DaVita (DVA) 2026年第3四半期決算説明会：IKCの見通しを引き上げ、ガイダンスを絞り込み

ダヴィータ（DaVita Inc.、NYSE: DVA）が発表した2026年第3四半期の調整後営業利益は5億6100万ドル、調整後EPSは3.82ドルとなりました。経営陣は統合腎臓ケア（IKC）の見通しを引き上げる一方、通期の調整後営業利益およびEPSのガイダンス範囲を絞り込みました。

要点

• 2026年第3四半期の調整後営業利益は5億6100万ドル、調整後EPSは3.82ドル、フリーキャッシュフローは計2億7600万ドルとなりました。
• 米国における透析治療数は前年同期比1.2%増加し、標準化一日あたり治療数は約65ベーシスポイント上昇しました。これは主に死亡率改善に伴う患者数の増加を反映したものです。
• ダヴィータは現在、2026年のIKCによる調整後営業利益を少なくとも6,500万ドルと見込んでおり、これは従来の見通しを少なくとも2,500万ドル上回り、2025年実績を4,500万ドル上回る水準です。
• 2026年通期のガイダンスは、調整後営業利益が21億7,500万ドル〜22億5,000万ドル、調整後EPSが14.30ドル〜15.20ドルに絞り込まれました。フリーキャッシュフローの見通しは10億ドル〜12億5,000万ドルで維持されています。
• 拡張型血液透析（HD）ダイアライザーの本格導入は、11月中に大半の対象患者に行き渡る見込みです。経営陣は2026年および2027年の調整後営業利益への実質的な純影響はないと予想しており、死亡率の低下や治療数増加によるメリットは2028年後半から現れ始めるとみています。
• 経営陣は、2027年の末期腎不全（ESRD）最終規則が通期で1.5%〜2%の純増益効果をもたらすと試算しており、その効果は第1四半期に最も強く現れ、年内の残りの期間は寄与度が低下するとみています。

主要財務データ

事業および業績の動向

米国透析事業

主に死亡率の改善により、患者数は前年同期比で1%強増加しました。しかし、第3四半期は治療取りやめが増加したため、治療数増加のメリットが一部相殺されました。経営陣は、第4四半期には治療取りやめ率が例年の前年同期比パターンに戻ると予想しています。

1回あたりの治療収入は前年同期比で約1.1%増加しました。通常の改定増は、民間保険比率の低下やリン結合剤の償還削減によって一部相殺されました。ダヴィータは、医療保険制度改革（ACA）の強化税額控除の失効に伴い、2026年に前年比で約4,000万ドルの逆風が生じると引き続き予想しています。

1回あたりの患者ケアコストは2.4%上昇しました。リン結合剤コストの低下が通常の人件費インフレを一部相殺したものの、医療用品費や専門家賠償責任保険費用が予想を上回りました。経営陣は、これらの項目が時間の経過とともに通常レベルへ戻ると見込んでいます。

第3四半期のテクノロジー関連支出は前年同期比で20%以上増加しました。ダヴィータはテクノロジープラットフォームの近代化に10億ドル以上を投じており、臨床結果、収益管理業務、労働生産性、IKCケア管理、薬局コストの支援に充てています。経営陣はテクノロジー支出の伸び率は減速すると予想しているものの、2027年も支出自体は引き続き増加すると見込んでいます。

統合腎臓ケア（IKC）

IKCは、主にCKCC（Comprehensive Kidney Care Contracting）事業およびメディケア・アドバンテージの価値ベースケア契約におけるシェアードサヴィングス（削減コスト分配）率の向上により、計画を上回る業績を達成しました。医師への支払増加やヒューマナ（Humana）との慢性腎臓病プログラム立ち上げに伴うコストが一部相殺要因となりました。

ヒューマナとの提携により、約1万人の慢性腎臓病患者に対してより早期のケアが拡大されます。経営陣によると、テクノロジーの改善と臨床介入により、回避可能な入院や再入院が減少すると同時に、計画的かつ最適な透析への移行が増加しているとのことです。

拡張型HDダイアライザーの導入拡大

ダヴィータは150カ所のセンターで1万人以上の患者を対象にパイロット運用を完了しました。全患者数の約75%が臨床的に適用対象であり、パイロット運用の対象患者における採用率は90%を超えました。全米の臨床スタッフの95%以上がトレーニングを完了しています。

全米での本格導入は翌週から開始される予定で、対象患者の大多数が11月中に移行を終える見込みです。新しいダイアライザーは、ダヴィータの既存の透析装置と互換性があります。

