Fresenius Medical Care AG (FME) Earnings Call Transcript & Summary

Ladies and gentlemen, thank you for standing by. My name is Emma, your Chorus Call operator. Welcome, and thank you for joining the Fresenius Medical Care Expert Call on sustainability and person-centered care. [Operator Instructions] And I would now like to turn the conference over to Dominik, Head of Investor Relations. Please go ahead, sir.

Thank you, Emma. We would like to welcome all of you to the Fresenius Medicare Expert Call Series 2021 with sustainability and person-centered care. We appreciate you joining today. As always, I have to -- and I'm happy to start out the event by mentioning our cautionary language that is in our safe harbor statement on Slide 2 of the sustainability and person-centered care presentation. For further details concerning risks and uncertainties, please refer to this document as well as to our SEC filings. At Fresenius Medical Care, we are driven by our person-centered mission to provide holistic care for patients with kidney disease around the world. I'm pleased that we can give you deeper insight into our sustainability journey as a company as well as how we are addressing global health care challenges while improving patient experience and care. I'm delighted to have Dr. Frank Maddux, our global Chief Medical Officer; and Charlotte Stange, our Global Head of Sustainability, here to present today. Please be aware that this call will not cover the financial background or any costs or revenue questions in this relation. And furthermore, I would like to ask you for your kind understanding that we will not answer questions about COVID-19 situation, vaccination rates, excess mortality. Please, let's focus on the topic we are presenting today. We will give an update on those topics with our Q4 results in February. I will now hand over to Charlotte to begin the presentation. The floor is yours.

Thank you, Dominik. It is my pleasure to start with an update on how we drive integration of sustainability into our business around the world. Our actions are driven by our vision to create a future worth living for patients worldwide in every single day. Consequently, also our sustainability efforts focus on activities that support this mission for the long term. Putting our patients at the center of what we do has been our guiding principle since day 1. This year, we celebrate 25 years of Fresenius Medical Care. And while doing that, we also had a look at how we have come with our sustainability efforts and where we're heading. Turning to Slide 4. Let's have a look at the strategic framework. Our approach to sustainability has developed into a broad global agenda. We are implementing a global sustainability program over 3 years to ramp up the integration of sustainability in our business worldwide. Here, we have identified 8 key sustainability focus areas, and our dedication to patients is on the top of that list. We measure how we're doing with a scoring model that evaluates more than 50 aspects. Also, we have implemented a global governance for sustainability and as Head of the company's Sustainability Decision Board, our CEO takes direct responsibility for the program and also for its progress. Also, the role of Lead Independent Director in our Supervisory Board is strengthening corporate governance in line with best practice. Here, since the launch of our global sustainability program last year, we have made significant progress, and we're happy to share some insights here today. We have defined some global sustainability standards for a number of areas, and we have also agreed on key performance indicators that measure success. We have also developed some global ESG goals, and we will also continue to do so going forward. Also, we have invested in global systems to measure our footprint even better because only then can we build on decisions that are based on reliable data, and it helps us to identify areas for improvement and drivers to do so. We have also increased our disclosure along this road. You might have seen our publication on the GRI standards, on the SASB standards and also on the recommendation from the Task Force of Climate-Related Financial Disclosures. Moving on to Slide 5. So why do we have a global sustainability transformation program? Coming from a decentralized business model, it is key for us to build a solid foundation for managing our sustainability performance globally. That's why we are defining global ESG standards and quantify our progress of the sustainability program. We harmonize processes, and we also want to measure our impact most efficiently, and we also want to drive knowledge sharing and also best practice sharing among our colleagues around the world. This will be the solid base to have a global sustainability management that is integrated in the line after the completion of our sustainability program at the end of next year. Turning on to Slide 6, please. Part of our sustainability journey is to strive for continuous improvement. To help us achieve this ambition, we establish qualitative and quantitative targets. We use these targets to measure how we're doing. And this also includes measurements, which represent our commitment to deliver safe and high-quality care to a growing number of patients. Here on this slide, you can see that we continuously monitor and analyze the performance of our products and services. As a result of our global sustainability program, we can now measure, for example, the satisfaction of our patients with our services on a globally harmonized level. And we also have defined key performance indicators that help us monitor our quality objectives. Here, we disclose the audit score, which measures the performance in certification audits. It indicates the ratio between major and critical findings to the number of external audits. Part of our dedication to increase choices for patients is also our goal to increase the share of patients on home dialysis. Turning to Slide 7. Here on this slide, you can see some key achievements in sustainability focus areas over the past couple of years. You see next to quality of care and quality of products, providing excellent health care for us has many more aspects. We regularly collect feedback of our employees, for example, to increase engagement and evaluate their feedback. This year, 74% of our employees participated in our survey, which is an increase of 6 percentage points compared to last year. While our environmental footprint might not be as big as that of the companies in other industries, it's still a key element of our sustainability agenda. To give you some examples, in 2020, more than 170 environmental initiatives were reported from our manufacturing sites around the world. They contributed to the reduction of greenhouse gas emissions, on the use of water and also on waste management. Here, also the increase in digitization is important to have better data availability and to identify the biggest lever for improvement. When it comes to responsible business practices, we also put a focus on robust controls, and we are advancing our compliance program. Here, we rely on our code of conduct and business ethics to make our employees aware of how they should interact with patients, with each other, with business partners, officials and also with the broader public. And one example of what we're looking at here is that more than 113,000 employees were enrolled in code of ethics trainings last year. And we also did third-party assessments with more than 37,000 third parties. You'll see all of the sustainability aspects and more are important for us to be successful for the long term. They help us to increase our positive impact and also look at the biggest lever of sustainability there is for us. And that's addressing global health care challenges and providing the best possible care for a growing number of patients. And for some deeper insights on this, I'm very pleased to hand over to our Chief Medical Officer, Dr. Frank Maddux.

