Fresenius Medical Care AG & Co. KGaA (FMS) Q2 2026 Earnings Report, Transcript and Summary

Ladies and gentlemen, welcome to the report on Second Quarter 2026 Earnings Release and Conference Call. I am Valentina, the Chorus Call operator. [Operator Instructions] And the conference is being recorded. [Operator Instructions] 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 second quarter of 2026. I appreciate your flexibility to join this earlier call. We felt it is more helpful to have the call earlier given that we had to publish earlier than originally planned. I do apologize for the inconvenience, in particular for those of you who are located in a different time zone or those of you who cover another company hosting a call in parallel right now. 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. The call is scheduled for 1 hour. In order to give everyone the chance to ask questions, we limit the number of questions as always to two. Thank you for making this work. 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, and thank you for joining at this earlier time of the day. I will begin my prepared remarks on Slide 4. We continued our strong start to the year, delivering another quarter of highly profitable growth, supported by solid organic revenue development and further improvement in profitability. Operating income growth accelerated to 23%, in line with our planned phasing for the year, and we realized another quarter of margin expansion. This was also supported by the continued execution of our FME25+ transformation program, which delivered EUR 67 million of sustainable savings during the quarter. We also completed our initial EUR 1 billion share buyback program on an accelerated time line and have already launched a second EUR 1 billion program, underscoring our continued focus on disciplined capital allocation and reigniting shareholder returns. With a net leverage ratio of 2.6x, we remain around the lower end of our target corridor and continue to maintain a strong financial position. With that overview, let me turn to the key second quarter highlights across our operating segments on Slide 5. Beginning with Care Delivery. The international markets delivered 0.8% same-market treatment growth. In the U.S., same market treatment growth declined by 0.9%. At the same time, I am genuinely encouraged by the progress we are seeing where it matters most for our patients. Our continued focus on quality and patient care is making a real difference. Missed treatments and mortality improved in the quarter. These are outcomes that are deeply meaningful for the patients who rely on us every day and for all of us who are committed to their care. The same market treatment growth declined due to our own clear operational miss in our business development approach to capture our fair market share of referrals. This exposed an execution gap and led to a further softening of referrals in Q2 compared with Q1. We have promptly addressed this with an organizational change, enabling rapid implementation of the necessary prepared measures. While these measures will take a few months to gain traction, we remain confident in our path to restoring referral rates in the affected areas. Given the compounding effect of lower first half of referrals from the rest of the year, we now expect U.S. same market treatment growth in 2026 to be around the Q2 level. I also want to recognize the strong execution driving accelerating momentum across several strategic priorities under our Reignite strategy. We are making significant progress accelerating the rollout of our 5008X in our clinics in the U.S. We have a dedicated slide on high-volume HDF coming up, where I will provide a broader update. As we continue to strengthen our core operations, we remain disciplined in optimizing our clinic network. We have successfully completed the clinic footprint optimization, exiting around 100 select underperforming clinics. We are realizing favorable rates and seeing contributions from our revenue cycle management initiatives, providing further evidence that our operational improvement efforts are gaining traction. As already indicated, we are beginning to see the impact of our catheter-related bloodstream infection preventing efforts. We saw a 23% reduction in bloodstream infections over the past year, which supports lower infected-related hospitalizations and also translates into lower patient mortality risk. Next, on value-based care. We continue to build on the strong momentum we have established in this business. The quarter reflected continued positive operating income as well as an increase in member months driven by contracting growth. We are demonstrating how our vertically integrated model translates into better patient outcomes. We are seeing meaningful improvements across key clinical measures such as reduced missed treatments, lowered mortality and hospitalization rates when FME patients are managed by InterWell Health. On October 12, we will host an expert call with Tommy O'Connor, the CEO of Value-Based Care, where we will give more insights into this segment. Information about the call is available on our Investor Relations website. Turning to Care Enablement. The 5008X rollout gained also momentum for Care Enablement with growing sales supporting favorable business growth. Overall, we continue to realize positive pricing and volume development outside of China, driving momentum in our underlying business. Despite recent headwinds from regulatory changes, China remains an attractive products market for FME. With refreshed leadership, we are reviewing our strategy to win as well as our product portfolio for this market. We are navigating elevated raw material and logistics costs, driven by the conflict in the Middle East. While these external cost pressures remain a headwind and are something we are monitoring closely, they are currently absorbed in our guidance range. This further reinforces the importance of our continued execution of our FME25+ program to drive sustainable savings. Before I turn to the 5008X update, there are two other innovations that I want to highlight. Recently, we introduced -- sorry, recently, we announced the introduction of TherapyWise, a cloud-based analytics capability designed to provide retrospective program level insight into kidney replacement therapy delivered in acute and hospital critical care settings. TherapyWise reflects our continued focus on innovation and critical care by applying data analytics. This helps hospital and clinical leaders gain visibility into how kidney replacement therapy is delivered across their organizations, supporting informed discussions around workflow, consistency and quality improvement. We also launched kinexus, marking a significant milestone in our home dialysis strategy and our broader digital transformation journey. By bringing peritoneal dialysis and home hemodialysis capabilities together on a single platform, we are creating a more connected experience for patients, caregivers and clinical teams. We have already achieved our patient go live with encouraging initial feedback, and we look forward to expanding adoption as we continue to scale the platform globally. Most importantly, kinexus establishes a global digital foundation that will enable future innovation and help us advance our commitment to delivering high-quality person-centered home care. Next on Slide 6. I'm excited to update you on the progress we are making with our 5008X rollout, which is accelerating as planned. We are firmly on track to meet our 2026 targets, including converting around 20% of our machines in our own clinics. By late July, we had converted 227 clinics across 23 states, representing 10% of our machine base. Of the more than 600,000 treatments on the 5008X around 170,000 have been HDF and more than 100,000 high-volume HDF. So far, we have produced 4 million consumables for the 5008X, which is in line with our plan and is rapidly ramping up. Our extensive training efforts have covered around 5,000 renal nurses and patient care technicians. It has been a tremendous undertaking to achieve all of this, and I am proud of how much we have accomplished so far. Last Wednesday, we announced BEACON-US, which is a major research initiative designed to generate real-world evidence for high-volume HDF in routine U.S. clinical practice. This reflects our commitment to bringing innovation to patients thoughtfully, responsibly and with rigorous scientific evaluation at scale. We are encouraged by the positive early experiences we are seeing from both patients and clinicians. To give you some examples, patients report feeling better both during and after dialysis. And for example, data shows 40% fewer muscle cramps. More than 70% of treatments using AutoSub plus technology in our research cohorts are already reaching the high-volume HDF target of at least 23 liters of convective volume per session. Clinical experience suggests simplified clinician workflows, optimize resource utilization, including reduced water consumption and a much quieter overall dialysis clinic experience. Early observations are tracking consistently with previously published international, randomized and real-world studies including the landmark EU-funded CONVINCE study that collectively have associated high-volume HDF with fewer hospitalizations, fewer missed treatments and improved survival outcomes compared with conventional hemodialysis. I will now hand over to Martin to walk you through the second quarter financials in more detail.

