends are an integral part of this. Going forward, we target a stable and predictable dividend development, resulting in a 30% to 40% dividend payout ratio in relation to adjusted net income.

Fresenius Medical Care has a long-term track record of attractive dividend growth and payout with the most recent 2024 dividend marking the so far highest dividend paid in the company's history.

Today, we are very excited to announce a new regular share buyback program that allocates excess cash to our shareholders, complementing our new dividend policy. This contributes and reignites value creation for our shareholders. They will participate in the strength and future value creation of our business.

The initial share buyback program foresees EUR 1 billion of share buybacks. As part of the program, we do intend to acquire own shares on the stock exchange and subsequently cancel them. We plan to execute the program in multiple tranches in line with the new capital allocation framework and supported by continued strong cash generation.

We plan to start in the second half of 2025 and complete the initial program within 2 years. A precondition to executing the full program is a renewal of the 10% authorization for share buybacks at the AGM in 2026.

Going forward, our new capital allocation framework provides further opportunity for regular share buybacks.

I would like to summarize my presentation on the following highlights. We further enhanced our reporting transparency by introducing Value-Based Care as a new segment starting in the second quarter of this year.

We plan to further increase our profitability by advancing operating income margins for each segment to industry-leading metals by 2030. A key contributor will be savings from the FME25+ program.

We are committed to a solid investment-grade rating and sound finding strategy.

Our future capital allocation framework has a clear focus on value creation for shareholders. This includes investing in our business for sustainable, profitable growth. At the same time, we are returning excess capital to shareholders in the form of attractive dividends and regular share buybacks. And in parallel, we maintain an optimized strong balance sheet and capital structure.

Our new capital allocation framework is a proof of our confidence in FME's future value creation. It is also a proof of how reigniting FME will pay off for our investors.

And with this, I hand back to you, Helen.

Thank you, Martin. As you have seen today, we are incredibly energized by what is ahead and our ambitious strategy to accelerate growth and returns. We are turning a page. This is a new chapter for FME and one we are not only confident in, but also incredibly excited about. By leveraging the strength of our vertically integrated business model and market-leading positions in an industry with accelerating underlying trends, by bringing industry-setting innovation to the market, by continuing to execute with clear focus against our strategy, we are reigniting FME. We will reignite the core, reignite growth and innovation, reignite our culture.

This is our path forward designed to achieve our 2030 aspiration of reaching industry-leading mid-teen margins and reigniting value creation with enhancing returns for our shareholders. And we do all of this with a clear vision to create a future worth living for patients worldwide every day. Thank you.

Wow, at least I'm reignited despite the room being so cold. Thank you, Helen, Frank, Martin, for your presentations. I know there were a lot of insights and we already cut out 60 slides. There's a lot of details and strategy in there.

We will now go into the Q&A section. We will ask you to ask 1 question only first so that everyone who wants to ask a question can actually ask a question. There is also the opportunity if you want to make a positive statement, you can do that, too. So don't be shy, that's possible. Don't be afraid.

For those on the line, I'm sorry, you can't ask questions.

I would ask you to cover my poor ability to remember names by saying, for the people online, company and name when you ask a question and I will come down and who wants to kick us off. Oh wow, good. Then I'll start here who is closest.

It's Graham from UBS. Maybe first one for Frank around volumes and maybe go GLP-1 first as a dynamic. Just how much data do you have already in-house from patients who would have been on GLP-1 as your patients and their reaction in terms of the CV benefits in the ESRD stage. It would be good to get a sense as to what sort of data you have there.

Yes. In the ESRD space, we have in the United States about 12,000 patients on GLP-1s. These are almost all diabetic patients that are -- have quite high BMIs. To date, those patients -- even those patients have exceedingly high discontinuation rates. We see the discontinuation rates at 1 and 2 years being well over 3/4 of the patients.

We are looking regularly each quarter at clinical parameters in this population versus the other. And other than some relatively mild reductions in blood pressure, there aren't any other really visible changes right now.

Okay. Good. Lisa.

Lisa Clive from Bernstein. Thank you for the very helpful guidance on where you were hoping to get the margins over the next few years. I just want to focus on Care Delivery. You're some ways off from industry-leading margins in that segment today. Could you just provide us with some building blocks for how you get there? Is it around reduction in bad debt, which is clearly fairly accretive; clinic optimization, whether that's in the U.S. or abroad? Or does it involve continued exits from some subscale international markets, which you've clearly been focused on? Just it'd be helpful to get a bit more context there.

Thank you for your question, and let me take that. As we outlined on the margin bridge, and yes, we didn't quantify it, there is, number one, the topic of increasing the number of patients, which speaks to what Frank was relating to and also with our work that we do on the patient inflow as well as reducing the patient outflow.