Charlotte, thank you for that. I think on Slide 8, we recognize that our mission is, in fact, delivering health care in many, many diverse systems and that the growing number of patients that require kidney-related care and advanced care continues to expand in both -- all sorts of different health care systems. If we can move on to Slide 9, please. When we look at addressing global health care challenges, it's quite clear that our medical office, global clinical and quality agenda that we develop annually is aligned with the United Nations sustainability development goals and recognize that many of these aspects that you see on this slide are things that we deal with on a daily basis. And the pressures within health care systems are -- have many challenges to be overcome, some of which are global and some of which actually are translated quite locally. Next, on Slide 10. At this point, I think when we look at 1 component of our clinical and quality agenda, you recognize that our strategic initiatives are guided by these principles of creating sustainable health care systems in a variety of diverse environments and recognizing that as we are committed to taking care of patients, we're highly aligned in how to improve health care delivery around the world through a continuous quality improvement framework, through recognizing that patient-reported outcomes and patients' experience of their care is critical to that as well as the ability to, in fact, create not only access to health care, but continuous improvement in the level of that health care towards what some dynamic optimal degree of delivery occurs. We see that not only in the actions we do under our sustainability program, but in our relationship to the fields of medicine that we operate. And our clinical vision related to that is directly in line with these global strategic initiatives that support the education of patients, the education of health care providers in the collaborations that we do across the world. On to Slide 11. When we look at our clinical agenda in detail, we have a variety of pillars that act as themes for the organization to pay attention to. So instead of strategically recognizing tactical elements here, we are really looking at those themes that we think need more attention, more conversation, more discussion and ultimately, more action. One of those key pillars has been person-centered care, recognizing that the ability within an organized framework of health care to understand the individuals that need that care and those people around them that are affected by that care gives us an opportunity to create the appropriate treatment for an individual patient at the appropriate time. And key partnerships and collaborations that we have are continually part of this, not the least of which is how we have evolved our look at patient-reported outcomes, symptom management and the patient experience level. On to Slide 12. If we look at how we are devising the patient and the person at the center of this care, it involves quite a few different systems that we have in place. And all of this is around developing enhanced power and choice for patients as they navigate their journey with a life-threatening disease and one that we can highly impact. So whether it's directly in coordination of their care with other health care providers, with their local environment and their family that's involved, whether it's actually creating learning systems where they have the ability to be -- have a higher understanding of the decisions that they make and the impact on their outcomes or whether it's technology that begins to involve our digital standards that give us a connected health environment, not only seeing them when they're right in front of us, but actually seeing them when they're in their home environment, all of these are highlights of the kind of work that we're doing to enhance patient power and choice and to connect our sustainability goals related to patients to this person-centered approach that exists. If we can move to Slide 13, please. One of the key things that we've evolved over the last several years has been the ability to get qualitative data from our patients. And that qualitative data is frequently listening to their voice and recognizing that there are key performance indicators that allow us to support sort of more proactive management of kinds of initiatives that will help patients and their families make good decisions. This feedback loop is part of the continuous quality improvement program, and it relates very highly to this performance agreement that we have with physicians and providers of care that we work with. And there are 3 elements to that performance agreement: One, we recognize we need to measure ourselves on both quantitative and qualitative inputs on the care that's delivered. The second pillar of this performance agreement is that we look to identify where we have a best practice and how do we scale that best practice. And then the third is, if we are falling short in some area, we look at how to learn from that and don't accept that, that's the best it can be. We have a belief that there's always room for improvement in these areas. So when we look at the sustainability program and the patient pillar in this, we look at the quality of care and education, the excellence in service and the ability to individualize that care that all relates to the patient experience that we see in the measurements, whether they are through the patient survey, whether it's through looking at our Net Promoter Score or whether it's through other detailed practices that we've identified that need to be enhanced. If we can move to Slide 14, please. Promoting access to health care is really critical around the world. Not all patients have access to health care for kidney disease today. And so the person-centered care approach that we have is educating and making treatments available, recognizing the economics and trying to make sure that we are as cost conscious and value based in the way that we look at that as well as making physical accessibility for all patients -- patient groups and recognizing that there are markets that -- around the world that are underserved and populations and communities