Intuitive Surgical, Inc. (ISRG) JPMorgan Healthcare Convention Name Transcript

Intuitive Surgical, Inc. (NASDAQ:ISRG) JPMorgan Healthcare Convention Name January 10, 2024 12:00 PM ET

Firm Contributors

Gary Guthart – CEO & Director

Brian King – Head, IR

Jamie Samath – SVP & CFO

Convention Name Contributors

Robert Marcus – JPMorgan Chase & Co.

Robert Marcus

Good morning, everybody. Pleased to proceed day 3 of the JPMorgan Healthcare Convention. I am Robbie Marcus, the Medtech Analyst. Actually happy to introduce our subsequent session. CEO of Intuitive Surgical, Gary Guthart, will do a fast presentation, then we’ll be a part of him on stage for Q&A. Gary?

Gary Guthart

Good morning. Pleased to be with you right here in the present day. And Robbie, thanks for the chance to talk. As you realize, we’ll be discussing some issues which might be forward-looking. We encourage any of you to go to our web site on the Buyers part and evaluation our disclosures and SEC filings. For these of you who have not adopted our firm, our mission is fairly simple. We predict that minimally invasive care and acute interventions, people who occur in skilled healthcare environments are necessary, that we will enhance them utilizing superior applied sciences and that there is a important want to enhance them.

And, we predict that these enhancements may be substantive, not a few % right here or there, however transformative. And we predict that there is an urgency to it. We predict it may be profoundly higher than it’s. We have been at it. The corporate was included in December of ’95. We have been at it for a while, and I believe we’re nonetheless in the long run of the start, not the start of the tip, and we’ll speak somewhat bit about that.

This final yr, our clients used our merchandise in one thing over 2.2 million procedures within the yr. Whole expertise on da Vinci platforms is now over 14 million. It continues to be an lively topic of scientific analysis, the overwhelming majority of which isn’t sponsored by us. We do sponsor analysis. The mass — the database is pushed nearly solely independently of Intuitive. And I believe each of these issues are actually wholesome. I believe it is wholesome for us to speculate. And I assume it is wholesome for folks to evaluate independently.

We had an excellent yr in placements. We are actually 3 completely different {hardware} platforms, our multiport platform. Over 1,300 placements are versatile bronchoscopy platform, Ion, over 200 placements in our single-port slender entry surgical procedure system, SP at over 50. Whole put in base of methods now over 9,100. Multiport at over 8,000, Ion at over 530 and Single port over 170. So beginning to get thrilling. 2023, I might like to make use of this convention as somewhat little bit of a glance again after which look ahead. Yearly has its power and its challenges. I believe readability on these issues is de facto necessary for our group, and I might prefer to share it with you I will not learn the goals. For these of you who have been with us, you realize them, there have been some challenges.

There was a big quantity of environmental uncertainty in China. A few of it was regulatory, a few of it was round pricing regulation of your entire well being care discipline. And that put some strain on our enterprise in China relative to our hopes and plans at the beginning of the yr. We have now these new platforms. They got here with some extra manufacturing challenges than I’d hope. That is somewhat bit off par for the course with advanced applied sciences. We have now extra scrap prices and a few margin — product margin pressures within the yr. We’re working them down. They’re advanced — these are advanced provide chains. I truly assume that there is excellence and aggressive benefit in resolving them. However they take focus and energy, and we’re centered and are exerting effort to resolve them.

We began the yr talking to all of you concerning the impression of GLP-1s on bariatric surgical procedure. And that has continued by the yr. The close to time period, we nonetheless proceed to see a deceleration of bariatric surgical procedure with the rise of GLP-1s. What which means for future years will likely be resolved. We are able to speak — I am certain we’ll discuss it one other time. However the deceleration hasn’t stopped, we’re nonetheless rising, but it surely’s decelerating. And in our versatile bronchoscopy area, our installs have truly been restricted by our availability of producing quantity for the components which might be utilized in each case, the consumables, that is the catheter. We’re the constraint. We’re working extremely laborious to resolve these sense of constraints.

