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DaVita (NYSE: DVA)
Q3 2024 Earnings Call
Oct 29, 2024, 5:00 p.m. ET
Summary of Discussion Points
- Opening Statements
- Q&A Session
- Conference Participants
Opening Statements:
Operator
Good evening. My name is Michelle, and I will be your conference facilitator today. [Operator instructions]. At this moment, we welcome everyone to DaVita’s third-quarter 2024 earnings call.
[Operator instructions] Thank you. Mr. Eliason, you may commence
Nic Eliason — Group Vice President, Capital Markets and Investor Relations
Thank you for joining our third-quarter conference call. Your interest in our company is appreciated. I’m Nic Eliason, the group vice president of investor relations. With me today are CEO Javier Rodriguez and CFO Joel Ackerman.
Please note that today’s call may include forward-looking statements according to federal securities laws. These statements carry known and unknown risks that may cause actual results to differ significantly from our expectations. For more information on these risks, please review our third-quarter earnings press release and our SEC filings, including the latest annual report on Form 10-K and quarterly reports on Form 10-Q. We base these forward-looking statements on currently available information and do not intend to update them unless legally obligated to do so.
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Please note, today’s call includes discussions of non-GAAP financial metrics. A reconciliation of these measures to the equivalent GAAP financial measures can be found in our SEC press release and on our website. Now, I will pass the call to Javier Rodriguez.
Javier J. Rodriguez — Chief Executive Officer and Director
Thank you, Nic, and thank you all for being here today. I want to express my gratitude for the hard work of our frontline caregivers as we provide excellent care to our patients while managing the challenges brought on by recent hurricanes and supply chain disruptions. Despite these hurdles, we continue to enhance operational efficiency and innovate across our care services. I’ll discuss our performance for the third quarter, provide a supply chain update, share insights regarding the upcoming CMS 2025 final rule, and end with a glimpse into next year.
As customary, I will begin with a clinical highlight. This quarter, we recognize the incredible resilience displayed by our patients and team during recent storms. Over the last month, Hurricane Helene and Hurricane Milton caused significant disruption, but the majority of our centers quickly reopened, with only one remaining affected. The dialysis community excelled in coming together to support those in need during these challenging times.
In response to the storms, our care teams across the nation mobilized resources. DaVita provided generators, water tankers, over 20,000 gallons of fuel, and deployed teams to conduct wellness checks and locate missing patients. Local leadership worked relentlessly to ensure all patients and staff were accounted for while coordinating urgent access to dialysis care. Our Asheville Kidney Center even opened on the Sunday following Hurricane Helene, utilizing backup power to serve patients from six surrounding facilities.
Along with others in kidney care, we extended treatment to anyone requiring care, regardless of their usual provider. Witnessing the dialysis community unite in support of patient care was truly inspiring. Our efficient emergency response underscored the significance of having ample resources and operational discipline. Even though the storms have passed, we continue addressing humanitarian needs, including food and housing assistance.
In the wake of these challenges, we collaborate with affected communities to aid in rebuilding efforts. I’d like to commend all teammates who have gone above and beyond for their colleagues and our patients. Furthermore, our suppliers faced disruptions because Hurricane Helene impacted Baxter’s North Cove facility, which supplies most of our peritoneal dialysis (PD) solutions and saline for hemodialysis treatments.
Baxter and other manufacturers have managed to maintain sufficient supply for our existing PD patients, albeit new patient onboarding has been temporarily halted. I am optimistic as we expect to resume new PD enrollments next month and anticipate supply stability returning in the first quarter. For saline, Baxter is currently able to provide approximately 60% of their pre-storm volumes as they work to restore the North Cove facility. Fortunately, we have secured alternative supplies to ensure patient safety and care continuity.
Although these challenges arose toward the end of the quarter, they had minimal effect on Q3 financial results. For Q4, we anticipate a financial impact ranging between $10 million and $20 million due to increased supply costs, fewer new PD patients, and decreased productivity among our home caregivers. This has been factored into our 2024 adjusted operating income guidance range, and we expect some of these effects to persist.
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Company Confident in Future Despite Current Supply Challenges
Expectations Surrounding ESRD Final Rule and Market Basket Update
As we look into 2025, the focus will be on the ongoing supply challenges. Now, let’s discuss the anticipated ESRD final rule from CMS, expected to be published soon.
