But everything that we’re doing, and we’ve done so far this year continues in Q4. On your question on same market treatment. Obviously, we are encouraged by the continued sequential improvement into positive territory once you’ve adjusted for the acute contract. The improvement in Q3 over Q2 is obviously encouraging. The — we have guided minus 1% to plus 1%, and we are — having said that we’d be more than 1% in ’23. So we haven’t put anything out there for ’24. So we’re still working through our internal budgets on that. So we feel very confident in our minus 1% to plus 1% and the trend that we have seen sequentially improving this year.
Veronika Dubajova: And apologies, I didn’t mean to imply that you’ve guided for ’24 yet. I just think what you have said is you would have expected an improvement in ’24 versus ’23. So maybe let me rephrase the question, which is do you expect an improvement versus the minus 1% to 1% that you’ve guided for, for ’23 still in 2024?
Helen Giza: I would — I don’t — I would expect a continued improvement in that trend.
Operator: The next question comes from the line of Oliver Metzger with ODDO BHF.
Oliver Metzger: The first one is more broader. So now with the final — or DPS rate, can you elaborate about your expectation? What does it mean for the U.S. dialysis market? So the rate is clearly below inflation. So do you really think that this is a rate where also some smaller operators might be forced to leave a field? And the second question is on your value-based care approaches in general. So also, Hassan mentioned, you had similar problems with the ESCO some years ago. And it looks, at least from the outside that, yes, you get less money for bringing some extraordinary work. So is there any very red line? Are we talking only about some lower benefits? Or would you describe it more as a general problem that potentially CMS-driven value-based care looks nice on the paper, but eventually, it makes only sense to do value-based care with some commercial operators?
Helen Giza: Thanks, Oliver. Look, clearly, our PPS final rate is disappointing. And we continue with the industry to engage with CMS on this calculation. And clearly, they’ve acknowledged that there’s a forecasting error in their calculation. There’s a lot of pressure here from the service providers to get the right reimbursement increase in this higher cost environment. So we continue to kind of put the efforts in the right place there. And I think coming out of the final rate, we will still kind of be pushing for the right methodology on the calculation. So we’re not giving up and we continue to do the good work that we do there. What does that mean? I mean, obviously, for us, we’re also kind of working hard on our operating leverage and our cost structure and everything else through this year and beyond, and we have a scale where we can.
What does it mean for smaller players, and not just in lower reimbursement, but a higher cost of capital environment? I can’t speculate on. Obviously, for us, we’re focused on our own turnaround and being moderate in how we are forecasting it, so that we can rightsize our organization accordingly. And as I said, that was within our kind of our guidance assumption. CBC. Clearly, CKCC was a disappointment, but still positive. And I think, at the end of the day, we will continue to have those discussions and take a hard look at the government programs that we are participating in. We are extremely excited about the role we are playing in value-based care and our partnership with InterWell. I mean, I think our ability — so CKCC whether we had InterWell and value-based care or not, we’d have been hit with that under the old Fresenius health plan true-ups that we saw with the ESCOs. What we are increasingly doing is turning the conversation and the discussion about our work with InterWell and how we are participating in value-based care arrangements with the payers in Medicare Advantage and so on.
I mean, look, I think as we were talking about the — managing patients earlier in the CKD kind of funnel, that’s really where this work with InterWell is really helpful in kind of supporting these patients in the CKD population driving earlier detection and management to patients, which would begin — we feel the management of these patients at an earlier age. So we — kind of it’s still early days, I would say, in the maturity of the environment for VBC. We know that when we intervene in the management of this care of this patient population that the medical loss ratio show us that we can save cost in care. And I think for us, it’s making sure that we — getting the full benefit, we believe, will improve with a more stable — of framework for VBC programs.
And CKC is a part of it, but not the whole ecosystem. And we are clearly the market leader in this value-based care environment with the number of patients that we have on contracts as well as our partnerships with physicians. So I think this is one where it’s still an early environment, but one we’re incredibly excited about and they’ll kind of see that we can participate in it. But of course, the government programs, we continue to take a hard look at, and we’ll have to determine whether we stay in some all or none in the future.
Oliver Metzger: One quick follow-up in this context. So basically, there seems to be, say, a disagreement about metrics or quality metrics, which have to be fulfilled. So is it just so difficult to define the right targets and to agree on a variety of targets? Because if you — we are living in a digital world and normally it’s a yes or no, and it seems to be even some more room for discussions in these programs?
Helen Giza: Yes. Look, I — we’ve come a long way. I mean, I know you might be all — being a little — kind of questioning this right now, but we’ve come a long way to the ESCO programs. What we entered into with the CKCC programs was a much better improved program. But what we are seeing — I mean, it’s still not the full transparency and kind of the variability in the government reporting, as I said, that’s making it a little bit more challenging for us. I think what is good is the ability to have the discussions and make sure that the kind of the intent of the plan is what’s being delivered. So look, I think we — now we’ve got data and now we’ve got reports absolutely makes us equipped to continue to have the conversations with CMS.
So it’s not a closed door. And I think it’s just more making sure that we are getting what we believe to be our fair share of our participation in the program and get paid for what we believe our data suggests. So yes, I think just more to come on this, but obviously, we had to wait to get — kind of get this report in before we could even see what we were dealing with. So I think that’s a little bit of the challenge as well is the visibility into what’s happening and what we — when we get it. So yes, I think more to come, and we’ll continue to provide updates on our VBC book of business.
Dominik Heger: Okay. We can take one last question.
Operator: The last question comes from the line of Graham Doyle with UBS.
Graham Doyle: Just a quick follow-up on the volume question from Veronika. Just one of the points you made, I think, on the last call was just around some — working through some mortality in the sort of pre-ESRD funnel. Have you got any visibility on kind of what stays rather than that? Have we got a few more quarters to go and then we’re back to normal? It’d be good to get a sense of that. And then one bit of pricing, it would be great to get a sense of is in the negotiations in terms of what we’re thinking about for next year, even 18 months’ time, are private payers being a bit more sensible about inflation than perhaps Medicare has been?