I am truly fairly happy with the progress we’re making right here within the fourth quarter. However we may have put in additional methods, have we had extra catheters, however we didn’t need to set up methods after which be inadequately then with the quantity of product they should develop their packages on the tempo they needed. We did not need to get in a scenario the place we had extra methods out than we had catheters to provide, in order that throttled us somewhat bit within the yr, we’re beginning to work by that and are available out the opposite aspect.

We did have areas of power. Basic surgical procedure procedures in the USA grew very properly. I am certain we’ll discuss it extra. The efficiency in Europe and in Japan was actually heartening within the final yr, for these of you of you who’ve adopted us, we invested so much to get there. These aren’t single-year turnarounds, you make investments to do it. These are multi-specialty groups that we have now put in, and I am simply happy with them. I believe they’ve performed a fantastic job. We’re beginning to transfer Ion and SP into areas outdoors the USA. We’ll contact on that somewhat bit.

And System placements are robust, not simply in the USA. We predict that these items matter globally, and we prioritize which international locations we predict are in an excellent place to just accept them, and that has labored out properly for us actually within the yr.

In process tendencies, we noticed a rebound submit pandemic 22% process development within the yr. You’ll be able to see the splits between type of the massive classes, urology and gynecology and also you see now that basic surgical procedure is the most important of the classes globally. Trying into 2024, we predict we’ll see between 13% and 16% development, you will have an opportunity to speak to Jamie Samath and Brian King shortly they usually’ll let you know the whats and the whys are behind that.

Worldwide capital system placements yearly, you possibly can see incremental or greenfield at nighttime bar on the left and within the gentle bar, these are trade-ins. That is in our multiport product line that da Vinci XI, our fourth technology system was launched in 2014. We adopted with a worth mannequin known as Vinci X a few years later.

So trade-ins, these are properly penetrated. I am going to present you within the subsequent slide, however that appears like put in base grew 14%. So 22% process development, 14% put in base development, simply do the fast math and also you’re seeing utilization development go up. That could be a implausible factor. So procedures per system per yr, that is an estimate of worth and return on funding for our hospital clients. We prefer to see that advance, and that is been good.

As you play by, that is what income has performed. So good procedures, good system placements that interprets to development in income. Income development charge is just not as quick as process development charge and capital set up charge, partially as a result of we’re doing the next mixture of risk-sharing preparations and leasing in our capital portfolio. I am certain it is one thing we will speak to you about later. That implies that the combo of recurring income, that income that we’re paid on when folks use our merchandise has elevated through the years. That is been intentional on our half. We predict that, that aligns us properly with our buyer. It removes capital acquisition boundaries after they need to construct their packages. And so we’re happy with this quantity. It’s not with out trade-offs.

Whenever you do transfer to leasing versus gross sales, it isn’t a uniformly great point, however we predict these trade-offs are properly managed and understood. For those who type of zoom out and say, what are the expansion drivers, 22% development on a pretty big base, that is fairly good efficiency. The place is it coming from? Yr-over-year development outdoors the USA in segments outdoors of urology, which is beginning to turn out to be penetrated are actually 35% so actually wholesome development. 25% U.S. basic surgical procedure development. So that you’re each the most important class and amongst the quickest rising. In order that’s a uncommon occasion, and we’re happy. And all the things else that is not in these classes rising fairly properly, too. So it is a multi-segment development alternative for us.

Sizing the market, we are usually extra conservative on this than a few of our friends. Let me let you know what it’s and the way we predict. So the very first thing is for merchandise in the marketplace in the present day as we stand right here in January of ’24, with the clearances we have now within the international locations by which we function, we predict there are, give or take, 7 million sufferers yearly who — for whom this might be an excellent resolution, the economics work, the healthcare system can take up it. So we have been at 2.2 million. That is — for those who say, properly, what are you engaged on? We’re believers in innovation. We have now a strong innovation pathway, issues in improvement already or issues in our analysis labs. We predict we will develop that chance yearly to be about 21 million, however that is one of many issues that we’ve not delivered to market but. For these of you who’re modeling, I’d not mannequin all the things the identical on the 21 million as you do on the 7 million. These are the issues we work on.