This rule includes many elements, but two critical areas will capture our attention. First, we are looking at the market basket update, particularly how CMS addresses the new proposed wage index and the base rate. We recall that the proposed rule suggested an increase of about 2.1%. The second major aspect is the upcoming transition of oral-only drugs into the bundle starting January 1st.
This transition is a statutory mandate concerning oral-only drugs, mainly phosphate binders, which will move from the Medicare drug benefit to Medicare Part B. While CMS has clarified its intent for these drugs to be included in the bundle, we still await crucial details on initial reimbursement and unbillable items. We firmly believe this shift will enhance patient access to vital therapies. Nonetheless, some pharmaceutical manufacturers are lobbying for a delay in implementing this long-standing rule, while we urge legislators to prioritize patient access.
We are ready to support our patients through this transition. Regarding our third-quarter performance, we reported an adjusted operating income of $535 million and adjusted earnings per share of $2.59. We consider our third-quarter results straightforward, consistent with our firm commitment to delivering value this year. Although we continue to face challenges with treatment volume growth, our business proves resilient, offsetting volume pressures through margin expansion and strong results in our IKC and international sectors, all while investing in future growth.
Our cash flow remains robust, and we are adhering to a disciplined capital allocation strategy that includes returning capital to shareholders via share repurchases. Looking ahead to the full year, we are on track to meet or exceed our 2024 guidance, reaffirming our adjusted operating income guidance of $1.91 billion to $2.01 billion, which now accounts for the Baxter supply shortage.
Third Quarter Financial Performance Explained
While it is early to provide specific guidance for 2025, we recognize that many are looking ahead. Over the next few months, we will gather more information about key components like open enrollment, the inclusion of oral drugs, and integrated kidney care. We plan to offer formal guidance for 2025 during our fourth-quarter call, as per our usual schedule. Contextually, following tough years in 2021 and 2022 due to the pandemic, we are positioned to achieve our second consecutive year of double-digit adjusted OI growth, despite ongoing volume and labor pressures.
Going forward, we look to align our adjusted OI growth with historic growth patterns seen before the pandemic. I will now hand it over to Joel for further insights into our financial results and outlook.
Joel Ackerman — Chief Financial Officer
Thank you, Javier. For the quarter, we reported an adjusted operating income of $535 million, adjusted EPS of $2.59, and free cash flow of $555 million. Let’s delve deeper into the Q3 results.
Treatment volume per day remained steady from the previous quarter, matching our forecasts due to strong admissions balanced with elevated mortality and slight increases in mistreatment rates attributed to adverse weather, particularly Hurricane Beryl in July and Hurricane Helene in September. Despite these challenges, we remain confident our full-year treatment volume growth will fall between 0.5% and 1%. Revenue per treatment rose by more than $4 compared to the second quarter, aligning with our expectations.
Our revenue cycle performance has maintained strong RPT results throughout the year, with growth projected between 3.5% and 4%. Patient care costs per treatment saw a $2 increase, primarily impacted by ongoing labor cost pressures and higher medical benefits in the quarter.
General and administrative costs rose by $19 million due to normal quarterly fluctuations. Depreciation and amortization also increased by $11 million in Q3 versus Q2, primarily due to higher costs from center closures. On the international front, operating income saw a slight rise due to strong operational performance, although foreign exchange negatively impacted results by $4 million. In our Integrated Kidney Care segment, adjusted operating results increased by $32 million sequentially, driven by lower costs in our special needs plans and shifts in revenue recognition related to the CKCC government program.
For accurate evaluation contexts, we advise taking a yearly look at IKC performance, considering its typical quarterly volatility. We anticipate IKC will incur an operating loss of approximately $50 million for the full year. Regarding debt, third quarter expenses were $37 million higher than Q2 due to two main factors: the expiration of our 2% interest rate caps and the additional debt raised in August. Following our second quarter earnings call, we successfully completed two debt transactions worth $2.1 billion, using proceeds to repay a Term Loan B, shifting our nearest debt maturity to 2028.