that still need to be reached. And our aspiration is not just to recognize that it's about the number of clinics or the number of markets, but to realize that as access to care becomes standard in a medical deliver -- or a health care delivery system, we then begin to look at how do we offer greater choices in the treatment modalities, the journey that occurs, the affordability of that care and the ability to look at -- in different cultures and environments, the health equity component of this. As we educate people and we look at how they look at the journey of life that they will have with a chronic advanced disease, it recognizes that there are some areas that we want to promote in a larger way. And some examples of that include, we have this target for giving people the option to do therapies outside of the traditional health care facility and our home therapy targets have distinct opportunities for peritoneal dialysis, for home hemodialysis and for making sure patients are educated and exposed to all of the available modalities that they may be able to participate in. We have a variety of technologies that help engage patients in that activity. And as an example, throughout the U.S., we have a patient hub that provides an opportunity for patients to be engaged and directly invested in understanding the level of care that they need at that time and the type of care that they have. In 21 countries in other parts of the world, we have what's called the myCompanion app. And this application is for patients that also gives them an opportunity to recognize what are the health behaviors, like exercise and movement and such things, that can actually keep them in the best physical condition to take on the challenges of advanced kidney disease. And finally, as we've looked at themes in our annual medical report, I'll simply recognize that there are technologies that are evolving into our standards of care that include our ability to look at patients and be connected to them not only when they're on treatment, but also during times when they're in their own environment and utilize that data to help us understand kidney disease, the progression of this disease and the things that might impact it going forward. We have active activities looking at the impact, and this is a highly topical topic, especially in the U.S., as there have been distinct discussions on the use of a race-based estimated GFR assessment and the issues around race, ethnicity, geography and education become prominent. For us, these are all topics that we are actively discussing today and looking at how do we create an environment where we are actually looking at how we are bridging that gap: first, identifying health equity challenges; and then secondarily, what are the things we can do to impact those or affect those. If we can go to Slide 15, please. Medical education is a core component of the activities that we do and our global initiatives to expand medical education have occurred not on just the provider level with regard to medical education of health care providers and nephrologists to make sure they're staying current with the standard of the science. There is lots of that going on, as an example, through advanced renal education program where this year, there will have been more than 40,000 e-learning opportunities and over 13,000 live seminars, 2 large events that we have sponsored like the Life/2021 events that occurred earlier this year. We've educated more than 55,000 youth in our Kidney Kid program and trying to understand the impact that kidney disease has on their life if they make wise or unwise health choices as they're growing up. And recognizing that our direct patients that are referred to us for care, there's a tremendous amount of education to try to work with those individuals to make sure that they understand the impact of the choices that they make in their life. This year, we recognize that we had a gap in our ability to participate more actively in the conversations related to the journey of -- in kidney disease for patients with regard to using transplantation as their method of kidney replacement therapy. And so we added a Global Head of Transplant Medicine, who is very well known within the transplant community, to both educate ourselves and raise the questions of how we can become more relevant in understanding the components of transplant and the issues of transplant that need to be improved in the course of our health care delivery. This is 1 of several areas where we think our quality performance and quality improvement model recognizes the full renal care continuum as Charlotte described it earlier in that prior slide. Turning to Slide 16. At this point, I would simply say our global management of quality performances is looking at several primary themes. It's looking at not only the traditional measures of quality of care that are typical physiologic measures we've had for patients with end-stage kidney disease on a particular dialysis treatment. But it also includes the recognition that there are lots of issues related to access to care around the world where we want to make sure that we are promoting smart policy decisions around the world to try to recognize the health equity deficits that occur around the world and how we might be able to make more care available and affordable as well as recognizing that the patient experience and their opportunity to grow and their choices and the power that they have to understand what is the experience that they'll have in interacting with us are quite important. These are topics that we're still maturing into and the sustainability program that Charlotte described is a key component to focusing our attention on many of the aspects that I've just discussed that I think we have made tremendous progress in, but still have a long way to go on that journey, in my opinion. We're looking continually to improve and to highlight both our improvement and our achievement of these results as we look at a balanced perspective of how kidney disease is cared for throughout the world, and we perceive our role as leaders in that particular care. With that, I'll conclude my remarks and turn it back over to you, Dominik, for our Q&A session.