So we predict there is a future alternative, and we’re excited to pursue it. Once more, I believe we’re upside. We’ll converse somewhat bit to one of many issues we have been doing. It has been on a really good development curve and that is versatile bronchoscopy. Everyone knows lung most cancers is a severe world challenge. Lung most cancers detection stays a big unmet want. That is simply roughly talking, estimated incidence of lung most cancers by area. We have now our Ion System, versatile bronchoscopy. First indication is biopsy for distal lesions within the lung. So we’re cleared and making good progress in the USA. We’re cleared in Europe simply beginning our Section I launch. We’re within the U.Okay. now. We’re cleared now in Korea, only a current clearance, and we’re on the pathway, we’re submitted in China and getting enthusiastic about what that may supply us over time.

So that is what Ion has performed. As I stated earlier than, multiport, that is the usual, or the da Vinci system you are used to. Ion is rising properly and continues to get good uptake placements on high utilization on backside, main robotic bronchoscopic system available in the market.

SP, single entry procedures. SP has been available in the market somewhat bit longer. Due to our interactions with our world regulators, the best way they view it has been somewhat completely different than they’ve with da Vinci multiport and so we want further indications. However you are seeing an acceleration in placements, we’re truly seeing some good uptick in development in procedures, once more, 48% process development in 2023.

So research and submissions, we accomplished our accrual and are engaged on the submission for the colorectal IDE. We accomplished that in ’23 for Thoracic IDE. We accomplished that accrual. We have now breast oncology, nipple-sparing mastectomy, IDE in flight that’s nonetheless accruing, and we have now current clearances, BPH clearance in Q1 of ’23 in the USA, we have now broad clearances in Korea and now Japan, and we anticipate a broad European clearance on this first quarter of 2024. So we’re beginning to have the ability to get the regulatory area, the regulatory clearance is required to drive this as a multi-specialty platform. We’re fairly happy with system efficiency.

Unmet want. So let’s simply speak. After we exit and speak to our clients, that is from the American School of Healthcare Executives and ask them what’s on their thoughts, that is what they arrive again with. This high 4 is roughly what you hear all around the world when speaking to healthcare methods, they reorder somewhat bit by which nation you are in. Our workforce challenges stay a severe concern, each availability of staffing turnover and prices. Monetary challenges as pandemic monetary help for healthcare methods has been drawn down, monetary challenges have gone up.

In the USA, behavioral well being and dependancy points are on the rise. And naturally, at all times on the record affected person security and high quality of end result, one thing we care so much about. We focus our group by how we will truly do that, how can we assist on this manner I believe we have now demonstrated that we may help in all of them, and we proceed to drive it. So after we sit down with hospital C-suites, we begin right here. We all know you are engaged on this, how can we provide help to? After which we go from there.

adoption. You concentrate on our platforms, and we have now all the things from fairly well-established platforms like our da Vinci platform to newer ones like Ion, the development that goes on for our hospital buyer is, first, they take a look at what we’re saying they usually say, “I’m willing to adopt. So I’m going to put it into a pilot program, let’s see what you can do”. That is how they begin. And because it begins to look good and if we ship on our claims they usually begin to see proof that we will impression these issues that I simply confirmed you, then they’re going to purchase one other one, they usually’ll begin to operationalize it.

So this sort of thought of going from 1 to 2 is a giant step. One, they purchase on perception and, two, they purchase on proof is fairly thrilling. So how are we doing? Nicely, for those who take a look at built-in supply networks that personal 20 or extra, these are subtle organizations, they’re company, they’ve analytics capabilities that we associate with them on. How are their packages going? That is the expansion charge of IDNs who personal 20 or extra da Vinci methods of their portfolio. It is rising at 22% as of This fall of 2023, and single buildings, a single hospital constructing with a number of ORs, what number of have 7 or extra? I am undecided that after I noticed, I began in April 1996, I am undecided that 7 was a magic quantity. I would not have thought that. However you stroll by OR1, OR 2, OR3, they usually all have a da Vinci all the best way as much as 7. What number of, that is rising at 48%.

So there is a level at which they standardize. It is not unknown. It is not a threat for them. It is the best way they need to do their enterprise. And to do this, you need to present scientific worth, you need to present working worth and working excellence, and you need to present ROI in order that it is economically possible. So we glance to this as a result of it is proof of what they do, not what they are saying.