There is also the topics on rate, which includes some of what you refer to, which is the rate as well as the yield, so to say, of the rate, which also speaks to some of the work on the revenue cycle.

And then there is other topics, which we highlighted with efficiencies and productivity on the process work that we do, but also optimizing our clinic network.

Please also don't forget that we outlined assumptions around this where we do need to overcome labor and also inflation, which we quantified with the 2024 reference of net in '24 of around 3% as well. And those are the major building blocks that will drive this.

Veronika Dubajova from Citi. I'm going to just follow up on Lisa's question around Care Delivery and margin progression. Just to challenge you, if we do not see a volume recovery to the 2%-plus that you are targeting, what would the margin path look like?

And maybe just a follow-up of that shape improvement into the mid-teens. Martin, is this fairly consistent year in, year out? Or is this more front end or back end loaded?

Yes. So let me frame it first. If you have a starting point of our 2025 guidance that we have and the implied margin of 11% to 12%, this is a 300 to 400 basis point improvement for us as a group. So with that and overcoming the headwinds that I referred to, we are focusing on the 3 segments' building blocks that we outlined.

You can assume when it comes to the phasing for Care Enablement and care -- and Value-Based Care, a more straight line-ish kind of development until 2030. Due to the nature of the work that we do with Care Delivery, I would say it's a little bit more a back end-loaded improvement that we drive there because some of the measures that we outlined like the benefit from high-volume HDF introduction or also some of the rate and other topics, when they materialize in combination with the labor cost inflation, do take a time until they do improve profitability overall.

Veronika, maybe I would just add specific to the volume piece on the 2%-plus. Obviously, you saw the underlying fundamentals from Frank and that we do see -- we know where we've been and where we're going here. Part of that volume uplift in terms of treatments will also come from HDF.

As we've always said, it's not volume that makes or breaks that margin. I think some of the other building blocks that we've outlined like the rate, the mix, kind of the pricing -- moderate pricing reimbursement as well as FME25 contribution to CD are as important building blocks. So obviously, I think from an operating leverage, we see that 2% being key, but it's not the make or break of this margin progression through 2030.

Next question, Hugo?

Hugo Solvet from BNP Paribas. Just a quick one on HVHDF. So could you please share the number of patients or the share of patients that could benefit from this instrument? And how do you prioritize FME clinics versus competitors' clinics? The latter, I guess, being important in trying to claw back the consumables revenues and -- in terms of going to that 100% of consumables share. Could you talk to maybe the IP or the commercial strategy that underpins that?

Yes. Thanks, Hugo. So our current assumption is that 75% of our patients will be on HDF. As you saw from my presentation, the first mover advantage will be in our clinics and we are modeling where -- which clinics to go to first, and we want to do it clinic by clinic.

We also feel this is incredibly important for patients and for the industry that all providers participate in the new treatment therapy. And obviously, we won't go into the dynamics of that, the competitive set right now. But as you can imagine, with the improved outcomes that we are seeing on this therapy and all the benefits, there is significant interest from other providers other than ourselves in the United States.

Obviously, with the consumables, I have to smile when I say we only have 66% share because most companies would love to have 66% share. But the point here is we now, with a captive machine and captive consumables, can take that 66% to 100%, which obviously benefits Care Enablement across all providers, including us.

Did I get all aspects of your question? Yes, good. Thank you.

Okay. It's Oliver Metzger from ODDO BHF. Question on value-based care. So historically, the value-based care programs have shown also some disappointments when it comes to the remuneration of your services. So how do you think about or guarantee that the savings you generate is also sufficiently rewarded by the payers?

Yes. Thanks, Oliver. Look, we have a lot of experience in value-based care, about a decade now, right, with all the different schemes that we have participated in. What we are seeing, we've learned a lot, particularly as we kind of stood up into [ all ] the last couple of years of these insights into contracting and how -- what the contracting rate needs to look like to take on this risk and how we can drive the cost down to improve the loss ratios.

What we are seeing is that payers and health care systems can't do this alone. These patients are too complex and too expensive actually for them to not manage. And for us, we see -- and they're increasingly wanting to offload that risk.

So for us, what we see are these 3 benefits, right, where we have dedicated caregivers that can manage these patients, the largest nephrologist network in the country. We obviously have our dialysis network that can be levered. And as you saw from the presentation, our own unique Acumen EHR system. So we feel our ability to manage care in this space is greater than most.

There are 3 models, if you will, in the U.S. There's the ones that, like us, the large dialysis providers that participate in value-based care. There were the offspring of private equity and value-based care companies, some of those are no longer. And then you have the kind of the accountable care organizations or the larger systems, if you will.