As of the end of Q3, leverage stood at 3.17 times EBITDA, slightly above Q2 but still below the midpoint of our target range of 3 to 3.5 times EBITDA. We utilized $2.7 million in share repurchases during the third quarter, with an additional 600,000 shares repurchased thus far in October. To close, as noted by Javier, we are reaffirming our adjusted OI guidance range of $1.91 billion to $2.01 billion.
Even with anticipated impacts from hurricanes in the fourth quarter, we expect our ongoing operating momentum to counterbalance these challenges. Our adjusted EPS range remains between $9.25 and $10.05, and we anticipate free cash flow of $950 million to $1.2 billion. While it is premature to provide specific guidance for 2025, we recognize a few potential unique influences. Elevated mortality rates are expected to persist, and the Baxter facility closure’s impact will continue into 2025, along with the full-year effect of expired interest rate caps affecting EPS.
Positive influences may include declining center closure costs and the beneficial impact from our international business in Latin America. Additionally, if pharmaceutical companies do not succeed in delaying the inclusion of oral drugs in the bundle, it could serve as a tailwind. We predict that both RPT and patient care cost growth will be higher than pre-COVID levels. We will provide an update on these factors, along with clearer guidance, during the Q4 earnings call.
That concludes my prepared remarks for today. Operator, please open the call for Q&A.
Questions & Answers:
Operator
[Operator instructions] Our first caller is Andrew Mok with Barclays.
Analysis of Hurricane Impact and Future Financial Projections at Company
Andrew Mok — Barclays — Analyst
Good afternoon. The operational changes implemented to navigate the hurricanes sound extensive, but most effects will manifest in Q4. I wanted to clarify how much the hurricanes affected Q3 treatment volumes.
Additionally, Joel, I believe you mentioned an expected full-year treatment growth of 50 to 100 basis points. This suggests a substantial acceleration in the fourth quarter despite the hurricanes’ effects. Could you elaborate on this and reconcile those statements?
Joel Ackerman — Chief Financial Officer
Thanks, Andrew. For Q3, I estimate the impact from the hurricanes was around 10 basis points, notably appearing in the mistreatment rate. As for Q4, while there may be some impact, it is likely to be less significant than the 10 basis points we’ve observed so far. However, the quarter isn’t over, so we may encounter additional challenges.
Andrew Mok — Barclays — Analyst
So, we do not anticipate hurricanes will significantly affect Q4 volumes?
Joel Ackerman — Chief Financial Officer
Exactly, it’s likely to be less significant than the previously mentioned 10 basis points.
Andrew Mok — Barclays — Analyst
Understood. I appreciate your insights on the challenges and opportunities for 2025. Can you specify the scale of these factors, particularly regarding the financial implications of including phosphate binders in next year’s results?
Javier J. Rodriguez — Chief Executive Officer and Director
Starting with the phosphate binders, we faced challenges providing a useful estimate due to limited information. Several dynamics are at play. Notably, a class of drugs known as phosphate binders will be critical in our oral drug bundles. However, we are awaiting government guidance on reimbursement rules, which could change our forecasts. Additionally, pricing and mix differences across the four products complicate the situation, particularly between branded and generic options. Some patients, approximately 10% to 15%, do not participate in Medicare Part D, which could affect access. Given these variables, our projections can vary significantly. We anticipate clearer insights in the next quarter.
Joel Ackerman — Chief Financial Officer
To follow up on your first question, I identified several factors impacting operating income: three tailwinds and two headwinds, in addition to interest expense, which primarily affects EPS. Each factor involves uncertainties, so quantifying them separately is challenging. However, a reasonable estimate is that these headwinds and tailwinds will largely offset each other on the operating income line.
Andrew Mok — Barclays — Analyst
So, when considering the target growth of 3% to 7% pre-COVID, that accounts for both tailwinds and headwinds?
Joel Ackerman — Chief Financial Officer
Yes, that is correct.
Operator
Our next caller is A.J. Rice with UBS. You may proceed.
A.J. Rice — UBS — Analyst
Thank you. Hello, everyone. I believe I know the answer, but I want to confirm. The $10 million to $20 million impact from the hurricanes is likely regarding EBITDA rather than revenue, correct?
Additionally, last quarter you mentioned treatment patterns returning to pre-pandemic levels. How does this quarter compare? Is the trend stronger or the same? Also, regarding elevated mistreatment rates, is this effect solely from the hurricanes, or are there other contributing factors? Lastly, could you clarify the prolonged mention of mortality rates extending into 2025?