One of many issues that we have been engaged on, we have been within the Web of Issues for surgical robots for about 13 years now. We began our AI efforts possibly 7 years in the past. So how will surgical information science, that is how we like to consider AI, quite than utilizing the buzzword. Let’s discuss what we predict it means to us. How is the surgical information science goes to assist?

I believe it will be fascinating. I believe it is highly effective. I believe will probably be messy. Will probably be an fascinating decade and I believe will likely be exceptionally highly effective by the tip. However let’s discuss what the necessity is, and let’s discuss the place Intuitive is concentrated within the area. So the wants are fairly simple, plain phrases, proper? To begin with, AI/ML, huge studying, huge information, these are all instruments. They don’t seem to be goals. They are a device in help of a necessity — enhance affected person care by higher outcomes. There may be enormous variability in affected person end result. Not each surgeon can get the identical end result as the easiest and the easiest have alternatives as properly. You take a look at the supply of well-trained care groups in most economies, they usually’re brief and it is getting worse as a result of the demographics of most of our societies are growing older.

So that you’re growing older out your educated care groups and your affected person inhabitants, which incorporates all of us, is on the point of want extra care. So that you want higher care groups sooner. We sit with our groups and go — look the targets higher to care groups sooner. How are we going to do this? What can we do?

And the final one is monetary strain. Similar factor, demographic points are going to place strain on consumption of care, fewer staff, extra folks consuming care, we bought an issue. So if we do not begin getting a manner towards decrease consumption of sources on a per-episode foundation, you are going to be harassed. So that is what the necessity is. That is what we must be focusing on these investments in direction of.

All people has one thing to say about AI today since you all are enthusiastic about it, and due to this fact, everyone has to place it of their speak. Let’s discuss what we predict we will do. Why are we ready to do one thing? We do analytic investments the place we take a look at mixed information units of what we carry and what our hospital clients carry. We did greater than 1,000 of these in 2023. Our merchandise are high-tech, interconnected, cloud linked ecosystems with 99.9% uptime. I might like that to be higher, however it isn’t trivial to get to 99.9% is implausible. I believe our clients belief us.

We do workflow consulting. We get in there to grasp effectivity, how we may help them. We work with their groups. We do not ship them white papers from California and hope to get it. We deploy our groups into their environments to assist them get what they want. We did that over 3,300 occasions within the yr. The put in base now could be fantastic for gathering perception information and the power for us to generate motion from that perception. And we have constructed some belief with our buyer that will likely be there. If something goes unsuitable, and we’ll get out and repair it.

What does that imply when it comes to merchandise and issues we carry to market? We carry to market issues that assist with preoperative planning. We discuss 3D fashions. The interior title for that has been Iris, that is augmented actuality for the OR. We’re in type of Gen 2 of our product simply popping out of Gen 2 now. We’re fairly enthusiastic about it. Each surgeon that goes by our studying channels makes use of Intuitive Studying, which is combined medium on-line and of their palms. Alternative, SimNow is digital actuality coaching. It’s absolutely embedded in our studying pathway, and it has been for a decade. Persons are enthusiastic about VR. VR has been absolutely embedded for us. And these items are linked on the again finish and changing into more and more so we have now alternatives to hyperlink them even higher that enables you entry to your information, the power to handle your personal digital life by our app.

That app is now properly penetrated, continues to develop up, appears actually good. That turns into interoperative steering, issues you should utilize within the OR to assist the case within the second that features Intuitive telepresence. Consider that as a HIPAA-compliant face time for the working room and that runs by our Edge Compute, our computing system that sits within the room that is known as Intuitive Hub. And that is good. Okay.

You bought pre-op, you bought inter op, you bought postop, what occurs to postop? You had an opportunity to assemble that information to see what occurs. Our AI suite our analytics engine is named Case Insights that goes again, appears on the information over many procedures appears at what you simply did and assesses the way you’re doing that is early, however extraordinarily thrilling. So this will likely be early and messy and thrilling. The prototypes are spectacular and validation is difficult. So, it is easy to indicate you one thing that may blow you manner. What’s fascinating is to validate it clinically. Is it determinant as to higher end result or not? And I believe we have got to show that. And are within the viewers. I’d ask that anyone to say it show it.