So for us, it's a critical component of our vertical integration. And hopefully, you saw that coming through, not just as value-based care benefit from care delivery and our ability to manage the patients, but also for access to technology and vice versa.

If we improve optimal starts and we have healthier, better managed patients being covered through value-based care, that benefit also comes into care delivery. So we have kind of an optimal start patient who might have had their health managed better by all the reasons that Frank outlined rather than somebody just crashing into dialysis.

So it's definitely nascent. I also want to say, I mean, it's lumpy, right? And it's challenging to manage and forecast a lumpy business, as we know. But I think we've learned a lot. We know where we can access the patient and where we can manage the care, and we know what to do to manage down costs.

I think the other piece of this is it does feel more stable. We are seeing the kind of the rates increasing. We're seeing the partnerships with the managed care payers. So that's why we have the confidence to kind of project what we have and also give more visibility into it on a go-forward basis.

Obviously, it can be a big revenue business with a low margin, but we also feel that we can participate. I think not participating in this space is not an option for us. So strategically, it fits when the kind of the core assets that we have and the vertical integration. So irrespective of that profitability, I think we're still the biggest. We still have the best outcomes. And we're still, I don't know, the least less profitable of all the plans out there, but we see a clear plan to turn that around.

Victoria Lambert from Berenberg. So FMC has the only FDA-approved HDF system in the U.S. Who are the main competitors outside the U.S.? And how long do you think you'll remain alone in the market in the U.S.?

So I think the -- as we look at the HVHDF rollout, the opportunity to -- given the very high market share that we have gives us not only a chance to bring our 5008X machine in the market to recognize that there are no other machines that can provide this therapy in the United States today. Likewise, there is no other machine that can meet what the U.S. standards are for maintaining a single daily disinfection of the machine as opposed to disinfection after each of the treatments that occurs. So we feel that the machine is both an efficient and effective way to do that.

So I can't speak to how the other companies may be approaching this particular area, but we think this is a distinct advantage for us that will give us the chance to maintain this remarkable market share.

It's Hassan Al-Wakeel from Barclays. On your HDF rollout, thanks for the phasing detail, is the incremental CapEx from the EUR 700 million that you've seen over the last few years to the EUR 800 million to EUR 1 billion mainly a function of HDF and a reasonable estimate?

And appreciate you see a benefit after 3 months of use at high convective volumes, but when do you expect this to move the needle on U.S. same-store growth? So versus that 2% market growth that you're talking about in 2030, where do you see your growth?

So let me take the CapEx question first. Regarding CapEx, the band that we provided from EUR 800 million to EUR 1 billion is broader than HDF, yes. So it does include the HDF rollout, for sure, and it also covers the time until 2030 where we talk about own conversion, but also the investments into the Care Enablement production ramp-up that we see as well.

For Care Delivery, it's mainly a function of buying new machines and buying 5008X instead of 2008T as well. That's why I outlined that for the last 2 years, we have slowed down a bit on the replacement.

Last one perhaps on the CapEx, this does also include what we talked about investment into innovation for the next product platform, investment into innovation for the patient experience, but also the treatment that we want to provide as well. So this is a comprehensive CapEx plan that covers all our businesses.

Yes. Hassan, I'll take the second part of your question in terms of when we will expect to see timing. Clearly, any patient that is on HDF we can expect to start that clock ticking after the 3 months, and within that 2.5-year period, see the full benefit. Obviously, as we've outlined today, we've been talking a lot about the CONVINCE study and the mortality benefits, but I think you also see this reduced hospitalization and the patient feeling better. So patient retention also plays into that.

We will see this ramp up over time. And as I mentioned, it's a complex balance right now of, as you can imagine, I'm impatient and I want to go as fast as possible, but at the same time balancing disruption and what we already have installed and getting all of our clinic staff trained.

So I think you'll see this ramp up over time. And some of the benefits will come soon. But the 2%-plus patient growth, HDF, we see on top of that. And obviously, as we are rolling this out, we'll report accordingly over the course of the next quarters and years.

It's Robert Davies from Morgan Stanley. My question was on the savings targets that you put out with the additional EUR 300 million. I think you made some comments on the expected margin trajectory across the 3 divisions. The Care Delivery business to be more, I guess, back end-loaded whereas the other 2 are more straight line. Can you just sort of walk us through the building blocks for that bridge, I guess, out to your mid-teens margins if you've got effectively a front-loaded savings target for '26-'27?

Yes. So as we outlined before, there's multiple building blocks. And the FME25+ program is one element that addresses the first 2 years, so to say, of that journey for all our segments. And for Care Delivery specifically, we are focusing on supply chain optimization as well as further optimization of our clinic footprint and efficiencies that we want to drive also in the real estate program.