Thank you, Helen, and welcome, everyone. I will continue on Slide 8. In the second quarter, we achieved solid organic group revenue growth of 5%, supported by growth in all 3 operating segments. At constant currency, revenue increased by 4%. Regulatory pressure in China continued to pose a challenge to revenue development in Care Enablement. Divestitures negatively impacted group revenue development by 50 basis points in the second quarter. For the full year, we continue to assume an unfavorable impact on the year-over-year revenue growth of about 30 basis points from the execution of our portfolio optimization plan in '25 and '26. We significantly increased operating income by 23% at constant currency. This growth was driven by contributions from Care Delivery and value-based care segments and is in line with our planned phasing for 2026. Special items in the second quarter amounted to a negative EUR 103 million, mainly related to the TAVNEOS impact. As background, the European Commission's recommended revocation of the TAVNEOS marketing authorization led to an impairment of intangible assets at Vifor Fresenius Medical Care Renal Pharma. That resulted in a negative impact on our income from equity method investees of EUR 70 million, which was treated as a special item. Special items further include EUR 42 million FME25+ onetime costs and also positive effects from the Humacyte reevaluation. I will continue on Slide 9. Our group operating margin again expanded and further improved by 180 basis points. Care Delivery as well as value-based care contributed positively. I will cover the drivers of the segment profitability a little bit later. The greater intersegment elimination reflects the growing sales of the 5008X in our clinics in the U.S. With further advancing our rollout, this trend will continue. Corporate costs increased by EUR 47 million, mainly driven by the impact from virtual power purchase agreements and the planned cost of the strategic IT platform investments as we continue to transition to SAP S/4HANA. In addition, FX translation effects had an impact of negative EUR 19 million this quarter. The average U.S. dollar exchange rate in the second quarter was EUR 1.16 compared to EUR 1.17 in the first quarter and compared to EUR 1.13 in the second quarter of 2025. I will now walk you through the business development in each segment, starting with Care Delivery on Slide 10. Care Delivery realized 5% revenue growth at constant currency and organic revenue growth of 7%. In the U.S., organic growth of 7% was supported by the positive impact from TDAPA reimbursement regulations, favorable rate development and continued progress in revenue cycle management initiatives, further enhancing revenue yield. These benefits were partially offset by lower treatment volumes, driven by the referral dynamics Helen discussed earlier. The international business continued to contribute positively. Divestitures as part of our portfolio optimization plan negatively impacted revenue growth by around 90 basis points. The main driver here was the prior year divestment of our clinics in Brazil. Care Delivery achieved strong earnings growth in line with planned phasing for the year, accelerating operating income growth to 45% with a 390 basis point step-up in margin. Importantly, underlying operating income, excluding the TDAPA effects, improved by 34%. This improvement was driven by higher rates, FME25+ contributions, in particular from the clinic closures as well as benefits from revenue cycle management. Additionally, the growth was supported by a lower prior year base, which includes effects such as elevated medical benefit costs. This more than offset the impact from lower treatment volumes in the United States. As assumed, benefits from TDAPA reimbursement regulations for phosphate binders and catheter lock solutions were a driver of earnings with around EUR 18 million year-over-year benefit in the quarter. The TDAPA effects are assumed to be a headwind in the remainder of the year. Moving on to value-based care on Slide 11. Revenue in Value-based Care segment grew by 9% on both organic and constant currency basis. This was driven by an increased number of member months and a favorable effect from premium rates. Revenue increase was partially offset by the change of the risk type for a large contract, which resulted in a different type of accounting treatment and lower revenue recognition. Value-based care delivered a strong improvement in profitability in the second quarter, with operating income increasing to EUR 18 million from a EUR 9 million loss in the prior year. The margin improved by 500 basis points, marking another profitable quarter. Supporting favorable business growth in the quarter was an improved savings rate, reflecting the strength of our contracting. FME25+ savings additionally had a smaller, but positive effect on earnings as well. Looking ahead, due to the positive business development, we expect '26 revenue for value-based care to decline by EUR 150 million to EUR 200 million, which is lower than the initially assumed EUR 300 million decline. I will finish the segment overview with Care Enablement on Slide 12. Care Enablement delivered organic revenue growth of 3%, supported by continued positive pricing and volumes outside China. Regulatory measures and stricter tender requirements in China remained a headwind as assumed. However, the underlying momentum across the rest of the business continues to be encouraging with growing sales of the 5008X increasingly contributing to that momentum as well. Care Enablement earnings declined by 5% in the quarter, reflecting the adverse regulatory impact in China as well as increased inflationary pressure, including higher raw material costs and elevated logistic expenses related to the Middle East conflict. As the Middle East conflict continues, we are closely monitoring the increasing inflationary pressures and implementing mitigation measures where possible. Currently, these higher costs, especially for raw materials and transportation are absorbed in our guidance range. For our Care Enablement China business, as expected, we saw a headwind of around EUR 20 million in the second quarter. These negative effects were partially offset by positive volume and price effects outside of China and continued contributions from FME25+ savings. Next, I will look at cash flow growth on Slide 13. We delivered a strong increase in operating cash flow of 11% in the second quarter, primarily driven by disciplined working capital management. Free cash flow remained stable at EUR 625 million, while we increased our investments in the business, reflecting the continued strength of our underlying cash generation. Total net debt and lease liability as well as total net debt and lease liabilities increased by 6% year-over-year as expected. After canceling 8.5% of shares, which we bought back as part of the share buyback program completed in April of this year, we initiated a new share buyback program starting in May with a total volume of around a further EUR 1 billion. The new program will be executed in tranches over a 12-month period with the first tranche of up to EUR 600 million expected to be completed by mid-December. By the end of the second quarter, we already repurchased 2.5 million shares for EUR 94 million, representing 0.9% of total share capital and approximately 16% of the first tranche. After initiating our new share buyback program, we continue to maintain a net leverage ratio of 2.6x, remaining around the lower end of our target corridor of 2.5 to 3x and underscoring the strength of our balance sheet and disciplined approach to capital allocation. I will now hand back to Helen.

