Chief Financial Officer at DaVita
Thanks, Javier. Despite the operating challenges Javier referenced, we delivered another quarter of strong results. Operating income was $475 million and earnings per share was $2.36. Our Q3 results include a net COVID headwind of approximately $55 million, an increase relative to the quarterly impact that we experienced in the first half of the year. As Javier mentioned, the latest COVID surge resulted in excess mortality in the quarter of approximately 2000 compared to fewer than 500 in Q2. We're also anticipating the mortality in Q4 to be higher than it was in Q2, although we've seen a decrease in the last few weeks that we hope continues. Our current view of the OI impact of COVID for the year is worse by approximately $40 million compared to our expectations from last quarter. For 2021, we now expect a total net COVID impact of approximately $210 million.
Treatments per day were down by 536 or 0.6% in Q3 compared to q2. The primary headwind was the increase in our estimated excess mortalities and higher mistreatment as a result of the COVID surge. In addition, the quarter had a higher ratio of Tuesdays, Thursdays and Saturdays, which lowered treatments per day for the quarter by approximately 300. In light of the current Delta surge, and the compounding impact of mortalities on our year-over-year growth, we believe that the timing of a return to positive nag will now be delayed into 2022.
Revenue per treatment was essentially flat quarter-over-quarter, patient care cost per treatment was up approximately $5 quarter-over-quarter, primarily due to higher teammate compensation and benefit expenses. This is the result of higher wages, additional training costs associated with an increase in our new hires and seasonality in healthcare benefit expenses, which we expect to continue into Q4. Our Integrated Kidney Care business saw an improvement in its operating loss in the quarter, which is due primarily to positive prior period development in our special needs plan. We continue to expect increased costs in Q4, especially in our projected CKCC markets, as we ramp up staffing in preparation for 2022.
DSOs for our US dialysis and lab business increased by approximately three days quarter-over-quarter, primarily due to fluctuations in the timing of billing and collections. Other loss for the quarter was 7.6 million, primarily due to a $9 million decline in the mark to market of our investment in Miromatrix. The value of this investment at quarter end was $14 million.
Now turning to some updates for the rest of the year and beyond. As I mentioned on the Q2 earnings call, we excluded any impact of a significant surge in COVID from the Delta variant in our revised guidance, but noted that a wider range of outcomes was possible depending in part on how a fourth surge would develop. Now that we've seen the impact of the Delta surge, we are increasing our estimate of COVID impact for the year by $40 million. Given where we are in the year, we are now incorporating this COVID impact into our revised adjusted OI guidance of $1.76 billion to $1.81 billion. We are also narrowing our guidance for adjusted EPS to $8.80 to $9.15 per share. And we are maintaining our free cash flow guidance of $1 billion to $1.2 billion, although there is some chance that our free cash flow may fall below the bottom end of the range, depending on the timing of our DSO recovery.
Our revised OI guidance implies a decline in our Q4 financial performance relative to Q3. This is partially explained by the incremental COVID mortality impact, and by expected higher salaries and wages for existing frontline teammates. Our guidance anticipates Q4 operating income to be negatively impacted by approximately $75 million of seasonally high or one-time items, including certain compensation expenses, elevated training costs, higher health benefit expenses, and G&A.
Looking ahead to 2022, the three expected headwinds I talked about on the Q2 earnings call remain. As a reminder, we expect to have added expense related to the greatest portion of the industry effort to counter the ballot initiative in California. We anticipate a year-over-year incremental investment in the range of $15 million as we continue to grow our ITC business. And we will also begin depreciating our new clinical IP platform, which we expect to be approximately $40 million.
A few additional things to help you with our thinking about 2022. COVID remains a big uncertainty. We are anticipating the end of the temporary sequestration suspension, which would be a $70 million headwind for the full year. We also expect that some of the costs that spiked during COVID, in particular PPE, may not return as quickly to pre-COVID levels due to the challenges of the global supply chain. Finally, COVID impact on mortality next year remains a large swing factor. Another winter surge would negatively impact treatment volume and could delay the timing of achieving positive NAG. However, if the recent surge proves to be the last significant COVID search, then we would expect a tailwind from lower than typical mortality, which could result in treatment growth higher than pre-COVID level.
In 2022, we expect net labor costs will increase more than in typical years as a result of market pressures. Our current estimate is a net headwind of $50 million to $75 million. We expect to offset a significant amount of these incremental costs, with continuing MA penetration growth above historical level, and strong management of non-labor patient care costs. From an operating income growth perspective, we expect 2022 will be a transition year with some significant but largely temporary headwinds to get through, after which we expect our platform to continue to support strong profit growth. While the range of potential outcomes for 2022 is broad, a reasonable scenario could result in an OI decline of $150 million from our 2021 guidance. This includes the impact from the expected ballot initiative, IKC and the increased depreciation. This scenario also includes a modest headwind from COVID, although there are scenarios where the impact of COVID could be significantly worse.
Looking forward to 2023, we anticipate a reversal of the net impact of these 2022 headwinds, plus incremental operating income growth, such that we expect 2023 operating income to show a low-to-mid single digit CAGR from the midpoint of our updated 2021 guidance, which would be in line with the multi-year outlook we have shared historically. We expect this to be the result of the lack of ballot initiative-related costs, the recognition of savings in IKC, an improved COVID situation, and continued growth of the core business. We'll have more to say about long term guidance at our Capital Markets Day in a couple of weeks.
Finally, during the third quarter, we repurchase 2.7 million shares of our stock and in October to date, we repurchased an additional 1.2 million shares.
Operator, please open the call for Q&A.