Joel Ackerman — Chief Financial Officer
To clarify, the hurricane impact in Q4 will primarily affect EBITDA, with a small possibility for revenue loss if patients shift to another provider for peritoneal dialysis.
On the factors affecting volume: there’s nothing new regarding admits, which remain consistent with past trends. The mistreatment rate historically averages about 6% annually, with variances across quarters. The 10 basis points added by storms is higher than what we would typically expect, but it isn’t the entirety of the mistreatment rate. We haven’t encountered new information affecting our 2025 mortality view; the continued elevated rates inform our expectations, but no recent findings have significantly shifted our outlook.
Operator
Next, we have Pito Chickering with Deutsche Bank.
Pito Chickering — Analyst
Good afternoon. I want to revisit the non-acquired treatment growth numbers. Can you provide figures for the number of new patients added in the first three quarters? Additionally, how many patients have been lost to transplants this year? Any insight on patients shifting to other centers or regions would be helpful. I’m trying to understand treatment growth in light of the delayed USRDS data on incidence and prevalence.
Javier J. Rodriguez — Chief Executive Officer and Director
Thank you, Pito. Let’s approach this broadly…
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During a recent financial call, executives at DaVita discussed ongoing trends in patient volumes and treatment rates. The conversation revealed that while there are fluctuations in the data, the overall mix appears healthy.
Joel Ackerman — Chief Financial Officer
In response to questions about the company’s performance, Ackerman noted that quarterly volumes experience natural volatility. He indicated that a decrease of 60 basis points in the quarterly NAG—Net Admission Growth—should not be interpreted as a substantial trend. According to him, it reflects temporary factors like treatment rates and census timing during the quarter.
Pito Chickering — Analyst
Chickering inquired about the annual reconciliation with payers. He expressed concern about recent market volatility and how it might affect DaVita’s operations.
Joel Ackerman — Chief Financial Officer
Ackerman reassured listeners that the company remains on track for the year, maintaining its original guidance of a negative $50 million for the year, a figure confirmed throughout the year despite payer market fluctuations.
Pito Chickering — Analyst
He further asked about the timing of annual true-ups with payers, to which Ackerman confirmed that they are progressing as expected during the third and fourth quarters.
Pito Chickering — Analyst
Chickering then shifted gears to discuss price increases for 2025, curious if they align with historical patterns.
Javier J. Rodriguez — Chief Executive Officer and Director
Rodriguez responded that everything is progressing normally and within expectations.
Operator
Next in line to ask questions was Lisa Clive from Bernstein.
Lisa Bedell Clive — Analyst
Clive sought insight into volume growth patterns, specifically how the anticipated growth for 2024 might change given previous estimates of 0.5% to 1% growth. She also requested information about the economic structure of IKC reimbursements.
Joel Ackerman — Chief Financial Officer
Ackerman affirmed the continued outlook for a growth range of 50 to 100 basis points for 2024. However, he promised to provide further insights regarding the economic split of IKC reimbursements later.
Operator
Next, Joanna Gajuk from Bank of America joined the conversation.
Joanna Gajuk — Analyst
Gajuk echoed interest in DaVita’s volume expectations for the next year and the ultimate goal of achieving 2% same-store growth.
Joel Ackerman — Chief Financial Officer
Ackerman detailed that future growth largely revolves around mortality rates. He explained that starting from the current year’s volume base of 75 basis points allows for modeling potential growth, taking into account various headwinds and tailwinds that could arise next year.
Ackerman identified clinic closures and issues with PD (Peritoneal Dialysis) from Baxter as possible challenges, but he balanced that with the potential for favorable conditions as those factors evolved over time.
Joanna Gajuk — Analyst
She asked for clarification regarding DaVita’s home dialysis mix, specifically the distribution between PD and Hemodialysis.
Javier J. Rodriguez — Chief Executive Officer and Director
Rodriguez reported that DaVita’s PD mix remains steady at approximately mid-15%, while Home Hemodialysis (HHD) is around 2%. He acknowledged the important role that Baxter and government partnerships play in ensuring that patients receive necessary supplies.