Thank you, Martin. I will pick up with our outlook on Slide 15. We continue to expect a broadly flat revenue development. For earnings, our priority is to sustain the higher level of profitability established in 2025. Accordingly, we expect operating income to remain at a consistently elevated level in 2026 with an upside, downside range of a mid-single-digit percentage change. While we do not provide quarterly phasing, we communicated that we expected a strong first half earnings contribution in 2026, supported by the mentioned underlying earnings improvement and positive TDAPA effects. TDAPA is expected to become a sizable headwind in the third and fourth quarters, resulting in negative earnings growth in the second half. For full year TDAPA contributions, we now expect a lower year-over-year headwind of around EUR 50 million compared with the previously anticipated negative impact of around EUR 100 million. The second quarter demonstrates that the strategic actions we are taking are yielding meaningful improvements in underlying profitability in Care Delivery. Despite the headwinds from lower treatment volumes in the U.S. and a tougher base in the second half of the year, we expect continued improvement in the underlying profitability of Care Delivery. Overall, we expect to deliver Care Enablement margin improvement in the second half and full year 2026 as we continue to execute our Reignite strategy while offsetting increased inflationary pressure from the Middle East conflict in our Care Enablement business. And we continue to assume value-based care to perform around breakeven for the year, reflecting the assumed phasing of contributions and prior year effects. Given our strong first half performance and current expectations for the remainder of the year, we are confirming our full year outlook. This concludes our prepared remarks, and I will 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, I would like to remind everyone to limit your questions to two. If we have remaining time, we can go another round. With that, I hand it over to Valentina to open the Q&A, please.

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

Thank you, Valentina. And the first question comes from Jonathan from Barclays.

The first one is just on same market treatment growth. If you could just help us to understand really the detail on the deceleration from Q1 to Q2 in that number, specifically on the referral piece. I'm really just trying to understand what you can do to improve the inflow of patients there? And how should we think about the relative impact of clinic closures, referrals and the outflow issues of patients that you previously pointed to. And then thank you for giving the 2026 expectation. So is it fair to assume that you expect same market treatment growth in the U.S. to get worse throughout the year? How do you see the phasing? And where do you expect to exit 2027 from the same market treatment growth perspective?