That feeds into the client portal that offers you analytics about how your program is working, both you personally or the establishment that feeds into our customized hospital analytics. That is simply shorthand for a way we combine with the hospital digital medical report. And folks can navigate on role-based methods from their moveable units.

So that is what we carry. That is an instance. I do not assess an excessive amount of significance to this, simply to provide you a way of what these sorts of issues appear to be for folks each — just about each most cancers operation has earlier than the 3D mannequin that is constructed by CT imaging or MRI. These issues are constructed for radiologists. They don’t seem to be constructed for surgeons. In order that radiology picture is sitting there, you purchased it, you paid for it, and it is nearly by no means used. It is not, truly, it isn’t a factor. So we’re type of — easy factor, why do not we simply get into the PACS system?

You order up a picture. We’ll do machine studying to create an anatomical mannequin, put it into 3D, drop it. We have now a radiologist take a look at the tip to a confirmatory step, drop it into your iPad and also you get to have a look at it, resolve what you assume it’s that identifies the place the tumor boundaries are, the place the arterial buildings are you possibly can evaluation it with the affected person earlier than the case, one of many highest values is that. After which you possibly can drop it into your surgical console and use it as a reference information when you’re doing the case. And over time, as we get higher, these will likely be utilized as augmented actuality. Pokemon GO for surgical procedure.

Intuitive Hub, you will hear this from us. What’s it truly? It is a pc with a touchscreen that’s built-in and cloud linked to our da Vinci system and synchronized. It is not an extremely bizarre expertise, however synchronization and information dealing with is de facto necessary. So what will we do, we enable that synchronization that enables each the surgeon and the care workforce and the machine studying algorithms to know what occurred in a synchronized manner. It seems actually, it is necessary. We have now some fairly good instruments which might be getting stronger to can help you do case assessments and to permit the machine that can assist you with these case assessments after which rotate them rapidly into your My Intuitive App. We’re simply to start with of it, but it surely’s beginning to velocity up and appears actually good. And it permits for built-in teleproctoring over time.

So the beginnings of telemedicine or teleproctoring make it straightforward. For those who want an skilled to faucet in and provide help to in a case, think about it is simply as shut as constructed into your da Vinci system and sitting in your cellphone. It is not a third-party factor. You do not have to run round and do it. This stuff are already cybersecure and HIPAA compliant and so off you go.

We have now talked about with you prior to now, one thing that we discuss as a computational observer that is type of the, my view of it, the model title for it’s Case Insights. And it is this query of now with machines and machine studying and real-time evaluation. Can the machine know what is going on on and supply an summary or perception into a few issues? Off-line, higher surgeon is quicker. Keep in mind that quote. Can we decide watching surgeons within the wild, who wants assist and the place they need assistance? And the reply to that seems to be sure. Now that is again to you have to present the validation of a giant — a big group of individuals to make that declare. And we’ve not performed that validation but, however we’re doing it. That is what we’re as much as.

After which the opposite factor is, are you able to, if you realize that, are you able to establish issues which might be occurring within the case in actual time and ship these insights to the surgeon in order that they do not make a mistake or that they’ve further data to make an excellent choice. We predict that is completely true.

So this will likely be sluggish to start with and quick on the finish. We’re within the sluggish to start with part. What which means is that you just take a few of the information that we have now, and that is consultant, it isn’t all of it. And also you begin asking questions, that is the place you are machine studying capabilities and algorithms may help. What’s significant within the case. There’s an unlimited quantity of knowledge from what they’re doing with their palms, to the place they’re wanting with their eyes to what sort of devices are utilizing to, how they’re making use of vitality to, what the case traits have been a part of the case for the affected person.

As you take a look at that set of knowledge, what’s predictive of higher end result? That is the query you are asking these information units. And we’re beginning to see a settling as to what includes efficiency or excessive efficiency. I am going to provide you with a real instance. It is type of a bizarre one. I have been round these methods for a very long time. I am a fairly dexterous particular person. I can sit down and use it the best way it was supposed for use within the lab, however I am not a educated surgeon and I do not function down something aside from the lab. And it may decide that I each know use the system and that I am not a educated surgeon. That these computational observers are ok to know that I do know what the buttons do, however I’ve not been educated in approach.