Thank you, Charlotte. Thank you, Frank, for the great presentation. I think this was very comprehensive, insightful and also detailed. I will hand it over to Emma to see if we have any questions.

[Operator Instructions] The first question comes from the line of Oliver Metzger with ODDO.

One question that I jumped in later about, on the medical education, it's clearly a great initiative. And I think it should have some interesting side effects as basically many patients of CKD are not aware of the disease. So it's more about also -- it's not an immediate financial question, but what's your guess? How much education among population is needed that at the end CKD might be identified earlier? And if this is the case, it should lead to a bigger market initially for PD. So can you share with us your views how the underlying, let's say, market for U.S. dialysis provider could be expanded if these education translates to higher rates?

So I'll take that question, Oliver, thank you. Chronic kidney disease is certainly part of this continuum that, depending upon the source of the injury to the kidney, can be identified relatively early but it's frequently identified in the general health care population. And so part of the education that occurs and is occurring is identification of instances of kidney disease that need attention and thought at an earlier stage. The opportunity within the value-based care environment is quite great to try to have impact on the recognition that CKD is so highly associated with cardiovascular disease that the earlier you identify it, the greater your opportunities are to protect the heart as the kidney disease progresses at whatever rate it will progress based on the underlying disease. So I think the pool of patients with CKD is as heavily influenced by the progression of chronic kidney disease. It's as influenced by the progression of cardiac disease as it is by the progression of the chronic kidney disease as to the number of patients it will progress. So our belief is that we have to insert ourselves at an earlier stage, especially in our value-based care arrangements, to recognize that the more we can, in fact, begin to connect and work with patients at an earlier stage, the better opportunity we have to keep their hearts healthy, to keep them healthy and help them make good decisions as their journey will continue because once you have chronic kidney disease, there are relatively few instances where it just completely goes away. It almost always has a progressive nature and that progression can be delayed and slowed by certain actions, but it certainly is one of the things that I think -- we think we have a responsibility to participate actively in. And so the education of our general health care providers to the need for identification of early-stage kidney disease, the opportunities to treat that at various stages and the ability, if there is progressive disease, to adequately prepare for those choices that patients have that will certainly help drive the adoption of home therapies, and therapies that patients may need as a key part of their therapy as well as the opportunities for people to be good candidates for transplant. So I think it's an important question. And I think that the population remains quite large that has CKD, and that population has continued to grow both in the U.S. and certainly outside the U.S.