Thanks, Jonathan. I'll take that question. And recognizing there's probably a lot of similar questions around same market treatment growth, I think it's helpful to kind of just maybe walk through that in a bit more detail than normal. As we already outlined, the same market treatment growth declined by 0.9% in the quarter. At the same time, we are encouraged by the progress we are seeing where it matters for our patients and that focus on quality and patient care is making a real difference. And we were really encouraged to see missed treatment and mortality declining in the quarter. As we discussed in Q1, we are executing a lot in parallel in the U.S. dialysis business, which is an operational stretch. We obviously exited around 100 clinics with execution speed, I would say, in half 1. We've closed clinics faster than we would -- than we ever have before. Obviously, the progress on HDF is exciting, but at the same time, that does cause a fair amount of work in the clinics that we are impacting there. And at the same time, there's been a major clinic operations we -- that touched about kind of a couple of thousand people with the whole focus here on driving profitable growth. In the same time, recognizing that we had the ACA subsidies expiring, we also have implemented some enhanced insurance verification on our patients. And while we are pleased with the quality and patient safety initiatives, obviously, rolling out these solutions did also have an impact on the operations. So all of that is really to say the clinic operations are managing significant demand in parallel. And I think we saw that emerge on referrals in Q1 with a little softness there. And I would say that there was an underestimation of the impact that created. As we came out of Q1 into Q2, it was clear that there was -- while that disruption may have been understood, it was clear that it was masking an underlying issue. And I think what we -- as I've kind of worked kind of closely with the team there and with Cassie directly, it's clear now that we have an operational miss, specifically in the business development approach, which is capturing our fair market share of referrals. We are not seeing a market issue. We are seeing a volume capture issue in terms of getting the patients that we see into our clinics. So that was the execution gap that has led to a further softening of referrals in Q2 compared to Q1. We are all over it. We've made some -- we obviously saw the organizational changes. We've also made organizational changes in the business development group. That will take a few months to gain traction. Cassie is crystal clear of those priorities, and we do remain confident in our path to restoring those referral rates in those effective areas. And obviously, we're looking at this region by region. However, given the compounding effect of the lower first half referrals on the rest of the year, that's why we are now saying we expect the same market treatment growth in '26 to be around the Q2 level. Obviously, that compounding effect has caused a gap. We also know that we've got to do work that will take time. So that's why I think we're trying to be realistic here and call the year at a similar level to Q2. Obviously, we do expect that work to take hold and for that benefit to pull through. But realistically, I think we're seeing that more into '27 than we were originally thinking in '26. In terms of kind of the exit rate for 2027, clearly, I'm not going to speak to that today. I think we can kind of see where we see '26, what '27 looks like. I need a few more quarters under our belt. And obviously, we'll be able to give that outlook when we get to February. The kind of the areas of focus, as you can appreciate, are making sure that when we get those referrals, they're accepted referrals, and we are gaining our fair share there. We had said, and I think it's fair to acknowledge this, that we didn't have an inflow issue earlier or maybe the end of last year, it was an outflow issue. I think we have done some significant work on outflows and that's really showing up in the mortality and mistreatment numbers. What we have now is not a market or a patient issue, we have an accepted referral and inflow issue that is 1,000% the focus of Cassie and the organization. So I think that answered all the pieces there. And apologies for the longer answer. I think it was one that's on a lot of people's minds.

The next question comes from Veronika from Citi.

I have 2, please. Apologies. The first one is going to be on the same market. And Helen, I just want to get a better shape of understanding of the quarter. I appreciate you don't report monthly. But I remember when you were on the road, you were talking about April being down 40 basis points, so not hugely similar, which would suggest that May and June really sort of fell off the cliff in terms of U.S.A. market treatment growth rate. I was kind of wondering if you could comment on that. And I guess if you have any early indications for how the referral piece is improving in July relative to how poor it must have been in May and June, that might be helpful to give us all a bit of a confidence in terms of the forward path. And then my second question is on the TDAPA phosphate binder assumption for the year. By my math, you're probably at around $130 million already for H1. It sounds like the new guidance is $150 million to $170 million. Just trying to understand if maybe you're being a little too conservative on that given how strong the first half of the year has come in.

Yes. Thanks, Veronika. I'll take the same market treatment growth, and I'll have Martin walk us through the TDAPA numbers because I know there's a lot of numbers here on that one. Yes. Look, you're right. When we were on the road in April, we were already indicating that April may be kind of a similar level coming out of the softness in Q1, I mean, don't forget, April still had the benefit of the lower flu base in 2025. So that was kind of maybe also not giving us the clear picture. There's no question, as you see the number for the quarter that May and June did deteriorate. And I think that's where the focus has been over the last couple of months is really getting under what the root cause is and where the area of focus was. I mean I can buy disruption to a point, but we also have to make sure that the underlying core operation is operating as we expect it to. And I'm the last person to want to speak to an operational miss, but clearly, we have one here. And that's why I think we're just being careful on how we guide the rest of the year. In July, I haven't seen numbers yet. But I think the fact that we are thinking of calling it for a similar level to Q2, I don't expect to see the improvement overnight, but I do expect to see it take hold as we go through the next couple of quarters here. Martin, do you want to take TDAPA?