Now overall, for Care Delivery, as we outlined, a building block is also the growth in patient numbers, which is focused on the management of the inflow as we outlined as well as the outflow. And the inflow, I think Frank gave a lot of, let's say, fundamental data when it comes to CKD and ESRD and the transition as well as the role that certain medication plays. But also on the outflow you see high-volume HDF but also the focus on patient care and quality being there.

Then it is about driving other efficiencies, and also when Helen talked about driving that process efficiency and deploying technology, that is another element in it. And we are focusing also here not only on process, but also on improving our yield for the rates, both on the rate as well as on the revenue cycle management side, which is also a process management initiative to improve our yield.

So when you look at those together with the continued rollout of 20% of installed base conversion for the high-volume HDF and then the picking up benefit from the HDF treatments, both on the treatment yield and the reduced mortality, that leads a bit to the back-end loaded-ness, so to say, on the volume side because also here if we include increased utilization of our clinics, you will see an over-proportional contribution as well from that side.

Falko first.

It's Falko Friedrichs from Deutsche Bank. How should we think about sales growth for your company over the medium term until 2030? I think that was one of the few missing parts in your financial guidance.

So there's 2 elements here. We did not provide you a revenue guidance. We did provide you with a view on how we see the fundamentals develop. We gave you that view on both key segments. We gave you that view on Care Delivery as well as Care Enablement when we talked about the 4% to 5% growth per annum on the patient number and also the 2-plus percent in the United States plus the increase in treatment yield, which is the fundamental drivers to sales growth next to the reimbursement.

On the assumptions we laid out, that only moderate reimbursement increases are part of our assumptions as well as a mix improvement is also part of the assumptions that we took.

And then on the Care Enablement piece, we did talk about continued innovation, leveraging the strength of the market share that we have to gain further share and also pricing, making sure that we get reimbursed for our innovation power as well.

Lastly, on the Value-Based Care topic, it is a function of us looking into margin improvements while at the same time managing the right contracts that we want to acquire, which will also drive, to a certain extent, growth.

Holger Blum, Patinex Management. I think the 5008 machine was launched 20 years ago in Europe already. So I wonder why it took so long to get it to the U.S. with the incremental improvement over the years, over -- took 15 years to start the CONVINCE study. We have the data since 2 years. So do you -- would it happen again at that speed at Reignite at FMC? Or would it happen faster?

Yes. So 5008 series machines launched quite a few years ago and HDF began in its various forms of modalities, likewise, quite a few years ago.

The machine that is prepared for the United States has multiple special features that in the breakout session this afternoon you'll hear quite a bit about from Katarzyna and Joe. But it recognizes that there were many features to that series of machines that were built specifically for operating in the United States. That's one reason why it's taken this long to get there.

The regulatory framework is slightly different in the United States. This will be the first machine that produces online of fluids for intravenous substitution fluids in the United States that will remove saline bags from the work that we do in this. And I think the complexity of these machines while bringing it in is one.

Now on the other side, the tipping of the balance on the clinical evidence really came when the European Union decided to fund the CONVINCE trial. And I can recall the development of that trial was leveraged on the ability to generate patient-reported outcome measures. That's why they approved it in the way that they did. And that trial didn't report out until 2023. And being a large multinational, multi-provider, multi-location and background, there were no other -- most of the other randomized controlled trials were much smaller, not nearly as long and not nearly, as I hate to say, convincing, but in fact, convincing as this data. This truly was a sentinel trial.

I'll take your second part of the question. Would I love to have HDF in the U.S. sooner? Absolutely. We didn't, but we have it now and we're going to do our very best with it, and we're super excited about it. .

Don't forget, this MedTech organization didn't exist like it exist now less than 3 years ago. And this is the beauty of the operating model and how we've aligned around our verticals. We have a clear R&D strategy that is fueling the innovation, that is fueling the global launch.

Shouldn't have been lost on you this morning when I said the 5008X platform is the first time we actually have one machine all on a global platform. Out in the lobby, you can already see the 6008, which is available in parts of Europe.

So going forward, that is our operating and behaving like a MedTech company, we will continue to innovate the global platform and roll that out. I mean, we all know the U.S. regulatory framework is complex. It does take longer. But I think also with our mindset of any new machine, it's the extent that -- and any new machine should be innovated to provide better outcomes and reduce costs that all markets in the world should benefit from that innovation, and that's the go-forward approach.

David Adlington from JPMorgan. Maybe just on HVHDF again. I think you're hinting at potential for higher reimbursement potentially in the U.S. Just wondered what the payers will need to see that. And I think outside the U.S., you've only got higher reimbursement in a couple of markets. So what gives you the confidence you will get higher reimbursement?