海外事業と資本配分

海外事業の調整後営業利益は、中南米での成長と業績改善が主因となり、前年同期比2,000万ドル増の4,600万ドルとなりました。ダヴィータは2026年の海外調整後営業利益を約1億3,500万ドルと引き続き予想しています。

同社は第3四半期中に約60万株、四半期終了後にさらに50万株の自社株買いを実施しました。これには、バークシャー・ハサウェイの保有比率を必要に応じて45%に戻す契約に基づいて同社から買い取った株式が含まれています。

業績見通し（ガイダンス）

営業利益およびEPSの見通し範囲の絞り込みは、IKCの好調な業績を反映する一方で、米国の透析事業における費用増、特にテクノロジー投資による押し下げ効果が相殺したことを示しています。

2027年について、経営陣は治療数の伸び率が2026年を上回ると予想しています。ACA関連の影響を含む民間保険比率は、引き続き1回あたりの治療収入に対する逆風となると見込まれます。医薬品コストはリン結合剤を中心に減少する見通しですが、テクノロジー支出は低速ながら増加を続けると予想されます。

リスクと注視点

• 第4四半期の治療数は、稼働日数構成（デイミックス）による前年同期比約1%の逆風に直面しています。
• 民間保険の支払者構成（コマーシャルミックス）は、ACAの強化税額控除の失効による圧力を引き続き受けています。
• テクノロジー関連支出はダヴィータの当初の2026年予測を上回って推移しており、通期業績の重荷となっています。
• ESRDの表面上の改定率3.5%増は2027年第1四半期に適用されますが、TDAPA（新技術等加算）構成要素の四半期ごとの再計算により、その後は低下する見込みです。
• 経営陣は、拡張型HDダイアライザーに伴う死亡率改善が治療ミックスや収益性に与える影響を特定するのは時期尚早であると述べています。
• 米国保健福祉省（HHS）の「腎臓ケア国家計画（Kidney Care National Plan）」のいくつかの要素は、さらなる政策策定や議会での法改正手続きを必要とする可能性があります。

アナリスト質疑応答の主なポイント

経営陣は、2027年のESRD最終規則が通期で1.5%〜2%の純増益効果をもたらすと試算しています。ダヴィータによると、メディケア改定率の1%の変動は年間で約3,000万ドルに相当します。大手透析事業者向けの固定部分は40ベーシスポイントであり、3.1%のTDAPA部分は、診療報酬が再計算される第1四半期以降に大幅に低下する見込みです。

IKCについて、経営陣は臨床能力や保険数理能力、統合テクノロジー、拡張可能なケアモデルにより、追加契約の追求が可能になったと述べました。ただしダヴィータは、経済的に合理的な契約内容と、提携する医師との緊密な連携が必要不可欠であると強調しました。

経営陣は、治療取りやめが正常化し、第3四半期の堅調な患者数増加が第4四半期にも引き継がれることで、第4四半期の標準化一日あたり治療数が加速すると予想しています。また、2027年の治療数成長率は2026年を上回ると見込んでいますが、2027年の完全なガイダンスを提示するのは時期尚早だとしています。

拡張型HDについて、経営陣はパイロット期間がまだ不十分であり、治療取りやめや治療法選択への影響を特定できていないと説明しました。現時点では、施設透析と在宅透析の間の大幅な患者移動は予想していません。

決算説明会トランスクリプト（全文）

決算説明会の完全なトランスクリプト

経営陣による説明

Operator

Good evening. My name is Michelle, and I will be your conference facilitator today. At this time, I would like to welcome everyone to the DaVita Third Quarter 2026 Earnings Call. [Operator Instructions] Mr. Eliason, you may begin your conference, sir.

Nic Eliason

Thank you, and welcome to our third quarter conference call. We appreciate your continued interest in our company. I'm Nic Eliason, Group Vice President of Investor Relations. And joining me today are Javier Rodriguez, our CEO; and Joel Ackerman, our CFO. Please note that during this call, we may make forward-looking statements within the meaning of the federal securities laws. All of these statements are subject to known and unknown risks and uncertainties that could cause the actual results to differ materially from those described in the forward-looking statements.

For further details concerning these risks and uncertainties, please refer to our third quarter earnings press release and our SEC filings, including our most recent annual report on Form 10-K, all subsequent quarterly reports on Form 10-Q and other subsequent filings that we make with the SEC. Our forward-looking statements are based on information currently available to us, and we do not intend and undertake no duty to update these statements, except as may be required by law.