Yes. Veronika, so on TDAPA, as we said, we have seen about EUR 80 million effect in quarter 2, and also, we said that we expect after the first half tailwinds to turn into a headwind for quarter 3 and quarter 4. Now total TDAPA contribution, we are now saying will be a negative EUR 50 million overall on a year-over-year basis, and that is reduced from around EUR 100 million we had on the previous expectations. As a reminder, we had last year a EUR 310 million positive year-over-year contribution. And we said there was a EUR 90 million DefenCath. DefenCath is unchanged, positive EUR 90 million first half, negative EUR 90 million in the second half. So year-over-year, that is a wash or a zero effect. For the binders, yes, we did see in the first half around the EUR 70 million positivity year-over-year. And we expect this to turn into a headwind of around EUR 120 million year-over-year in the second half, then resulting in the EUR 50 million for the full year. The lower headwinds is predominantly driven by our Pharma business, where we see lower-than-expected headwinds, and that gives us -- or gives you an impression on the overall TDAPA picture.

That's helpful. And Helen, can I just follow up? One of the things that really struck me this quarter is the volume growth got worse in the U.S. clinics business. But it looks like your revenue -- your mix is good, your revenue management is good. Is there a risk here that you're sort of so focused on profitability that you've ended up at a place where volume growth is suffering? Is that the issue that we're looking at?

No, I don't believe so. The work that we identified on rate and yield were very obvious things for us to go after where we were lagging, and we've made tremendous strides in those. And in many ways, there are different teams internally within CD as well focused on those. We will look at profitability measures like the clinic closures where we really can't see a way to make that clinic profitable. That obviously has been a profitability focus for us, but not at the detriment of the rate and the yield that you're talking about. But we clearly knew, right, that when we were closing these clinics, while we've held on to a significant portion of these patients, we knew we were giving up some of that volume, and we saw that play out in the market in Q1. I expect that to continue to play out in the market in Q2. I think the -- that was kind of a smaller piece of the overall same market treatment growth development though. But we're very mindful, Veronika, of what trade-offs we are making, and we don't go into any of them likely. But clearly, the profitability play on both the restructure and reorg and the clinic closures has been meaningful for us and a smaller part of that same market treatment growth give up. The real issue here is we're really focused to the business development area on accepted referrals, and we can see that by area. So it is isolated, which is why I'm kind of confident that we've got the right plans in place. We've got the right people now in place, and we can get at it.

The next question comes from Oliver from ODDO BHF. Oliver, the floor to yours.

Two questions from my side. First about the ARR commercial mix. So would you describe that your started initiatives to improve the mix since last fall have contributed already significantly to some of this mix improvements? Second question is still very early days, but we saw recently the first indications about the bundle rate, which also caused some volatility in the share price. Could you share with us how you think about the first indications? And yes, it will still change, but it would be great to hear your view.

Yes. Thanks, Oliver. I think I can tackle both of those. On the commercial mix, we continue to be very encouraged by the improvements that we see there. The wage improvement is real. We've done a lot of work in that area. It is slightly down to ACA that obviously has developed in line with our expectations. But overall, really pleased with the work that has been done on the commercial mix. On the bundle rate, the 1%, always disappointing. Clearly, we're in preliminary period. We're offering up a lot of comments to the administration on the moving pieces of that. We'll see what final brings. But overall, it's always challenging when it's less than inflation.

I was less thinking about the bundle rates, but more about also the additions which come to the total rate.

Oh, you mean the TDAPA add-on payments for...

Yes. Yes.

Okay. Yes, sorry. I heard you say bundle and I thought you were talking about the PPS rate that also came out since last quarter.

No, no, no. I said since this quarter, I meant also including TDAPA, sorry.

Look, 2 things there. Again, some of this is preliminary. We do expect the government to continue to capture the pricing for the next couple of quarters before it comes final. So for that, we would expect that payment to come down as it brings in more quarters, reflecting the lower prices and the rebates that exist in that. So that should come down as we get to final. And I think what we would see -- we wouldn't be surprised that, that continues to develop in line with our expectations. It's high right now just because it's -- I think it's a 2-quarter lag off to what more data would come in and show.

The next question comes from Aisyah from Morgan Stanley.

My first one is also, unfortunately, on the same market treatment growth, but for the International number, that number was quite weak and the weakest we've seen in 2 years. Were there any reimbursements there in the past that supported the growth and has resulted in a lower number in the quarter? And then my second question was on the ACA headwind that you expect, I guess, what was the number for the quarter, your expectations for 2026? And any early thoughts on the ACA headwind for 2027?