Okay. One follow-up. So is education already part of some value-based plans or ideas? Or do you expect that to come in the future?

No, it's already part of the plans. There's quite a bit of work that is done both through our medical office, our operational teams and certainly our value-based care teams to work with the physicians that we see in practice to both identify patients that have CKD and with that identification to begin to look at how they are educated so that they become well prepared as their CKD progresses. And so our -- whether we are doing it through written communications, live events through webinars, live events in person when we've had the opportunity to do that in the past or broadcast live events, we have quite a few opportunities to get these messages out to our constituent providers and the health care systems that we work with, whether they're acute health care systems and hospital systems or whether they're actual nephrologists and providers in the community. We've also supported through the National Kidney Foundation and other groups this recognition that identification and the early appropriate treatment of chronic kidney disease is quite critical. As you know, there have been some newer medicines that have come on to the market that help improve the cardiovascular health and the kidney health of patients with certain types of kidney disease. And I think we're quite supportive of making sure that the medical community is well aware of those opportunities.

Okay. Great. Potentially 1 very, very last follow-up. On -- how do you get access to these patients? Because just from a layman perspective, many patients sit in home -- sit at home in front of television. And so don't move that much and don't go to a nephrologist for -- and how do you think is the best way to approach these potential patients?

Yes. So it's a good question. And I would tell you most of the patients that come into the network that we have are identified in a couple of ways, but they are predominantly related to having had a routine lab test that people will get at their general physicians. The serum creatinine test is a blood test that measures kidney function. And today, in many countries and certainly throughout the United States, every 1 of those tests is associated with the recognition of what the kidney function is. It's this estimated glomerular filtration rate or GFR. As that is reported, it identifies to the doctor that's ordered the test, whatever kind of doctor they are, whether they're a general practitioner, an internist, an obstetrician, it could be any type of physician, the recognition of whether this person's kidney function is reduced from what they're -- what would be expected for their age and so forth. So this is probably the trigger that gets most patients identified as something should be looked at. There are other tests that are seen in the urine and other methods of referral that are part of, again, routine screening. If protein is seen in the urine or blood is seen in the urine, they are frequently referred. But patients come to us predominantly through identification and referral from the general health care system. The other source is payers themselves. Payers are watching what's happening to the people that they are financially responsible for. And so there are a number of programs that we have engaged with payers that recognize and identify CKD patients. And these CKD patients then begin to come into this evaluation and assessment period as well as educational opportunity.

Next question comes from the line of Tom Jones with Berenberg.

I had 1 question maybe for Frank and 1 for Charlotte. Frank, just thinking about the slide you put up on enhancing patient power and patient choice. But when I'm thinking about site of provision of dialysis, we still tend to talk about it in terms of home or clinic. But I remember a couple of years back, we -- there's more of a discussion around site-agnostic care plans with a kind of more fluid movement between clinic, hospital, home and maybe even including skilled nursing facilities in the spectrum of sites where patients could receive dialysis. So I was just wondering kind of what's happened in the last year or 2 in terms of moving patients from a more sort of siloed approach to a more site-agnostic approach to their dialysis. I mean then my question for Charlotte, I think we can all see the metrics that you publish on your website. We can look at the incentives of senior management. But the question for me is, with the 100,000-plus employees, how do you drive sustainability right down to the bottom of the organization? Because unless the nurses detect the drivers and everybody else plays ball, then it's going to be very difficult for the company to achieve its goals. So I was wondering how you incentivize or what policies you have in place to really ingrain these sustainability targets right to the bottom of the organization.