Additionally, we'd like to remind you that during this call, we will discuss some non-GAAP financial measures. A reconciliation of these non-GAAP measures to the most comparable GAAP financial measures is included in our earnings press release furnished to the SEC and available on our website.

I will now turn the call over to Javier Rodriguez.

Javier Rodriguez

Thank you, Nic. Good afternoon, everyone, and thank you for joining the call today. Once again, our teammates have delivered excellent care for our patients and solid results for our shareholders. We're seeing meaningful progress across our clinical strategy with investments in innovation translating into better patient outcomes and stronger business performance. Our maturing Integrated Kidney Care business is a prime example as it continues to deliver clinical performance for our patients while starting to demonstrate its economic potential. In the same spirit, our rollout of expanded HD dialyzer marks an exciting new chapter in how we're advancing kidney care.

Today, I'll share more on these priorities, review our third quarter financial performance, provide our outlook for the remaining of the year and briefly discuss policy. But first, as always, let's begin with our clinical highlights. Today, I will highlight our advancements in fluid management. We're often asked about the clinical drivers behind our recent mortality improvement. And fluid overload is one of those critical areas we target. Because kidney failure impairs the body's ability to shed fluid, managing fluid intake between treatment and safely removing excess fluid during dialysis requires constant vigilance for both patients and care teams.

Left unmanaged, excess fluid placed a strain on the cardiovascular and pulmonary systems contributing to high blood pressure, heart failure and respiratory difficulties. By developing specialized clinical protocols, combined with dedicated team and education and proprietary digital tools, we've uniquely empowered our care teams to manage fluid more precisely. Through these integrated efforts, we've seen a 10% improvement in treatment achieving optimal fluid removal, a 5% improvement in how patients manage weight gain between treatments and nearly 5-pound reduction in the average patient's weight. These advancements are critical drivers supporting our continued mortality improvement and enhancing our patient's daily quality of life.

While we're on the topic of clinical, I will transition now to an update on our efforts to deliver enhanced care for our patients through clearance of middle molecules. Last quarter, we highlighted recent clinical evidence for expanded HD dialyzers, including the potential for greater than 20% mortality improvement, along with our plans to deploy this technology broadly across our network. We have completed pilots in 150 centers for more than 10,000 patients to ensure a smooth and successful deployment at scale.

Based on this experience, here's what we've learned. First, the feedback from patients and physicians was overwhelmingly positive. As background, approximately 75% of total patient census is clinically eligible for expanded HD dialyzer. This eligible pool excludes patients receiving dialysis at home or in acute care setting, pediatric patients and patients with acute kidney injury. Adoption amongst those clinically eligible patients in the pilot was greater than 90%, exceeding our expectations.

And within that cohort, patients tell us they feel better after treatment and have more energy compared to their prior therapy. One goal with expanded HD is to enhance patients' quality of life, and it is exciting to hear early feedback to support this effort. Similarly, our physician partners have been overwhelmingly supportive. The buy-in from the medical community is critical to successful innovation and nephrologists have responded to the clinical evidence and are actively engaged to transform the standard of care. We deeply appreciate the collaboration of our physician partners in our continued efforts to innovate.

Second, we are operationally ready. Our teammates, systems, supply chain are well prepared to successfully manage this transition. Over 95% of clinical teammates nationally are now trained on expanding HD to ensure a seamless continuity of care for our patients. As a reminder, the new expanded HD dialyzers are compatible with our existing dialysis machines. As a result, we will begin our national rollout next week and expect a swift network-wide transition, bringing expanded HD to the vast majority of eligible patients in November.

Finally, from the financial perspective, we do not expect any material net impact on adjusted operating income for 2026 or 2027. We anticipate the positive impact of lower mortality and higher volume growth to begin in the back half of 2028 and grow over time. Most importantly, this innovation means more patients living longer, representing a key milestone in our path back to 2% or greater volume growth by 2029.

Transitioning to financial performance. Third quarter adjusted operating income was $561 million and adjusted earnings per share was $3.82. Joel will provide details on the moving pieces underlying those Q3 results. Taking a step back from the quarterly numbers to look at the full year, I want to highlight 2 trends shaping 2026 and our future performance.

Starting with technology. Over the past few years, we've invested more than $1 billion to modernize our technology platform and strengthening our capabilities across our business. These investments are delivering tangible clinical and financial benefits, contributing to improvements in mortality, revenue operations, labor productivity, IKC care management and pharmacy costs. I'm calling this out to highlight that our IT investments in U.S. dialysis is higher than we forecasted heading into the year. So it represents a drag on our full year financial performance. Going forward, we expect the growth in technology investment will decelerate.