Yes. I used the words reimagining reimbursement. Look, for the past 40 years, I mean, we've just been in an environment where it is trying to get paid for an increasing cost base and hope that the reimbursement covers that. This is the first time in 40 years that we really have a significant improvement in outcomes. And obviously, we've invested in this machine and you can see for yourself the benefits that this innovation presents not just for patients, but also for the dialysis providers in terms of efficiency.

The current road map that we have does not assume any change in reimbursement outside the moderate reimbursement increases. This -- the business case for HDF still works and is still strong with that assumption.

That is not where I'd like the outcome to be. I think there are many, many levers where we can look at the kind of the benefit of this therapy. I'll take commercial mix is a good example of that. You all know kind of the mechanisms of our business and where commercial mix sits. But today, on average, patients are only staying on commercial insurance for around 23, 24 months. As you know, in the current MSP set up, that's up to 33 months.

What we are seeing from patients and how they are feeling coming off HDF as well as the mortality improvement, we could start to see that mix improving in time. This MSP period of 33 months hasn't been changed in decades also. So I think, for us, talking about the outcomes and that 23% on average improvement does translate to about 18 months extra life. And I think the conversations that we are having with government and payers is showing those outcomes.

So for me, it's like kind of looking, okay, add-on payment for the machine looking at changing the PPS rate, maybe changing -- kind of tackling the MSP period. I think all opportunities that we know don't get solved overnight. They don't get solved tomorrow, but certainly over the next couple of years, that is kind of the approach that we will be taking. We clearly want to get rewarded for our innovation and obviously bringing something of this magnitude for the mortality improvement is significant.

So I think all of that together is the path that we're on where you saw the approach that we're taking to the launch. Obviously, our kind of contracting and government affairs pieces are part of that as well. And my goal is to truly get reimbursed for the outcomes that we are providing as well as obviously benefiting from the lower costs.

[indiscernible] from Invesco. Talked a lot on the in-clinic sort of dialysis at the moment. But in terms of the in-home dialysis, I mean, does this -- any chance of this technology, is there any spillover to improve that side of things?

And second part would be, could you just remind us on any sort of margin differential between in-home and In-Center, please?

I can take the first part of that question. As we think about using these 2 physical principles of diffusion and convection for treating somebody with a hemodialytic kidney replacement therapy, the opportunity exists to look at developing a home machine that would have the capabilities of doing HDF.

Today, that doesn't exist in the marketplace. And we think, first, the introduction for our In-Center patients which is the predominant number of dialysis patients is the right way to go, but there's certainly opportunity for home patients to benefit.

We're incredibly committed to home as part of our strategy. We see the benefits that our patients get from that. And I think all the financial benefits from a home setting, we have spoke about at length over the years in terms of it tends to lend itself to a younger, healthier commercial patient. With medical justification, they can get 4 treatments. We're kind of diffusing the cost of care by out-of-clinic to a home care setting and a caregiver. So all of those benefits for home are still there.

We don't disclose our margin by vertical. But what we do know is our home business is more profitable. The -- our aspiration, you heard us talk this morning, our home -- while home is an incredible part of our strategy, we've kind of stagnated at that low 16 percentage pace of home. And I say stagnated more because of the same labor that we needed to train in the home was the same labor we were desperately trying to get in our clinics in a post-COVID environment.

So incredibly excited about our continued aspiration of increasing our penetration in the home space. And I think the question that you're asking is one that we are tackling internally on how can we make even in a home setting this therapy kind of also fit in that a patient can still continue to select where they want their care, either in center or at home.

[indiscernible] I have a follow-up on the home dialysis situation. I remember your former target was about 25% in 2027 as penetration rate. Is it still valid? And what's your current assumption on the 2030 number?

Yes. We always said the 25% by '27 was an aspiration. And clearly, we're not there yet. It is still our aspiration to get there and we still believe we can, just a longer runway that will gradually increase over time.

It's James Vane-Tempest from Jefferies. Just a follow-up on the MSP question. Does your guidance include an assumption for increasing number of months on insurance? I'm just trying to clarify in terms of thinking about GLP-1s and SGL2s potentially slowing the funnel. And then if patients are potentially then living longer, thinking about if more of them move then on to Medicare, how we should think about what the improving mix assumptions are in your guidance?

Yes. To be crystal clear, we haven't -- we're not assuming a change in the MSP period in this. That is more of our thinking around reimagining reimbursement for HDF, where the MSP period of 33 months has roughly been about half of the time that a patient is on dialysis. So if you think about a patient being on dialysis 6 to 7 years, that MSP period is covering roughly half of that.

If you fast-forward and see an environment where patients are living longer on dialysis, whether that be HDF or even because of the cardiovascular treatment from GLPs, that life expectancy gets longer. And I think the question that we want to tackle is does that then give us an opportunity to push the MSP period in a different direction?