Charlotte, do you want to go first, and then I'll answer Tom's first question?

Happy to do so. Thank you, Tom, for that question. And very true, there is a reason that we call our sustainability program a transformation program and that we say it's a sustainability journey. So right now, we have our ESG progress linked to the Management Board targets. But in the future, we are also looking into how we're going to link ESG to the long-term incentive plan for our top managers and we invest internally a lot into also awareness initiatives. So overall, for the program, for example, we onboarded more than 300 people explaining why we're doing it, what we are planning, what the benefit of the activities are and we increased the internal communication for our employees to report on progress, to explain the why and also to explain how they can contribute. And we have some very nice example also from individual employees who come up with idea that really help improve our sustainability performance. But it's certainly something that is part of a longer journey and that we continuously have to invest in to explain what sustainability means for our company and how it can help our long-term success.

No, I was just going to ask a brief follow-up to Charlotte. How are you finding -- driving out these initiatives across your business? You have a very global business and different countries tend to have very different views on ESG matters. So I just -- some countries are very forward-thinking, other countries a bit less so. So I'm just wondering how you deal with that in a business like yours, which has clinics in 40-plus countries and sales products in 140-odd countries?

Again, very true. That's the reason why our sustainability program is set up the way it is. It is -- the activities we're doing are developed bottom up. For all our focus areas, we have project teams, and all the project teams are with people from all regions on all global functions. And they jointly agree on the way forward. And then we have steering committees deciding on the activities before they are presented to our Sustainability Decision Board and our Management Board. So we want to make sure that we actually have to buy in from all regions and all from global functions and that we develop activities that are also implemented by everyone in the end. That takes some time because, obviously, it's an alignment with many people with different agendas, and we also want to make sure that their views are represented and also their local demands and local regulations have to be considered. But for us, it's the best way to come to results that actually are implemented later on and that actually will bring the progress we're hoping they will.

Tom, I'll address your first question, and I appreciate you having recalled that prior conversation that we may have had in the past, recognizing sort of the potential for site-agnostic care. In our view -- in my view right now, I continue to think that although we call it home dialysis, it's really about dialysis that is directed in great part by the patient and their family members or their friends that are supporting that particular care and the power and choice that they have to design, with their provider and nephrologist, the regimen that they undergo. I do think there's been progress tremendously, especially during this time of the pandemic, where we've advanced our connected health offerings, our telehealth offerings and our ability to support essentially the provision of this type of care in a nontraditional health care setting. And that nontraditional setting, there are examples, whether it's nursing home or whether it's a more communal environment that patients may go to for that or literally in their own home. I think all of those have advanced somewhat. We have been able to achieve the penetration of patients that are selecting a home type therapy, whether it's peritoneal dialysis or home hemodialysis, towards, I think, recent Helen reported that we had met one of our targets recently. And I continue to think that this is really important. One of the models that I've been very interested in and continue to follow closely and we wrote about it in one of the chapters of our annual medical report this year is -- comes out of the U.K. and it's called the shared care model. And the shared care model begins to break down a hemodialysis treatment into many component parts and identify what are those parts that a patient can be engaged in directly and what are those parts that can't. And we continue to see examples of where some of that activity is expanding and growing. So I still believe it's a key component of developing a more holistic strategy that fits into our home strategy.

Yes. And I guess the follow-up to that is partly an allied question is dialysis frequency. It's sort of been creeping up with more -- every other day or 5-day week dialysis. But do you have any numbers to hunt as to kind of what your average number of treatments per week has done maybe over the last 5 years? Because, I guess, obviously, those more frequent treatment regimens are only really deliverable if there's a significant home component to that patient's care plan.