The second highlight is our results on Integrated Kidney Care or IKC. We are above plan in the third quarter, and we're on track to outperform our original IKC guidance for the year. We made meaningful progress delivering on the patient impact we began talking about in 2021, both upstream and chronic kidney disease and for existing ESKD dialysis patients. Let me provide some color on the 2 operating levers, which contribute to IKC's financial performance.

First is the medical spend under management. As we have noted in the past quarters, we have been disciplined as we seek opportunities to grow this business. We're making progress heading into the next year, including our recent announcement of Humana partnership, which will expand upstream care to approximately 10,000 chronic kidney disease patients.

Second is our savings rate, which reflects our ability to lower the total cost of care and has steadily improved year-over-year. This is particularly encouraging because it reflects continued gains in clinical performance as our care model matures. Our investment in technology are improving the ability of our care teams to identify where and when to intervene to help our patients be healthier.

Our clinical interventions are driving reductions in avoidable hospital admissions and readmissions while achieving higher rates of planned optimal dialysis transitions. These results improve patient outcomes while generating substantial shared savings for CMS and our Medicare Advantage health plan partners. This gives us growing confidence in 2026 and the long-term economic of the IKC business. We now expect IKC to deliver at least $65 million of adjusted operating income in 2026, an increase of at least $25 million over the prior guidance.

This all leads to an update on our financial outlook for the remaining of the year. With one quarter remaining in the year, we are now narrowing our full year 2026 guidance ranges. We now expect adjusted operating income within a range of $2.175 billion to $2.25 billion and adjusted earnings per share within a range of $14.30 to $15.20. This reflects the increased guidance for IKC, offset by higher U.S. dialysis costs, particularly higher technology investments, as I previously noted.

Before I turn it over to Joel, I want to briefly comment on 2 recent policy updates. First, yesterday, CMS released the ESRD final rule. This confirms the permanent incorporation of phosphate binders into the dialysis bundle, which is a great outcome for patients and has been a successful cost saver for the government. Within the overall rate adjustment, there are more moving pieces than in prior years. The headline rate increase for large dialysis organizations is 3.5%, which is up 1.5% from the proposed rule. Unlike prior years, this will be subject to downward quarterly adjustments after Q1.

And second, a few thoughts on the Kidney Care National Plan released by HHS last week. We shared the administration's goals around the earlier intervention, slowing disease progression, improving the transplant process, expanding patient choice and improving outcomes. We also appreciate the opportunity to work with the government to create a framework to encourage further competition within this complex ecosystem. Many elements of the plan will require policy development and potentially congressional action before translating into specific actions, and we look forward to working with HHS and the relevant agencies as that work progresses.

I will now turn the call over to Joel to discuss our financial performance in more detail.

Joel Ackerman

Thank you, Javier. For the third quarter, adjusted operating income was $561 million. Adjusted earnings per share was $3.82 and free cash flow was $276 million. Today, I'll provide further details on the quarter's results and some thoughts on Q4 and full year guidance.

Starting with U.S. dialysis. Adjusted operating income was in line with our expectations. I'll walk you through the trilogy, starting with volume. Overall treatment volume grew 1.2% over the third quarter of 2025 and treatments per normalized day increased approximately 65 basis points year-over-year. Patient census increases drove the year-over-year growth, primarily as a result of improving mortality. The census gain was offset in the quarter by an uptick in mistreatments. As a reminder, the fourth quarter will have an approximately 1% headwind on treatment volume due to year-over-year day mix.

Revenue per treatment was up approximately 1.1% versus the third quarter of last year and roughly flat sequentially. The year-over-year growth is the result of normal rate increases offset by lower commercial mix and lower phosphate binder reimbursement as expected. Through 3 quarters of the year, the impact on our exchange census from the expiration of enhanced premium tax credits continues to play out as expected.

Patient care cost per treatment were up 2.4% in Q3 compared to last year. Phosphate binder costs declined year-over-year as expected, and partially offset the typical growth in labor expenses. Medical supply costs and professional liability expenses were higher than anticipated in the quarter. We expect these costs to revert to typical levels over time.

U.S. dialysis G&A costs were up less than 2% versus Q3 last year, excluding non-GAAP adjusted cyber expenses in 2025. Technology spend continued to grow at more than 20% year-over-year in the quarter, but the nontech component of G&A was lower in the quarter compared to last year as a result of our ongoing cost control efforts and expense timing.