But none of that is included. It's kind of just moderate reimbursement increases and slightly improving mix.

Graham from UBS again. Just on the HDF side in terms of Care Enablement. So if you're rolling that in the U.S. and there isn't enhanced reimbursement for like consumables or per-treatment, is it still economic to do that? And as economic as it would be on the old device, in which case, is there any reason why another company would not just purchase as they naturally upgrade their installed base. So presumably you don't have to have an enhanced reimbursement on a per-treatment basis to sell this.

That's right, and that was the point I was making. Our business case is -- stands for itself with all the benefits that we've outlined without any significant change in reimbursement. The efficiencies, the cost structure and the extra patient volume alone makes it viable -- incredibly viable. Veronika?

I'm going to sort of phrase Graham's question slightly differently. Obviously, the HVHDF technology has been in Europe for a long time. But from the data that I can see, penetration is still fairly low at sort of 30% to 35%. I know there are some exceptions where you have premium reimbursement. But in general, the adoption hasn't been anywhere as dramatic as you're targeting in your own clinics and I think hoping to see in the market.

So maybe if you can talk through why that's the case and why you think the U.S. will be different. If we do not get premium reimbursement, why should the adoption be so much higher?

So yes, I'll be happy to take that. So Veronika, the way we look at it is the uptake in many countries was driven by their payment system and those payment systems occasionally required premium reimbursement. Some payment systems capped the number of the proportion.

Where we don't have any caps in those in our network, we have places like the Czech Republic that has 98% HVHDF. We have a number of countries that have extraordinarily high levels, and we see the results in the outcomes in those populations of patients predominantly in Europe.

The puts and takes on a variety of issues related to the new machinery offer the opportunity for us to deliver this therapy in the United States where reimbursement is unique to its own health system in a way that we can deliver that therapy without having a mandate that you must have that reimbursement to be able to offer.

And we think that the building blocks of diffusion and convection offer a good case for additional reimbursement, but it's not a required case in the models that we've done based on the outcomes that patients have, and that's both in a nonvalue-based care environment and in a value-based care environment.

Lisa Clive from Bernstein again. I was just going to follow up on James Vane-Tempest's question, which I think it was a slightly different question around in your assumptions, because you talk about improving mix, you mentioned that most private patients even though the MSP is 33 months are only there for 23, 24 months. It's helpful to understand that there is that gap. So how much of the improvement in mix is around increasing that?

And could you just give us a bit more granularity on this? Obviously, a lot of patients when they go on to In-Center dialysis have to quit their job. They end up on COBRA. COBRA only really covers them for 18 months. And so then it becomes incredibly expensive to keep that private insurance going, hence, you lose those months. Could you just talk about the dynamics and how that potentially changes? Obviously, home dialysis is a feature, but it seems like HDF may be a new angle on this possibility for more private patients or keeping private patients private for longer.

So let me take that on the assumption side. When we talk about mix improvements, and we were consistent over the last couple of years that we were also always very moderate because we don't want to make ourselves too over-dependent on the measures that we drive to achieve our financial performance. So we are not bullish on this, and we are consistent with past approaches.

Having said that, for the high-volume HDF benefit to kick in after 3 months and then with the continued rollout of 20% conversion, we see that hitting the overall population. It is not like it's hitting one proportion more. So it's impacting the population as it is with the mix as we see it. So there will be a benefit for the respective populations in commercial, in Medicare Advantage, also on the prolongation of life.

When we talk about the mix in the underlying assumptions, we talk about payer mix improvement that we also saw with Medicare Advantage and others to continue on the underlying trend in a nonaggressive way. I hope that gives a bit of color.

Lisa, the only other thing I'd add is that we've seen in our real-world evidence that the benefit of high-volume post-dilution HDF on the incident, the brand-new patient to dialysis is even stronger than it was in the CONVINCE trial. And that actually lends itself towards being able to start patients with HDF, get up to high convection volumes, see the benefit within those 3 months and actually have much better outcomes in the incident population, which is a substantial opportunity.

It's Oliver again from ODDO. I have a question on Value-Based Care. So you described market share of 11% Stage 4, 12% in ESRD. And how should we think about the value you can generate within the different stages? So is it fair to assume that's like 80% of the value, which comes from Value-Based Care is coming from ESRD? Or should we conceptually think more about the evolvement of patients who are in Stage 4 now and entering ESRD earlier?

I can start, I'll start with that. So this continuum of chronic kidney disease care from mid-stage CKD all the way through end-stage kidney disease and kidney replacement therapy is really quite a critical feature of where you get quality outcomes on all 3 parts of that.