Thanks, Aisyah. On the International same market treatment growth, Clearly, we have a lot -- there's a mix effect there. Clearly, we have a lot of countries and a lot of markets that we are focusing on. I think the piece that kind of maybe gets lost in this is we have exited some markets that had higher growth rates. So that would have an effect. And it's kind of a little bit of mix on the mix in the countries, countries like Brazil and Malaysia, for example. And then as we already mentioned, the kind of the flu impact in Q2 as well. So nothing that we are overly concerned about there. On the ACA, we had kind of sized a $50 million headwind for the full year. We had been watching that very, very closely, obviously, in Q1 to see how sticky this was and what would happen once patients had to start paying their premiums. It did step up as expected in Q2, which has meant that we've seen existing patients leave the exchange plans due to the affordability issues. And then we have seen some patients move to other coverage like Medicare Advantage or Medicare. And then, of course, some are no longer treating with us. So the underlying headwind remains consistent with our initial expectation of about $50 million for the full year. What we're also seeing is that we have been able to reduce the impact on our commercial mix by expanded payer relationships and signing new contracts in other geographies. So while it starts to get really difficult to tease out what patient went where, we can see what happened on the ACA exchanges. But anything else that results from that will be picked up in business growth moving forward. So we won't continue to track this ACA move. I think we've kind of been able to ring fence it for 2026, but all kind of played out as expected, even though there was this weird dynamic between Q1 and Q2, we're back where we thought we would be.

So if I can -- if I kind of interpret your comments and assuming that this impact kind of increases over the course of the year towards the $50 million you had expected for the full year, would it be fair to assume it's something like $10 million this quarter, $50 million next quarter, $25 million the quarter after that? Or is it more kind of a linear progression?

Probably neither. It's been a bit lumpy because of what happened in Q1 and then some of this grace period and then kind of how patients have fallen out. So I think we're not kind of getting into the quarter-by-quarter, but just like the whole $50 million sizing for the year, but develop in line with our half 1, half 2 phasing within our guidance range.

The next question comes from Hugo from BNPP.

I have 2, please. First quick one on tariff refund. Can you maybe help us quantify the impact in Q2, what you expect for the remainder of the year? I think you guys have already a marginal impact, but it would be helpful to have that number. Second, thanks for all the moving parts on 2026. But if we look forward to 2027, you guys have some tailwinds rolling off. U.S. draft reimbursement is 1% and inflation keeps running slightly above that at 3%. Could you walk us through some of the building blocks for 2027, which would lead to EBIT growth next year if that is the plan? Or is EBIT growth off the table next year?

Yes. Martin, why don't you take the tariff question, and I will head up the tailwinds and headwinds discussed for 2027.

As we had discussed, we had a limited tariff exposure in the past because of the breadth of our supply chain network and how we managed to mitigate it. As such, we also expect a limited refund. We have not received or booked anything in the second quarter. We expect a, let's say, high single-digit kind of range in the second half year. But it is, as I said previously on the headwind rather limited.

Yes. Hugo, I think you can appreciate I am not going to get into the moving pieces of 2027 guidance in August of '26. What I will speak to, though, is you know our usual building blocks, right? On the positive side, business performance and volume, rate and yield, FME25, clear expectation there that we continue to expand our margins across the business as well as getting the benefits from the HDF rollout. On the negative side, of course, we have the usual inflation and merit increases. And then I think the bigger moving bucket for 2027 is the binders and the TDAPA roll-off and that headwind into 2027. Obviously, we are not able to completely size that and won't do that today. But obviously, we've got to wait for what the final pricing does on kind of the pharma pricing of what goes into the bundle. But I think there's -- I think we've got our arms around what the moving parts of this business are by now. And of course, we'll size them accordingly by February.

The next question comes from Richard from Goldman Sachs.

I just want to follow up on the U.S. treatment growth and in particular, your comments about not capturing your fair share of referrals. What was actually sort of, I guess, in practice, what was happening to drive that? Have there been changes in your processes, your competitor processes? I just -- I guess, I'd like to understand more what the sort of the root cause of that is. And then sort of as a follow-up to that, what is going to be top of Cassie's to-do list as she sort of comes in to run that business and I suppose, tries to steady the ship.

Yes. Thanks, Richard. Look, at the end of the day, we could see that we were getting patients referred and we weren't getting them into the clinic. So we track incoming referrals, and we also track confirmed referrals. So when those referrals don't get confirmed, meaning a patient isn't in the chair, we know that they're going somewhere else. So we're clearly expecting share loss because those patients have gone somewhere, and we'll see how that plays out in the market this quarter, of course. What we are able to see is what those volumes and what those shares and kind of treatment volumes look like by region. And clearly, where we were falling short there, we have now targeted what area we need to make those improvements. So there is clear visibility on it. There has been leadership changes in that area as well. And I think our whole organization knows that every aspect of inflows and outflows on same market treatment growth are our #1 priority. What I am encouraged by, you know, Cassie has been with the organization, what, 3 quarters or so now. She clearly -- as we were looking through the noise of disruption and I was trying to get under the real root cause, she quickly identified that we had a business development and kind of in our own control inflow issue, if you will, and she's already working through those measures that need to be executed in. And as I mentioned, we're kind of putting the right leaders in and the right metrics to make sure that we're really focused on this particular root cause. As we know, I mean, it's a big operation. It's a complex operation. We know we've done a lot here, and I don't want to dismiss the work that has been done. And I think the work that we are pulling through on outflows speaks to that. So we're focused on it. And I think Cassie and I are very clearly aligned on the priorities and where we need to see improvement. And we'll obviously track it accordingly daily and weekly and monthly.