Turning now to IKC. As Javier noted, the business is performing ahead of our expectations. The outperformance this year is largely driven by a higher shared savings rate in our CKCC business, which is the Medicare fee-for-service demonstration project, as well as the value-based care contracts we have with Medicare Advantage insurers. This is partially offset by higher operating expenses due to higher physician payouts from our shared savings and the launch of a new CKD program with Humana. We now expect this year's IKC adjusted operating income to be at least $65 million, representing a $45 million improvement over last year and a $25 million improvement over our prior guidance.

Turning to International. Third quarter adjusted operating income was $46 million, a $20 million increase year-over-year. This performance is largely the result of growth and improved performance in our Latin America businesses. These results exclude a charge related to our operations in China, which is not included in our adjusted operating income.

The full year continues to track in line with our expectations for approximately $135 million of international adjusted operating income. Transitioning to capital allocation. We repurchased approximately 600,000 shares in Q3, and we've repurchased an additional 500,000 shares since the end of the quarter, including shares from Berkshire Hathaway. As a reminder, we repurchased shares from Berkshire each quarter as needed to bring their ownership back to 45% pursuant to our repurchase agreement.

We finished September with a leverage ratio of 3.38x consolidated EBITDA, about flat to last quarter. Debt expense in the quarter was $150 million. In light of rising interest rates, I will remind you that we maintain 3-year interest rate caps on approximately 80% of our floating rate debt.

For full year 2026, as Javier noted, we are narrowing our guidance ranges for adjusted operating income and adjusted earnings per share. Our new range for adjusted OI is $2.175 billion to $2.25 billion, and our new range for EPS is $14.30 to $15.20. We still anticipate full year free cash flow between $1 billion and $1.25 billion. That concludes my prepared remarks for today.

Operator, please open the call for Q&A.

Operator

[Operator Instructions] Our first caller is A.J. Rice with UBS.

質疑応答

Albert Rice

I appreciate the comments on the ESRD rule that got finalized over the last 24 hours. I know the industry has sort of felt like the rate in the original proposal for phosphate binders seemed adequate, but the underlying rate for the treatments, ex that, was challenging. With the adjustments made, is there an ability to comment? One of the tricky things is how -- I know you guys had said the phosphate binder reimbursement would drop because ASPs were dropping in the relevant drugs. Can you just comment on whether the drop in what they've included was consistent with what you're thinking? And how adequate is the move up in the rest of the rate?

Joel Ackerman

Yes, A.J., thanks for the question. So as you noted, it's been 24 hours, and we're still unpacking the calculations. I'll start with the big picture, which is our estimate right now, and I'll emphasize that it's an estimate, is that the net impact for us, for the full year '27, will be 1.5% to 2%. Just as a reminder, a 1% change in Medicare for us is worth about $30 million a year. This is an improvement over the prior rule by somewhere north of 50 bps. And the important thing to realize is the rule works differently now than it has in the past because of the change in the way that the TDAPA add-on payments are handled. They're now recalculated every quarter rather than recalculate it once a year.

So the published number is really only the number for Q1, and you really have to break it into 2 components. There's everything other than the TDAPA component, which is fixed for the year. And if you look at what that is for the LDOs, it's 40 basis points, and that will be constant for the year. And then the TDAPA component, which for the LDOs is 3.1%, that only stands for the first quarter. And we expect that number to come down significantly in Q2 and stay down and potentially further decline over the course of the year. So we've got that 40 basis points locked in that 3.5% will come down significantly. And the net impact over the course of the year, we think, is 1.5% to 2% stronger in Q1, a little bit weaker over the rest of the year.

Albert Rice

Okay. Okay. And maybe my follow-up, interested about your comments on the IKC. It sounds like -- business sounds like -- you feel it's solidly profitable now, you can start to grow. And obviously, you've got the Humana transaction. It seems like to me there's probably a fair amount of business up for grabs if you wanted to lean into growth in that area. Can you maybe think -- talk about now that you feel like you're at a consistent level of profitability? How much you might think about adding to that business?

Javier Rodriguez

Sure. Let me take that one, A.J., it's Javier. We are in agreement with you. Our confidence in our capabilities as both in the clinical and actuarial has now reached a point that we want to pursue more business. But as we emphasize, what you want is healthy contracts, you want your physician partners to be heavily involved. Our model of care is now scalable and you need integrated tech, which we now have. So we've got a lot of the pieces to the tools, and now it's about getting contracts and physicians that are aligned to make sure that we deliver on the care that both avoids hospitalizations and readmissions and brings down the cost.