As patients progress with kidney disease, their physiology requires that they have more problems that need medical attention. So their costs increase as they're progressing through the various stages. If they can be kept alive and you can, in fact, prepare them well for the ultimate progression to either kidney replacement therapy through a dialytic mode or through a kidney transplant or something like that, their outcomes are fundamentally better.

And this optimal start concept where patient starts in a non-emergent setting with a permanent vascular access or peritoneal dialysis without the need for an intravascular access is a huge area where InterWell has succeeded remarkably. And I think as you saw in Helen's presentation, they're 2.5x the national average in optimal starts with patients.

If you also recognize that 40% to 50% of our patients crash into dialysis today without adequate care in the last year of dialysis, this offers a huge opportunity to lower those costs in the late-stage kidney disease area and transition patients much more successfully.

Yes. And we think our sweet spot is in that late-stage CKD, ESRD. And also, what we know is taking on risk for ESRD only is not an option for either the government or the payers. And as we look about -- and we kind of look at the bridge of how we improve profitability and smart contracting or improved contracting, that's where we also will be laser-focused and hone in.

When you're talking to the managed care organizations who are entering into the value-based care arrangements, they want kind of the likes of us to take on more of that risk because, of course, it's the cost. But we're also trying to find that sweet spot where we can effectively manage the CKD pains at the right stage and intervene there to get a healthier patient ultimately coming into ESRD.

And of course, there's no question that ESRD is our sweet spot and that we know how to manage those patients. So I think that's the piece in terms of like the good contracting and making sure that we are putting our arms around a patient population that we can manage, and as Frank said, it is still hard to imagine in 2025 that half of our patients are finding out they have end-stage renal disease when they crash into an OR.

So I think, obviously, the more that we can participate in those patients earlier and have them optimal start and have a healthier patient coming in because we're managing the care, that's better for everybody. And obviously, as we've talked about, the value of the vertical integration into the Care Delivery business. So that integrated care is very key. And I think we can also see how we can participate even more even in our ESRD patient population and that patient engagement.

And you specifically asked on the assumption for VBC? You saw the improvement on the 3 levels that we laid out. You also saw the track record of reducing the negativity last year, where we generated savings. And also, you see ESRD and CKD.

So we know which contract works and what we need to do. In the last year, we learned that as well. And when we talk about reducing medical costs, it's about also making sure that we increase the penetration as we laid out in those. So it's more of applying the learnings over the last year to that population for VBC only next to the benefits for CD that we outlined.

Yes. And in the same way, when we look at our clinic business and you look at the contracting strategy there, we're looking at it here. As you heard me say this morning, we produced 80% of the gross savings out of the KCC program. We also look KCE by KCE, and we did exit some of those unprofit -- the same way we talk about exiting unprofitable contracts elsewhere, we also exited some of the nonperforming, unprofitable KCE. So we're taking the same approach that we do on the rest of our connecting strategy on CD to Value-Based Care to make sure that we are participating in the right place on drive profitable growth.

I think we've obviously -- this is a nascent industry. It's a new business. It's been building. So we've also been kind of setting this up. And I think the quality metrics are outstanding. We do have the best asset in this space. And now I think we start -- we've got a kind of a scale that we've built up that we can also leverage now in terms of operational efficiencies, too.

It's Falko Friedrichs from Deutsche Bank again. When you reported Q1 a few months ago, you told us that you would expect the U.S. same market treatment growth to improve again meaningfully in the second quarter. Now that the quarter has concluded, I'm not expecting you to give us [indiscernible] but can you at least confirm that you have seen more meaningful improvements again in the second quarter?

And then looking ahead into the next year, is this 2%-plus growth rate, is that already potentially achievable in '26? Or would you say it probably takes a little bit longer to get back there?

You know what I'm going to say about Q2. I appreciate the attempt of the question to get us give that insight. Obviously, we'll report out on that in early August. And you know we also have a lag on the data.

I think our early read of the data looks very similar to Q1. But obviously, we'll quantify that once we have the extra data points and the catch-up in the data. We'll still obviously have that guide out there of 0.5%-plus for '25. And as you saw from Frank this morning, as he unpacked all of those underlying fundamentals of the business, all looking strong and that's what gives us the confidence of the 2%-plus that obviously will increase over time here, too.

Our population impact modeling recognizes that post pandemic, we were headed on a very steady trajectory pre-pandemic. You had the pandemic occur and you had a dip that occurred. We're coming out of that dip at this point. So you don't hit the full potential of getting back on the growth trajectory that's expected instantly. But we see the trends working in the correct direction in both late-stage CKD and in patients that we have opportunities to treat.

Holger Blum, Patinex Management. You mentioned innovation as a key focus area going forward and probably we mentioned HDF 50 times or so, but...

51 now.