Joel Ackerman — Chief Financial Officer
Ackerman elaborated on the patient retention strategy, emphasizing that many new patients are already receiving treatment within DaVita clinics. He expressed confidence that most of these patients would be satisfied to defer transitioning to PD without experiencing major disruptions.
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Financial Insights Reveal Challenges and Projections for Next Year
Joanna Gajuk — Analyst
That’s valuable information. If I may ask another question regarding next year’s expectations. Based on your earlier comments, do you anticipate RPT growth for next year to remain elevated? Should we consider the current guidance of 3.5% to 4% as a benchmark for next year? Or is it likely to change slightly?
Joel Ackerman — Chief Financial Officer
It’s premature for a quantitative forecast, but I would estimate it to be lower than that range.
Joanna Gajuk — Analyst
Understood. So you’re suggesting it will be notably lower than 3.5% to 4%, yet still above your historical averages?
Joel Ackerman — Chief Financial Officer
Yes.
Javier J. Rodriguez — Chief Executive Officer and Director
This is Javier. I want to clarify my previous comment: 15.5% represents our total home patient mix, comprised of 2% for HHD and around 13% for PD. I hope that clears things up.
Joanna Gajuk — Analyst
Thanks for the clarification on the 13% PD.
Operator
Our next caller is Ryan Langston with TD Cowen. Please proceed.
Ryan Langston — TD Cowen — Analyst
Hi, thank you. I noted in the release that advocacy costs rose in Q3. However, they had decreased year over year in Q2. Could you elaborate on the reasons behind this increase?
Javier J. Rodriguez — Chief Executive Officer and Director
We have various factors contributing to our advocacy costs. Key drivers include developments in California and upcoming elections, as well as ongoing initiatives concerning patient restoration in Washington, D.C. We are also responding to pressure from pharmaceutical companies seeking to delay the inclusion of oral medications in the payment bundle, which has necessitated educational efforts in Washington.
Ryan Langston — TD Cowen — Analyst
Thank you for that information. Regarding the missed treatments, we’ve seen elevated rates for two consecutive quarters due to weather impacts. Assuming we don’t encounter further hurricanes or significant weather events, will treatment rates revert to historical levels?
Joel Ackerman — Chief Financial Officer
The rate of missed treatments remains elevated compared to pre-COVID times. While we expect it to gradually decrease, the exact pace remains uncertain. Keep in mind, these rates typically rise seasonally in Q4, so without new storms, we still anticipate some increase in missed treatments during that period.
Operator
Our next caller is Justin Lake with Wolfe Research.
Justin Lake — Analyst
Thank you. Returning to your discussion of headwinds and tailwinds, I noticed you didn’t mention RPT’s contributions for the annualized growth in 2024. According to my calculations, it appears you expect an increase from 2.5% to 4%. Doesn’t the strong growth in the second half of ’24 translate into a favorable tailwind for 2025? Are there elements I’m overlooking?
Joel Ackerman — Chief Financial Officer
Your calculations are accurate, and we stand by our analysis. There has been a lot of discussion on how to categorize unique headwinds and tailwinds. While we acknowledge the expected increase in RPT next year, we intentionally refrained from labeling it as a specific headwind or tailwind.
Justin Lake — Analyst
Understood. About the $135 million interest expense, should we consider this a solid baseline figure, or might it rise going into 2025?
Joel Ackerman — Chief Financial Officer
I consider this $135 million a reasonable benchmark. Our caps for next year are expected to be slightly lower than this year, suggesting a potential decrease in this figure over time. To clarify, the total for the year would be about $270 million.
Justin Lake — Analyst
Just to clarify, I was asking more about the sustainability of the number than a year-to-year comparison.
Joel Ackerman — Chief Financial Officer
I apologize for the confusion. The $135 million for the quarter appears reasonable for the near future. We’ve seen a mix of rising debt and stable caps, so substantial fluctuations are unlikely.
Justin Lake — Analyst
Thank you. Do those caps have defined expiration dates, or are they at a rate that allows for easy renewal? If they do expire next year, how does the current interest rate environment look?
Joel Ackerman — Chief Financial Officer
We’ve adjusted our strategy. Instead of having a set expiration, we now implement rolling caps. This means we won’t experience significant shifts like before, and adjustments will happen gradually based on prevailing interest rates.