Operator

Our next caller is Andrew Mok with Barclays.

Andrew Mok

Leaving the full year treatment guide alone implies treatments per normalized day would be up more than 1% in Q4. And an acceleration from the first 3 quarters. Is that the right way to think about the progression? And are you comfortable with that given the uptick in mistreatments you called out?

Joel Ackerman

Yes. So Andrew, first, your math is about right. It would involve an uptick in treatments per normalized day in Q4. I would expect that to come from 2 things. One is mistreatment rate reverting to a normal year-over-year pattern. What we saw in Q3 was mistreatment rates about 20 basis points higher than expected and higher than last year. And what we're assuming for Q4 is that it reverts to a normal pattern. We're assuming it will be consistent with Q4 of last year. So that's one thing.

The second component driving it would be census. Census growth was a little bit stronger in Q3 than we anticipated, and that census growth over the course of the quarter, drives higher treatment growth per normalized day in Q4 rather than Q3. So those 2 things together would drive the uptick in Q4.

Andrew Mok

Great. And can you update us on the ACA exchange headwind in the quarter and comment on where commercial mix is tracking relative to the about 10.7%, I think you were expecting in the back half?

Joel Ackerman

Yes. Mix is down a little bit relative to the first half of the year, very much in line with our expectations, and we think we're on track for that $40 million year-over-year headwind for '26.

Andrew Mok

Great. And finally, if I could squeeze one more in. I wanted to follow up on your comments around HHS' Kidney Care plan released last week. What were your initial impressions? And which elements of the plan do you think could translate into policy?

Javier Rodriguez

Yes. Thanks, Andrew. As we said in our opening comments, we have a lot of things that we like about the plan. And we are aligned totally, and we share the goals of the administration of fostering innovation, investing in early detection and prevention and increasing access to transplant. When the plant came out, I immediately reached out to the administration and told them we want to be right there at the table and want to be part of the solution.

And on each one of those, of course, you can go into the subcomponent. For the part that was a bit frustrating, it's how dialysis was portrayed in the rule. The fact is, we offer world-class service, and we are great economic value, and this is confirmed as I travel the world. And other countries really want our expertise to enter their countries. That said, there were some positive things around what they said within dialysis, which is they want to solve for innovation in the bundle, which we, of course, want as well. And they want to reduce regulatory burden, which we would welcome.

The part that's a little, let's say, not fleshed out enough, and we need to solve for, is the economic ecosystem. 90% of patients are covered by the government insurance with roughly 1% Medicare increase for the past decade. So there's an assumption in there that the cross subsidy by the private insurance and the 1 in 10 is accepted by the model. And so one of the main things that they want to do is attract new capital. And in order to attract new capital, we have to solve for this dynamic, and one of the things that the government will have to pay more.

If I was going to continue a little -- well, I got a little momentum because you hopefully can feel my passion on it, is that there's an under appreciation for the benefit of scale and expertise. That as I look at our body of work over the last couple of decades, we have developed and adhered to world-class protocols and best demonstrated practices. We have a dramatic reduction in mortality of roughly 25% if you measure it from the year 2000. When there's an emergency or disaster response, we are there. When you look at sophisticated tech, we have it. When you look at access to rural communities, 92% of patients in rural communities are within 10 miles of our centers. And by the way, you need a counterweight to big pharma and big insurance or else costs would go up a whole bunch.

So in summary, I really took a little to heart that we are part of the solution, not the problem. We welcome more competition. But I want to be clear, the linear competition is not due to how we operate, but rather how hard it is to take care of this vulnerable population with high needs at 90% government mix. And so you hopefully see the one part that got me going, but the rest of the plan, totally behind.

Operator

[Operator Instructions] Our next call is Pito Chickering with Deutsche Bank.

Pito Chickering

Can you give us the known puts and takes as we think about modeling next year, including the treatment growth you're seeing with the acceleration of the census in the third quarter? And the thoughts of redefer treatment next year with what you learned about HICS, then the tailwinds from lower IT investments and any additional IKC tailwinds that we should think about as these guys scale up?

Joel Ackerman

Sure. I'll take that one, Pito. It's early to give full guidance on 2027. That said, there's certainly a few things that we can help with. On the volume side, I would say we expect volume growth in 2027 to be higher than volume growth in 2026. On RPT, we expect a headwind from commercial mix with ACA being the big component of that.