So possibly not stunning, however I believe highly effective and fascinating as much as this second, up up to now, why are we excited? All this information existed. It was simply pouring out of those pipes on the ground. We’re simply dumping it into nowhere. And so one other query is, okay, properly, let’s not dump it into nowhere. Let’s begin to collect it, curate it, be certain that it is proper after which see if we will decide what’s actionable from it, that is what we’re as much as.

Simply to maneuver to shut, what we are saying would not matter practically as a lot as what we do. One strategy to do it’s simply go ask our buyer, how we’re doing? So we measure Internet Promoter Rating fastidiously. We do it year-over-year. It’s performed in a blinded manner. It is performed referencing different firms available in the market to see the place we stand, and we proceed to do properly.

What I am informed is that world-class is 70% or above in our figures right here. I believe that is U.S. determine, our determine within the U.S. is 80%. We’re doing okay, and we’re developing properly in the remainder of the world. Why? For those who ask how do you do that? Why do you assume that is working? I believe that the merchandise meet the necessity that they are after. I believe they’re reliable. We have now centered our industrial groups to be aligned with our clients’ mission. It is about them. It is not about us. We have now a severe concentrate on the info, you in all probability bought somewhat little bit of a sense of that now. And when we have now a problem, we handle it head on, we get in, we’re fairly clear, we cope with it.

What are we doing in 2024? 2024, we’re centered on innovation, growth of indications and launches of our platforms by area. There are a number of. They’re fascinating and we need to execute them properly. Our main indicator of buyer satisfaction and efficiency is how usually they use our merchandise. It is not capital placements that is, means to an finish, it is a crucial evil. What’s most fascinating is to make use of it for the issues that they need to get performed, they usually’re feeling good about it. We have now a must concentrate on the standard of our merchandise, our manufacturing pipelines and driving margin, particularly on the — on the manufacturing aspect, we have now excellent manufacturing groups. We give them extraordinarily laborious challenges. This isn’t to decrease their contributions in any manner. And we have now the chance to optimize our SG&A. So we’re engaged on that, and that is the final half. So with that, delighted to be right here.

Let’s go forward and take your questions. Thanks for consideration.

Query-and-Reply Session

Q – Robert Marcus

Nicely, thanks so much. There’s a lot to speak about in that presentation. However I need to begin with the nice fourth quarter you simply introduced. 21% development worldwide. A tremendous web new placement quantity that I used to be telling my workforce needed to do a double take and the way good it was within the press launch yesterday. So possibly we may begin there and stroll us by what you noticed U.S. versus OUS urology versus basic surgical procedure and every other tendencies within the fourth quarter, you assume are related?

Gary Guthart

Simply to leap in. I do know most of you realize of those gents, however simply so we do it formally, Jamie Samath, CFO, Brian King Head of Investor Relations and our Treasurer.

Jamie Samath

Sure. So possibly I am going to take capital. Am I on, Robbie? So for those who take a look at capital placements in This fall, 415, you are proper, Robbie, on a web new foundation. That was up considerably. We noticed power within the U.S., in Japan and in our distributor markets. And inside that 415, what you’ve got is definitely a decline in trade-ins. In order that’s why the online new placements look robust. A few drivers. The process development is the important thing driver. You see 22% process development for the yr. That drives the necessity for incremental capability.

We see that significantly within the U.S. In This fall, we additionally noticed robust Greenfield placements. So placements at hospitals the place they’re shopping for their first da Vinci. We noticed that within the U.S., we noticed that in Japan, and we additionally noticed that in distributor markets. U.S. is de facto pushed by current IDNs, truly investing in smaller hospitals, rural hospitals the place they’re putting in their first da Vinci. And that is the boldness they’ve of their packages general after which investing in these hospitals. Japan is de facto extra about the truth that they’re at an earlier stage. There are extra Greenfield accounts which might be open to us simply given the place relative penetration is.

On the process entrance, we noticed a robust OUS efficiency, so 29% development in This fall OUS. That, partially, displays what’s a robust print for China, however on a delicate comp. So for those who take a look at This fall ’22 in China, truly, the procedures have been destructive as a operate of what was occurring with COVID on the time. However we have had some good OUS efficiency in markets just like the U.Okay., Germany, Japan and China. For those who take a look at the 22% for the yr, final remark I would just make is on a full yr CAGR foundation, our process development is 17%. A big portion of the distinction between 17% and 22% is probably going the impact of this affected person backlog phenomena that we have described.