I remember the word pipeline just mentioned once. So maybe you can explain a bit more what else you got in the pipeline in the medical device space, but maybe also in the pharma space, whether there's anything there from the joint venture to expect that could have an impact on your P&L going forward?

I'm going to do a shameless plug for the deep-dive session for Care Enablement this afternoon because I think that's where they will show you some exciting deeper dive into that pipeline and the R&D and what they're thinking about. You can tell our excitement about 5008, but there is more, I promise. Do you want to take pharma?

Sure. There are a number of drugs in the field that have significant interest. The interest of big pharma has changed over the last few years with regard to this space. And I think there are a number of classes of drugs that have significant potential to really help patients with kidney failure. IL-6 inhibitors. The drugs that are used in transplant medicine are continuing to evolve as well are the opportunities for us to look at how we use both the data and some of the new drugs to optimize combinations of drugs.

We have distinct interest in how we might actually look scientifically at both the GLP-1s and the SGLT2 inhibitors in the end-stage kidney disease population where they're typically not used very much because we think that cardiovascular benefit might translate over into the population. That's going to require a fair amount of scientific studies still.

Hassan again from Barclays. So you've talked about share gains in consumables, extra volumes in the clinic from HDF. But what about the prospect of share gains in the clinic, at least in the short to medium term, given what will likely be a longer competitive upgrade cycle versus yours assuming no changes in reimbursement?

Yes. Look, I think it's fair to say that our improvement in care delivery and not only HDF and the other things that we've talked about, as we talk about the real focus on driving growth, you will have seen a lot of that was on patient retention and keeping -- once we got the patient in that focus on patient quality and admissions and kind of the adherence to treatment longer. So I think that's also a piece of that volume.

So yes, we do see opportunity to have increased treatments as the combination of once we've got the patient inflow, it's another part of reducing the patient outflow.

David Adlington from JPMorgan. Just on the right page, just in terms of revenue guidance, I know you're not giving revenue guidance, but perhaps you could try and quantify the headwinds you're potentially seeing from some exits from other markets or value-based care, anything like that, assuming you can sort of quantify the impact that could have in terms of headwinds.

Divestitures?

Yes. So what we do quantify is the headwind that we have in divestitures and what that does for 2025. Other than that, we have not given any specific guidance on headwinds that come out for the revenue side of our segments. On the contrary, we have been clear that we want to grow Value-Based Care business based on membership growth, and it's one of the topics that we also proactively addressed. And we have also given you a bit the assumptions around the underlying factors that drive patient growth.

And this patient growth, also the treatment growth with the increased yield. So I think that is, from our perspective, more underlying growth drivers and not so much headwinds that are coming there. And the 4% to 5% globally and the 2%-plus that we have in the U.S. is valid and applicable for both segments, if you wish, as an underlying revenue driver.

And our last question.

Last question.

It's James from Jefferies. Again, just another clarification question actually on guidance. So FME25+ goes to 2027 and you've given 2030 margin guidance. So can you just confirm you don't need another savings program to reach the 2030 margin target that you've given? So the second half of that period is going to be driven by the business model. So any new savings would be incremental to that guidance.

Yes.

Yes. And on the overall scheme, it's 100 to 150 basis points that FME25 only contributes to the 300 to 400 basis points overall.

Okay. Good. I think we got enough heat now. Thank you all for your really great questions. I know we might not have answered all because I wasn't fast enough.

You will have, as mentioned, enough time in the deep-dive breakout sessions to ask more questions in detail.

We'll do a 1.5 hour break now, which should enable all of you to either visit our [ board show ] outside, visit the care Enablement Product showcase also with our 5008X, which was somehow mentioned during the day so far. So please use that opportunity. We have brought in knowledgeable colleagues who show these new machines.

You can also use the time to buy Fresenius Medicare shares, cheap today, or upgrade your rating, if you wish to.

So one other important announcement from the pilot today is that you're connecting flights, also called deep-dive breakout sessions, will take off sharp at 2:00 p.m. on the mezzanine level, which is one floor down. So when you exit, there's elevator to the right, you can go one floor down or if you walk a little bit further there's staircases, too, to walk down.

To find your assigned sessions, just flip over your name badge. There is a small icon on the back, pointing you in the right direction. On the mezzanine level, we have put up some very clear signs to help you find your way to the group and room indicated that also on the leaflet you got this morning at the registration.

And to everyone who joined us via webcast, thank you for tuning in today.

We hope you enjoyed the Reignite sessions. All presentations as well as the historical financials for everyone who wants to make a new model now will be made available on the website after the event.

Thank you for bearing with me. And now enjoy your lunch, enjoy the showcase and do not forget boarding for the next flight is 2 p.m. downstairs. Thank you.