And then on the cost side, I'd really call out pharmaceutical costs, which we think will come down in 2027. Binders being the biggest component of that, but not the only component of it. You mentioned IT spend. IT spend will not come down next year. Our expectation is it will decelerate. So the 20-plus percent growth that we've been absorbing for the last 3 or 4 years, we think we can get down from that, but I would expect it will continue to grow. So I'd say that's the known stuff for next year.

Pito Chickering

Okay. Great. And then on the HD dialyzer. I think you said that all the centers will be doing it by November. And expected to see certain mortality in the back half of '28. But I'm curious for the 10,000 patients that you've been treating so far, have you seen any indication of lower mistreatments that could impact the near-term treatments? And how does this impact people on home hemo? Did they sort of come back in the center if people are having better results?

Javier Rodriguez

Thank you. And hopefully, you hear the excitement in our tone, and our physicians and our patients and our caregivers. This is one of the most excitement I've ever seen in the community. And the short answer to your question is, it's too soon to tell. This takes a while, as you can see from the studies in mortality that it takes a while to have the impact on the inflammatory side.

As it relates to people switching modalities, I doubt that, that will be the case. People make modalities on a lot of other matters. And if you look at PD as a modality, it already is quite good at clearing middle molecules as an example. And so I think it will be just one other thing to consider, but I doubt that there will be shifts in modality selection.

Pito Chickering

Great. And then last question because I'm getting asked this a lot. I mean, again, back to 2027, I know that it's way too soon for sort of guidance here. But is there any commentary around just do you think that your standard growth rates for -- that you've been having the last few years in the business can continue next year? With the headwinds and tailwinds, plus the HICS on top of that, is that the way of thinking about it?

Joel Ackerman

I think you're right, Pito. It is too early to answer that question. Look, as we said, we think we get a better volume tailwind next year than we've had this year on U.S. dialysis margins, I think we called out the headwinds, tailwinds. Headwind on RPT, a tailwind on cost, how those shake out, we'll know more in February. And then I don't think we've really got much to say on either international or IKC yet.

Operator

Our next call is Kevin Fischbeck with Bank of America.

Kevin Fischbeck

Great. Can you talk a little bit about the benefit to volumes that you saw from Fresenius closing sites? I wasn't sure if there was supposed to be any kind of improvement in Q3 versus Q2 from that kind of normalizing. What did you see there?

Joel Ackerman

Yes. No. Kevin, that played out pretty much in Q1. So no change from Q2 to Q3 from that dynamic.

Kevin Fischbeck

Okay. And how do we think about the profitability? I know it's a 2028 and beyond issue, but of the improvement in mortality from a new dialyzer, I think there's some question about this just kind of extending the life on dialysis and that's more of a Medicare as a percentage of revenue. Would that be as profitable? Should we be thinking about it if it added 1% to treatment? Is it that 1% to revenue and 1% to OI or is the growth algorithm different than that from improved mortality?

Joel Ackerman

Yes. So we're still waiting for better data on this. The natural thing would be to think that just the older patients or patients are adding on a year or 2 when you go from an average of 5 or 6 years to 6 or 7, and those are all Medicare patients. The early results are that is not the pure dynamic that there are younger patients earlier in their journey whose lives are being extended. So it's not purely an addition of Medicare treatments. How that shakes out, whether it's the same mix of 10% or 11% commercial as we see overall are not, too early to tell. But I don't think we're ready to conclude it's 100% additional Medicare treatments as a result of this improved mortality.

Kevin Fischbeck

Okay. And then last question here. Going back to that release from CMS a week or so ago. Seem like one of the things that they focused on was the AKF exposure. Can you just remind us where that is for you, how you're benefiting from that relationship?

Javier Rodriguez

Sure. Charitable Premium Assistance, for those of you that have not been keeping up with discuss very heavily, if you go back maybe 8 or so years. But we haven't discussed it for a while, so it's probably worth refreshing the topic. So it's basically a system that's been in place for many decades that enables patients, many who can no longer work full time due to kidney failure to maintain continuity of health coverage.

One of the things that's not known is that the vast majority of patients receiving CPA use the grants to support government and supplemental coverage. And so that's probably not known. It's assumed that most of them use it for commercial. But the significant majority of commercial patients actually don't use CPA. And for those that use it, most of them use it to retain coverage that they had before their kidney failure. So while there are many reasons to keep your private insurance, the most common is to retain it for family coverage and because there is a 3x more likely odds of getting a transplant if you have commercial insurance.