Yes. I think the person-centered care model actually begins to drive that a little bit. So if you look at our home population, you will see that many more of those patients, their physicians and the patients feel like they benefit from the -- potentially some additional dialysis treatments a week because it protects their heart to some degree. When we see our other environments, we recognize also that on the other end of that spectrum, there is a medical debate that goes on right now about incremental dialysis starts that people should start and build up to the full force of what the traditional 3 treatments per week is. I've been very involved in trying to continue a discussion both internally to the company and within the field that I think there is a great degree of artificiality to the 3-day per week regimen. There's no physiologic basis for that. It was a convenience that occurred as part of the payment system many decades ago. And this long interdialytic interval that occurs over the weekend for people that are in center is a risk to them. It is a risk because it changes the rate at which they have cardiac remodeling because of the volume changes that occur on such a routine basis for them. So I think the issue of cadence in dialysis is a very topical one right now and under a fair amount of debate. I don't think -- I have a number in mind, but I'm not sure it's appropriate for us to report number of treatments on aggregate proportion per week. But I would tell you that I think it very much fits into a physician and patient working together to try to figure out what's the safest treatment, most reliable, going to deliver the best outcome for them. For some, it will be more than 3 treatments per week. And for some, it may actually be less.

Yes. Sure. And when we often talk about more frequent dialysis, the discussion often quickly moves into the -- whether they're on home or in center, whatever it may be. But is there any kind of technological shortcoming at the moment or challenge or barrier that toward -- to doing more frequent dialysis? I mean are there things with the setup process that patients have to go through, the cleaning, whatever? Are there things that -- I guess my question is are there barriers to more frequent dialysis adoption that you can address not just through the way the service is provided, but actually with the product side of the business as well?

So I would say the barriers that exist primarily today are barriers in the payment system, the service delivery, the logistics and the fact that it's an additional 2 needle sticks in somebody's arm or wherever their vascular access is per day that can create some potential trauma or other things for them. On top of that, there is the barrier of the patient's own inertia. If they are trained and it's incorporated in this very passive dialysis where they just go in 3 days per week, trying to convince them that it's in their best interest to avoid a potential problem by dialyzing even more often than that is quite difficult. The -- I would tell you the technology could support whatever -- the current technology can support whatever the frequency is that's prescribed by a doctor. And that technology is not the limitation on a -- on the basis. I do think there is more observation that we could continue to look at doing, looking at hemodynamics and cardiac physiology related to treatments and our ability to manage some of those parameters might actually select which patients need more frequent treatment than others. But that's work that's still sort of in process at this point to try to understand what are the best techniques to look at that and try to make that assessment.

There are no further questions registered on the phone. So I hand back to Dominik.

Thank you, Emma. We have actually 2 questions from [ Gemma from Veritas Investments ] via [indiscernible] in the webcast. Frank both are for you. The first one is, can you talk about Fresenius Medical Care's expertise and ability to influence health policy globally as they look to improve affordable access? That will be the first one.