I appreciate the color. And if I could just squeeze in one follow-up. International Care delivery was pretty robust, especially in organic terms. What was driving that? Are there any one-offs that we should be aware of?

Martin, do you want to take that?

Yes. So you saw that the fair market premium growth was at 0.8%. We did see in the International organic revenue driver, a supporting accounting topic, which had an effect there. When you look at that in the second quarter, we had certain pharmaceutical product business activities that we still had in Care Enablement. And in the second quarter, we shifted that to -- it's neutral for the overall company. And to give you a bit of let's say, framing here, this is something that had last year to about $20 million roughly in revenue and a low single-digit in profitability. That is what is supporting international organic revenue growth. And we did that in order to also have a full visibility of the global pharma P&L.

Next question comes from Anna from Bank of America.

I wanted to dig in a bit on the HVHDF rollout and how much, if at all, you saw disruption from the rollout of the clinics affecting USA market treatment growth in the quarter and what the learnings are from the rollout in the first half to take into the second half? And then I also wanted to, if possible, ask about external sales of HVHDF. I realize that's not a near-term priority. The priority for the year is the internal rollout. But I imagine those discussions are in place. Just how are they evolving? And how has that maybe changed after the mother trial data? Any incremental color there would be super helpful.

Yes. Thanks, Anna. As you know, it's my favorite topic and one that we're thrilled with the progress on. And as you can appreciate, something of this scale, we get a lot of learnings. What I would say is a lot of those learnings were really helpful through that pilot stage of last year. Once we got going, I think the teams have really, really stepped up. Don't forget, it's still a relatively small part of the overall clinic network that has been converted. So it's not that it's a mass disruption to the 2,600 clinic network, it is obviously an impact to the couple of hundred that we have done so far. What we have seen is as we are gathering momentum, the speed and training and staff are just getting edge. And that's why I think you're seeing the acceleration and the kind of the progress of the 10%, which is wonderful. I'd say we were clear that we wanted to track this patient cohort that was on HDF, and you saw Charles put out the BEACON U.S. press release last week, which we're thrilled with. I think it's too early at this stage to give real mortality or missed treatment data on that cohort. But what we are able to see, and I referenced it earlier, is that the clinical benefits are tracking in line with the CONVINCE study. And the fact that we've got the patients reaching the high volume relatively quickly, we know that, that mortality benefit will ramp up over the coming years as well. So we're thrilled with what we're seeing so far as well as obviously, not just the performance, but the patient feedback, the physician feedback and obviously, the kind of patients reaching out to learn more and want to be referred to a HDF clinic. As you rightly said, the external sales are minimal this year because of the allocation plan to our clinics. So obviously, we're making our machines available as we have excess capacity to other providers, but that is something that is in pilot with some of those right now. And obviously, that's up to them on what they choose to do with purchasing the machines. Obviously, if that excess capacity that we've allocated doesn't get taken up in the short term, that would mean we would allocate more to our clinics and go faster. So I think we're in good shape where we are 6 months or 2 quarters into -- I guess, 8 months, but 2 quarters in at least to the launch and things are going incredibly well. And I think the speed of the uptake on the -- reaching the high-volume levels is incredibly exciting, and we're seeing that show up in the patient response.

The next question comes from Graham from UBS.

Just one quick one for Martin and then a slightly longer one for Helen. Martin, just on the TDAPA, just I've had a few people ask this specific total contribution for Q2. So is it fair to think of that as about EUR 120 million of EBIT in Q2 was from the full TDAPA, so catheters and phosphates. And then Helen, just secondly, on the guidance for this year. So the midpoint would imply something like a 12%, 13% decline in EBIT in H2. And when I think of H2 '26, H1 '27 looks quite similar in terms of the TDAPA driver in terms of the comparator there. That feels like not an unsensible way to think about H1 '27, and there's still a degree of headwind in H2 '27. Is it still reasonable to think of EBIT growth in 2027? I know you don't want to comment too much on it, but it just -- it seems like those headwinds are quite big.

Martin, do you want to take the TDAPA one?

Yes, Graham. So what we did disclose is that this quarter in 2026, we had a year-over-year improvement of EUR 80 million. We also disclosed in quarter 2 2025 that we had against the prior year period before TDAPA, an improvement year-over-year of the low end of a mid-double-digit impact. So when you take these two together, you are roughly where you said you would be and that constitutes kind of a 2x year-over-year improvement that we see. We think of it in a yearly slice normally, not as a total contribution. Does that makes sense?

That's super. That's super clear.

Yes. And then, Graham, on your second question, obviously, I don't want to get into the 2027 guidance, but I recognize everyone is already trying to put those building blocks together. Maybe what I would refer you to is the '25 to '28 CAGR aspiration that we put out there. Obviously, on '26, we are confirming our guidance. We always said that there would be this shift between half 1 and half 2 that has completely developed in line with our expectations, which is why we are confirming. And then, of course, we've put out a '25 to '28, 3% growth CAGR aspiration, and that is obviously still there. That used 2025 as a base that had the roughly $300 million of TDAPA benefits in there. So yes, that's how we're thinking about it. And don't forget, on that 3% to 7% CAGR growth assumption, we had also said there was underlying low teens growth. So obviously, we are expecting the businesses to continue to contribute on the margin expansion here.