Justin Lake — Analyst
Got it. Lastly, did you mention the mix for the quarter compared to the 11% from last quarter in the commercial market?
Joel Ackerman — Chief Financial Officer
No significant changes have occurred in our mix figures this quarter compared to previous reports.
Operator
Next, we have Andrew Mok from Barclays. Please go ahead.
Andrew Mok — Barclays — Analyst
Thank you for taking my call again. I’d like to follow up on G&A expenses. I observed a 7% sequential increase and a 10% rise year over year. What were the primary factors contributing to this increase?
Javier J. Rodriguez — Chief Executive Officer and Director
The rise in G&A expenses stems from several initiatives, notably investments in IT infrastructure. Additionally, increased wage costs and investments in our reimbursement operations have also played significant roles in the overall increase.
Andrew Mok — Barclays — Analyst
Thank you for the explanation. Regarding the commercial mix, how much of that is made up of ACA exchange plans within the reported 11%, and what growth trends are you witnessing in the ACA exchanges this year?
Javier J. Rodriguez — Chief Executive Officer and Director
Just to clarify terminology, I believe you are referring to QHPs…
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DaVita Updates Investors on Performance and Future Projections
Overview of Underrepresentation in QHPs
DaVita has noted its underrepresentation in Qualified Health Plans (QHPs). The company’s mix is around 7% to 8%, while the general population stands at approximately 3%. This discrepancy is largely due to patients selecting Medicare, which disqualifies them from QHP participation.
Growth Rate in Payer Class
Andrew Mok — Barclays — Analyst
Can you provide insights on the growth rate within that payer class?
Javier J. Rodriguez — Chief Executive Officer and Director
We are experiencing growth that aligns with the overall market. The trends we’re observing show our performance tracking closely with market developments.
Depreciation Outlook for 2025
Operator
Now, we will take a question from Pito Chickering at Deutsche Bank.
Pito Chickering — Analyst
Hi, can you clarify whether depreciation is expected to be a tailwind for next year’s earnings per share (EPS)?
Joel Ackerman — Chief Financial Officer
Yes, while I didn’t quite catch your first question, depreciation is likely to be flat or slightly down. This reflects the decreasing number of center closures. Aside from that factor, we expect depreciation to remain stable.
Analysis of Facilities and Financial Challenges
Pito Chickering — Analyst
Just doing some rough calculations, I recognize the mortality issue impacted us negatively. However, with the rapid ramp-up of facilities, I believe most of this will be evident in the initial quarter. Regarding interest capital, it seems like a straightforward calculation, and center closures are similarly straightforward.
Looking ahead, the variability lies in how the bundled payments play out. Will there be more headwinds or tailwinds based on the decisions made around the bundle?
Joel Ackerman — Chief Financial Officer
Can you clarify your question about whether the bundle will present headwinds or tailwinds?
Pito Chickering — Analyst
Certainly. I understand the need to analyze both the headwinds and tailwinds related to the bundle. Ultimately, the bundle’s direction will significantly impact our outlook.
Joel Ackerman — Chief Financial Officer
I believe you may be underestimating the variability in some of these factors. The outcomes could lean towards either a positive or negative impact for us, depending on how circumstances develop.
Closing Remarks
Operator
Thank you, we will now conclude the call. Please proceed with your closing comments.
Javier J. Rodriguez — Chief Executive Officer and Director
Thank you for your interest in DaVita. I would like to recognize the dedication of our care teams. Although we will incur additional expenses related to recent storms, we expect to manage these costs effectively through our continued strong performance. As discussed, while mortality rates are elevated, our investment in personnel and infrastructure has restored our operating income to pre-pandemic levels. Thank you, and take care.
Operator
[Operator signoff]
Duration: 0 minutes
Call Participants:
Nic Eliason — Group Vice President, Capital Markets and Investor Relations
Javier J. Rodriguez — Chief Executive Officer and Director
Joel Ackerman — Chief Financial Officer
Andrew Mok — Barclays — Analyst
A.J. Rice — UBS — Analyst
Pito Chickering — Analyst
Lisa Bedell Clive — Analyst
Joanna Gajuk — Analyst
Ryan Langston — TD Cowen — Analyst
Justin Lake — Analyst
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