Okay. So our ability to influence health policy, obviously, is dependent upon a whole variety of things. And I would tell you that the first among those is that we have to be credible within the field. We have to be not opinion-driven but data-driven. And when we are both data-driven and we pull the clinical evidence together that allows us to present a case to policymakers, wherever they are, they are obliged to respond to that, and they may respond and say, "Well, we just can't do any more than we can do." But if we can actually represent to them what organized health care can do and the benefits to society and a population, it gives us the opportunity to help some health care delivery systems recognize ways in which they might be able to mature their system. I would tell you, I think the influence is a very long-term strategy. This is not something we can say, I can go in and convince somebody of something and they're suddenly going to change the way we do it. I think we've got to bring to bear the larger picture and the longer term picture of how we bring innovation in health care to recognition that it's valuable and it's a fundamental change in the way delivery can occur. And I think one of our unique propositions as a company is that because we have both a focus that includes devices and products, medications that we're directly involved with and interested in bringing innovations to market and we have a network of patients in which they get access to those innovations early, we can, in fact, move the field a little quicker than it might move naturally on its own, I believe. I think we've seen that in a number of things that we've done related to anemia management. I think we've seen it in how we've advanced the sophistication of value-based care in the U.S. So I think we can -- we have good relationships with many governmental and regulatory agencies, and we have good relationships with many policymakers that are willing to actually listen to an honest conversation about what's happening in the field. But individually, do we -- can we go out and influence that policy to where we know what the end is going to be? Probably not. But I think we can, in fact, make a good, transparent and honest state of what is the affairs -- what is the standard of care and the state of affairs of medicine in this particular area, I think we are fairly credible in that area. We published scientifically last year. We had 162 peer-reviewed publications in the middle of a pandemic. So it's a substantial effort that we have to try to make sure that we are seen within the field not just as an industry participant, but something relatively unique. And I think in various parts of the world, the affordability side of that is challenged because the health care delivery systems are constrained by what the -- either the government payment system or the private payment system allows for. And it's our job to try to demonstrate what it could be for them and make sure they're aware of that.

Thank you, Frank. And the second question from [ Gemma ] is I'd like to hear more about the plans in transplant under the new Global Head of Transplantation. How does that fit into Fresenius Medical Care's business model?

Sure. So we know that within our value-based care programs, many of them, including the federal programs as well as private payer programs, there is distinct interest in understanding that transplant is a component part of that journey for a patient that has advanced kidney disease and ultimately develops end-stage kidney disease. In many cases, it's an optimal treatment for people, but it is not a treatment that goes on forever. So there's an imbalance in the supply and demand of organs. And so we, as a company, have recognized that we need to participate in the ability to at least understand and identify what some of the drivers are that might allow organs to be made more available or used more effectively in the transplant process and programs that exist. So our Head of Transplantation, Dr. Hippen, is -- recognizes that there's a lot of terminal things we need to do, both on the organ availability side and the organ procurement processes, and there are things on the care delivery side where we need to determine where we invest some of our resources in. So we've made some investments in some companies that are looking at novel therapeutic transplant opportunities to change the organ supply. We have been quite interested in following the work that's happening in xenotransplantation. We've recognized that there are a number of drugs in the pipeline that might actually impact acute kidney injury from cold ischemic time that occurs in disease donor kidneys. And we've also recognized that there is some high degree of health equity issue and variability in different parts of the world to access the transplantation that we feel we may well be able to provide some insights into and some understanding of how some of that might be able to be relieved in various communities of people. So we are at an early stage of identifying where the baseline is of our involvement, but it's both on the delivery side of care for people with transplant, making sure that the wait list management and patients are well prepared for that as a treatment option. It's how do patients who have a transplant and have to come back to dialysis safely do that and how do we begin to recognize not only where we invest but how we can support a more deeper interest in organ procurement and the ability to advance organ availability, both technologically and practically as a service. So all of those become things that ultimately will find their way into business interest that we have. But at this point, are really trying to simply recognize that we, because we know this patient population so well, need to be part of the conversation and part of bringing that field closer together with the areas of medicine that deal with patients with chronic kidney disease and end-stage kidney disease for the other types of therapies. And I think there have been good advances over the last 5 years and beginning to have open and honest dialogue with the transplant community, whether it's transplant centers and programs, organ procurement executives and, certainly, the transplant surgeons.

Thank you, Frank. That was actually quite helpful. I think we have no further questions right now. So with that, I would say thank you to both of you that you dedicated the time, Frank, Charlotte, for today and helping us to give a further detailed insight into person-centered care in our sustainability journey. And this was actually the final edition of our expert series for 2022. We hope you will join us again next year, the edition 2022. And with that, I would actually close the call. Thank you for joining, and have a good evening, afternoon. Thank you.

Ladies and gentlemen, the conference has now concluded, and you may disconnect your telephone. Thanks for joining, and have a pleasant day. Goodbye.