So I think we can all agree that those are worthy reasons to keep your insurance. Again, just as a contextual thing, the grants are administered by the American Kidney Fund, otherwise referred to as AKF, and they have been under some major heavy examination through investigations, inspections, rule-making and legislative scrutiny, and all have concluded that the grants benefit of vulnerable population and that the program follows the rules. And so now it's been sort of pointed out in the plan. That's something to look at. We, of course, welcome and we will transparently go through the process again.

But one of the things that is interesting about the dynamic is that the irony that if that program is somehow or other diluted, it would actually make more patients be paid by the government. So that 1 in 10 commercial would go down. And the other thing that would happen is that it would attract less capital. And so ironically, this would be contra their intent to bring more competition to the marketplace. That said, I think your question was around sizing it. And what I would just say is, that in looking at it and we disclosed the numbers roughly 8 years ago, the numbers have stayed completely flat. So that range still applies today.

Operator

Our next caller comes from Ryan Langston with TD Cowen.

Ryan Langston

On clinic capacity utilization, I think that's been kind of steady for a few years, but still kind of well below pre-Covid levels. So some of the initiatives you're working on like technology, RPT, and rolling out HD, kind of work themselves through at some point, just pressing on this lever become more of a higher priority. And what types of things can you do to maybe increase that utilization?

Joel Ackerman

Yes. So look, we would absolutely like to get capacity utilization up. The best way to do it is to grow our census count. That, we are doing that, as I mentioned before, our census count is up about 1%, a little bit more than 1% year-over-year. And we plan on continuing that. We do not have any plans right now to close clinics, that would be the other thing to do. So we'd like to get it up with more volume.

Ryan Langston

Got it. And then depreciation expense has been trending down sequentially for a few quarters here. Is this sort of a good run rate for us to kind of jump off of? Or might we expect that to come down a little bit in the fourth quarter?

Joel Ackerman

I think we're -- it's been coming down for many years now. I think we're getting to the point where we're probably not going to see a lot of continued declines. So I think we're in a reasonable spot where we are now. Next question?

Operator

Yes. Justin Lake with Wolfe Research.

Joel Ackerman

Justin, we can't hear you.

Unknown Analyst

This is [ William Westerfield ] asking for Justin Lake. We just want to circle back to the final ESRD rates that came out last night and LDOs were up 3.5%, with much of that coming from phosphate binders and DefenCath moving into the bundle. Could you just go through for us how you view that 3.1% increase in TDAPA payments across those 2 drugs? Like more specifically, how does the $12 loss binder number compared to your current binder rev per treatment for Medicare patients? And then for DefenCath, can you talk about how you will think about that reimbursement develop across 2027 and when you provide guidance for next year?

Joel Ackerman

Yes. Will, thanks for the question. So I treat the 2 very differently. Binders, very much in line with our expectation not much growth -- not much of that 3.1% growth, we think, is from binders. We don't have full visibility on the baseline for 2026, but because it incorporates us as well as others, but we don't think that's really the big story in the 3.1% growth.

We think it's largely about DefenCath. And the important thing to realize on that is because it's a post TDAPA add-on payment, it will get recalculated every quarter based on updated volume and updated ASP. And our current expectation is that number will drop significantly from Q1 to Q2 and stay low or continue to decline through the back half of '27.

Unknown Analyst

Okay. And then on top of that, is there something that you're tracking to understand the utilization and how it might develop across the industry here in the second half in '27 that could help investors get ahead of the potential changes in quarterly reimbursement for '27? For instance, can we track trends?

Joel Ackerman

I think the short answer is no. We don't have a lot of visibility into what's happening with the industry on that through the back half of 2026.

Operator

Thank you. And at this time, I'm showing no further questions. Speakers, I'll turn the call back over to you for any closing remarks.

Javier Rodriguez

Okay. Thank you, Michelle, and thank you all for joining the call. To wrap up, let me give some perspectives on our year so far. First, our business is resilient in the face of pressure both from RPT due to ACA declines and from treatment volumes growing below our historical norm.

Second is investment in innovation. We have heavily invested to modernize our technology infrastructure, and we're also in a full swing on the rollout of new dialyzer that promised to deliver step change in care with longer and higher quality of life for our patients.

Putting all this together, we're delivering on our financial commitments with adjusted OI growth in the top half of our long-term guidance, and we're working hard to finish the year strongly. It's unusual to say at this time of the year, but we won't talk until a little while. Have a great holiday season, and we'll speak soon. Be well.

Operator

Thank you. This concludes today's conference call. You may go ahead and disconnect at this time. And please have a good rest of your day. Thank you.