The next question comes from James from Jefferies.

Two, if I can, please. Firstly, you've completed 100 clinic closures this year. So I was wondering if volumes stay at around the 2Q level into next year, would you need to consider other clinic closure programs to manage your fixed costs? Or how should we think about decisions to manage your clinic capacity? And then the second question is, this quarter, you've renamed the operating cash flow line changes in other working capital and noncash items to changes in other assets and liabilities and other noncash items. So I was wondering why change the wording now? And was this purely presentational or does it better reflect the fact that a broader set of operating assets and liabilities now contribute to operating cash flow than historically? It does seem that cash flow improvements from this line in the first half were greater than the whole of the group. So it would be helpful to have some color on what's driven it is outside core operations, which otherwise would have decreased.

James, the clinic closure question sounds a lot easier than the second one. So I'll take the first one and Martin can clearly give him a moment to look that up while I'm answering the clinic closures. Look, what we -- this is the second round of clinic closures that we've done over the last couple of years. As we know, the deeper you go into that program on where they are operationally, the tougher they get in terms of the kind of the ROI on them. We feel really good about what we've done to date and this 100. We feel that we're well placed with our outlook on what we expect to get on volume and obviously, the benefits from HDF as they kick in. I've always said, while we're not planning for this not to kind of come back to growth, I've always said costs are not fixed indefinitely, and we would adjust capacity and overhead accordingly. And I think we've been very diligent in how we've done that and appropriate with the kind of with the outlook that we've got. So our expectation is still this underlying return to growth. Clearly, it's now picking up a little longer, but we will -- we're constantly looking at that overhead structure in line with that and would adjust if needed in the future.

Okay. So would it be fair to say if it was more like, say, minus 1.5% or something that would kind of probably sort of trigger that sort of discussion. I guess I'm sort of trying to understand the capacity that you have in terms of this managed and how much excess there is for you to do that. So how much headroom do you have at the current run rate maybe is a better way of asking the question.

Yes. I feel that we are rightsized for what we expect to see through this medium-term period. Okay.

So James, from my side. So there is no change in content, so to say, in the line. There's also no accounting changes that impact the line. It is only a better representation of the naming of the line.

So that's sort of understood. But in terms of what's driven that then, just given the swing is more than the cash flow from generating the overall group. Are you able to give us a sense what's gone into that cash flow improvement?

So overall, our cash flow improvement was driven by the working capital development that we had, as I pointed out, where we did improve, so to say, based on the collection side as well as on the receivable side with a strong cash velocity. And we also improved further as we also lined out already in quarter 1 on the payable side. So those were the main drivers on the capital.

I think it's just because of the wording, it now doesn't include working capital in that particular line. That's sort of what I'm just trying to understand. I'm happy to follow up off-line if that's easier. But given the magnitude just it would be helpful to understand.

So no content change. And the main drivers are the working capital.

The next call comes from Falko from Deutsche Bank.

My first question is on the Care Enablement business in China. Thanks for pointing out the headwind in Q2. I was wondering when you expect this situation to stabilize? And secondly, on the ACA topic, do you happen to have any early view on how we should think about this for 2027? And how much of an additional headwind it could potentially be next year on top of the EUR 50 million this year?

Yes, Falko. Martin, why don't you take the China question. I'll come back on the ACA topic.

All right. Sorry for that. That was a bit of a gap. So on China, we did see the first half expectations to be as we thought. We had EUR 20 million headwind in the quarter 2. We had in the quarter 1 half of the expected less than EUR 50 million. So for the second half, we see that to be normalized, and we expect for the full year also this to remain below the EUR 50 million. I would say through the first half, we are through the most of it. And with that the EUR 50 million assumption for the full year still intact.

Yes. And then Falko, on your ACA question, clearly, I'm not going to size what that is for 2027 because we don't really know. What we do know is the $50 million that developed unfavorably this year was in line with expectations. But as I also mentioned in my answer to my previous question on the same topic that we also are seeing shifts in kind of contracts and where patients are going. So I think ultimately, what this will all wash up in is our business growth number, and that would kind of now be in the base. But it's -- there's moving pieces here. So not all negative because of the positive moves in coverage with different insurers. So it's just going to be impossible to track separately moving forward. So when we give a business growth number for 2027, once we roll up these entire books of business and now it all settles out, we'll be able to kind of pop it in there so that we -- it's impossible to track where these patients ultimately will end up in 2027 between the different plans. But we'll do the bottom-up book of business build that goes into that business growth number.

Super. Thank you. So those were all questions we received. So there's no one waiting to ask a question. With that, I'll thank Helen and Martin for answering the questions and for all the interesting questions. And with that, we'll close the call and wish everyone a great summer.

Yes. Thanks, everybody. Appreciate the flexibility today on the earlier timing as well. Have a good summer, and we'll see many of you on the road soon. Thank you.

Thank you.

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