Robert Marcus

13% to 16% process quantity development for subsequent yr coming off a fantastic 2023. I used to be previewing 12% to 16%, lots of my friends have been nearer to 11% to fifteen%. This got here in above that. Perhaps converse to what’s included on the backside finish of the information and what’s included on the high finish of the information?

Brian King

Sure. So our process steering is 13% to 16% for 2024. I assume, one factor earlier than I get into the low finish and the excessive finish of the vary, I actually need to emphasize that in ’23, we had 22% process development for the yr. You noticed simply elevated stage of sufferers within the healthcare system or primarily backlog all through 2023. In order you are desirous about 2024, it is actually laborious to foretell what is going on to occur with backlog. So I am undecided, I do not know what’s actually going to occur it that if that really even carries over in 2024. However on the low finish of the vary, we’re assuming that bariatrics development, I might say, continues to say no modestly.

One of many issues that we did not in all probability discuss as a part of our process element is that bariatrics development charge truly had declined from final quarter to this quarter into round mid-single-digit development charges. I might say we’re nonetheless persevering with to take market share there. However as we look forward to our 2024 process development, we’re assuming that it continues to say no on the low finish of the vary.

We additionally assume that in China, anticorruption efforts, or actions which might be occurring there may proceed to delay the tender course of, which may delay put in base or development within the put in base, which due to this fact would have an effect on procedures after which additionally backlog, probably not carrying over into 2024.

On the excessive finish of the vary, 16%, we assume that bariatrics continues to — on the present development charges that we lately skilled. There’s not a big impression in China or from the actions in China that possibly there is a slight profit or kind of a continued moderation of backlog into 2024.

Robert Marcus

Nice. Gary. The enterprise is a really completely different place than the final time you launched a brand new multiport robotic. Leases are a giant a part of the enterprise. So while you guys launch a brand new robotic, in all probability this yr, possibly this yr, if you wish to remark? How ought to we anticipate the worldwide healthcare group to react when so many are in lease packages and in addition fairly frankly, you are doing so properly with the previous robotic, possibly there’s much less of a must improve to a more recent robotic?

Gary Guthart

Sure. Let’s discuss generational changeover basically phrases. So first, we’re at all times engaged on issues that we predict are highly effective and buyer is available in and sits now with us and says, are you engaged on one thing new? And the reply is, sure. In fact, Like asking Mercedes, are they engaged on the subsequent E-Class. I believe the reply is sure. We will do this. In truth, these improvement time strains are extraordinarily lengthy. So we’re not solely engaged on the subsequent one. We’re engaged on the subsequent one behind that, too. We’re now bigger and extra succesful group that manner, so we do this.

When do you carry it to market? Why would you carry such a factor? So three issues are required. One in all them is, it is necessary sufficient to matter in a significant manner. So does it, or does it not take the quadruple purpose and make a distinction that we predict we will show? So we actually do not need to rush one thing on the market simply because we really feel prefer it’s time. It is time to do it. And we did not make a change. That is not. We’re not going to do it.

The second factor is you have to get your provide chains proper. These are subtle. If you are going to do one thing significant is just not trivial to get the provision chain proper. And very last thing, the worldwide regulators have to return together with you and perceive it, evaluation it, problem you and settle for it. When these situations are met, then we come do it. And after we do this, we speak to our clients first after which we come speak to you not the opposite manner round.

Robert Marcus

So final yr, you expressly informed us no new multiport robotic coming this yr. Any remark for 2024?

Gary Guthart

No remark.

Robert Marcus

All proper. Jamie, possibly a query for you, the place I look and I listened to your commentary on gross margin for 2024. You have talked a number of occasions about rising depreciation flowing by the P&L. My mannequin has year-over-year declines in gross margin in 2024. The Road has year-over-year enhancements. Any shade now that 2023 is preannounced that you could possibly give us on ’24 gross margins and assume both the up or down within the magnitude?

Jamie Samath

Sure, I am not going to provide the route particularly as a result of we’ll present the steering, clearly, on the earnings name on the twenty third. What I’d say is, clearly, gross margin in, thus far in ’23 has been under possibly the place we have been prior to now, pre-COVID. And there is actually three areas of focus for us.

One is the product prices for significantly our newer platforms, and Gary described that, and as Gary stated, our groups are working laborious, they’re making progress. That could be a multiyear effort. Second, you have seen us have elevated capital expenditure, principally for manufacturing services that units us up for the medium time period when it comes to the capability that we’ll want, but additionally, we predict, provides us benefits within the virtuous cycle and what we will ship to clients. And so you’ve got a interval there the place you’ve got incremental depreciation expense. And so you need to work by over time how do you take up after which leverage that incremental depreciation expense.

And we do anticipate incremental depreciation expense coming in ’24. And that will likely be each in value of gross sales and in working bills. After which over time, clearly, we have now the chance to proceed to drive development by each our delicate tissue enterprise and our Ion platform. And over time, that offers us alternatives in gross margin. However we’ll give the precise steering for ’24 on twenty third.

Robert Marcus

Nice. Gary, the magic variety of 7-plus robots at 48% of hospitals…

Gary Guthart

Truly, it was a development charge, not an absolute quantity. Simply so we’re on the identical web page.

Robert Marcus

Sorry. It is nonetheless staggering. What number of hospital IDNs have 20-plus robots? What number of have 7-plus. And actually, what it exhibits, as you talked about, is the standard of the methods and the willingness for methods to speculate each within the infrastructure, the coaching and your entire ecosystem. And I am desirous about this, one, how this creates an enormous aggressive moat for Intuitive Surgical? And the simply huge quantity {that a} competitor must are available in not solely to interrupt into these methods, however then to what they would wish so as to add high of it to make it extra worthwhile given your utilization per system continues to go up as you talked about within the session. So how do you consider this one as a strategic profit for Intuitive Surgical and be as a aggressive moat for — versus opponents?

Gary Guthart

Let’s discuss competitors. I believe an important competitors and actually, I believe the toughest for the corporate to react to is competitors on the illness state stage. And GLP-1s are an ideal instance of that, which is what is the root factor occurring right here. Someone has a illness, they should handle it. And most of the implausible firms which might be at this convention are engaged on various things. And if any person comes up with a good suggestion, we’ll shift — we’ll shift all these boundaries. And in order that’s why we’re so pushed much less about technical options. Is it an open console? Or is it a factor on somewhat card? These are all means to an finish. Are you going to drive a distinct end result, and may you present it? In order that’s primary. That is the place we focus the group.

I believe quantity 2 is you need to ship on the quadruple purpose, higher outcomes, higher experiences for care groups, higher affected person outcomes, higher affected person experiences and decrease whole value to deal with — decrease whole value to deal with on the finish. And in order that entire ecosystem that we put collectively is to reveal after which again it with information that we will do this. And I believe what’s behind that 7 methods and the IDNs adopting is that we present of their palms with their information that the quadruple purpose works. And if one other competitor — one other firm comes out and exhibits that they will do this higher in our format or a distinct format, folks will likely be keen to maneuver.

However I believe what we have requested of everyone is present us the info, maintain us to it and maintain anyone else to it. And I believe that is our dialog. There will likely be firms that do it properly. And there are firms can have completely different approaches to mechanism of motion with illness truthful sufficient, and there will be completely different firms with completely different technical architectures to attempt to do it. The bar that we have tried to set is that we hit all the quadruple line that may show that we do.

Robert Marcus

I am supplying you with an unfair query as a result of we have now lower than a minute left right here. So I am going to make it a brief reply for you. AI and large information, you talked about it so much within the presentation right here, small, reasonable, main impression to Intuitive Surgical and Surgical Robotics general within the subsequent 5 years.

Gary Guthart

Financial impression as you see it within the P&L within the subsequent few years will likely be small. Impression to the sector within the subsequent decade will likely be important. Financial impression for individuals who do it properly as organizations will likely be important over the long run. So somewhat persistence upfront concentrate on efficacy, and it’ll have an financial return on the finish.

Robert Marcus

I’ve pages of questions left, however sadly, we’re out of time right here. Thanks a lot.

Gary Guthart

Thanks Robbie.