Okay. Good morning, everybody, and welcome to Jefferies' 2023 London Healthcare Conference. My name is Mike Sarcone. I work on the U.S. Medical Supplies and Devices team. And with us today, we've got InMode for this session. InMode's a leading innovator in the aesthetic space, and from the company, we've got CEO, Moshe Mizrahy. Moshe, thanks for joining us.
Thank you.
I was wondering if we could just kick it off. Can you talk about InMode's differentiation for its core platforms?
Of course. Good morning, everybody. Pleasure to be here. Well, medical aesthetic traditionally dealt with optical energies like laser and IPL. As everybody knows, laser and IPL cannot penetrate deep into the skin because the optical energy is absorbed by the pigment. So laser and IPL energy can do topical treatment, like hair removal, like a little bit of skin rejuvenation, pigmented lesion, superficial pigmented lesion, superficial vascular lesion, maybe treatment of acne, everything that is on the surface of the skin. But if you want to do something a little bit deeper and do a non-invasive or minimally invasive body and face reshaping, you have one option, and this is plastic surgery. So we have invented technology, which called Bipolar RF energy, which is minimally invasive.
It's not non-invasive, but we do the treatment, we do the entire plastic surgery procedure through one incision point. And the energy that we're using, the bipolar RF energy, we know how to melt the fat and take it out and tight the skin simultaneously, which is basically the holy grail of plastic surgery. That's what they do, isn't it? They cut the skin, they tight the skin, they take the extra fat out, and they reshape. So we developed the technology, and we develop it for the body, we develop it for the face, we develop it for every part, for the arm, different sizes of hand pieces.
A treatment, you need a single hand piece under local anesthesia, with a very low downtime—very, very low downtime, unlike full surgical procedure, when you go to a general anesthesia and a full downtime, I mean, sometimes three, four days. You need to go to the hospital. You need to have another doctor to do the anesthesia. With our technology, which we call radiofrequency-assisted lipolysis or liposuction, you can do it in your clinic. The doctor can do it in your clinic, in his clinic, in a surgical room. It doesn't have to be operating room. Local anesthesia, the patient is awake. Downtime, not more than 24 hours. And you get, you know, instead of doing facelift, you do FaceTite. Instead, you do...
Instead of doing a tummy tuck, you do BodyTite, you do arm, you do everything. We developed the technology in-house. We did not invent RF. RF is known in medical application for many years. Doctors are using RF, but monopolar RF for all kind of electrosurgical procedures. What we did, we took the same technology, and we developed it by doing a bipolar and not monopolar RF for aesthetic procedure, surgical procedure, minimally invasive surgical procedure. This is the base technology that we developed. Later, we developed another technology, which is a bipolar fractional RF, exactly the same with two polars on the RF, penetrating the skin up to 7 millimeters in the body and 4 millimeters in the face, all the way to the subdermal fat. Again, for aesthetic procedure.
Later, we developed a technology for women's health, for tightening the vagina, treatment of overactive bladder, treatment of, urinary incontinence, and, and many other indication. This is the platforms which call Empower. And then we took the technology into a dry eye, and now we're taking it into ENT, snoring, sleep apnea, and also for erectile dysfunction. The same technology, but different indication and different procedure. We own the technology, we develop it, we own the IP. Hi, Matt. How are you?
We own the IP. We start commercializing the product, the first product, in 2016, in the United States. That was the first year we received the first FDA. $22 million in 2016. Last year, we did $454 million, and this year, hopefully, we will cross with all the issues of this year, and I'm sure we'll discuss it, all the obstacles and the economic slowdown, we will probably cross the $500 million of revenue. We're very profitable. We have a gross margin of between 83%-85%, constantly, and EBITDA of about 45%, between 42%-45%. The company is based in Israel. We sell in 90 countries.
We have subsidiaries in 10 countries around the world, five in Europe, U.S., Canada, India, Australia. Now, we opened in Japan, but we're also selling all the territory. All together, we're 500 people worldwide. In addition, we have two production facility, which is another 200, two hundred and twenty people in Israel. We manufacture only in Israel, and we ship from Israel all over the world. That's in a nutshell. Did I, did I answer your question?
You did.
Thank you.
That's great. You had mentioned BodyTite, FaceTite, some of the core platforms. You've got Morpheus8, you mentioned Empower. Do you think you could talk about how, you know, those platforms are growing relative to the company's overall growth?
Yeah. Yeah. Okay, currently, we have nine platforms in our portfolio. Usually, when you come up with the new platforms, the first year is always the momentum year. So everybody, all the salespeople, wants to try to sell the new platforms. For example, Empower, we brought Empower in 2022 to the market, end of 2021, but mainly 2022. We gave a guidance of $20 million for the first year on these new platforms. It's a new territory for us. Women health was not. It, it's combined with aesthetic, but it's not exactly. And at the end, we end the year with $43 million of revenue. Usually, the second year of a new platforms is some kind of stabilization.
You are not growing another 20% and 20%. 9 platforms that we have today are basically selling about, on average, $50 million per platform. This year, we came up with two new platforms. One is the Envision, and one is the Define, which is the second generation for hands-free for face, and we hope that that also will be successful. We launch it in the second half of this year. So on average, I would say that every platforms that we make stabilize around $50 million a year.
Okay, great. And, you know, just getting to recent results, 3Q, you know, growth has slowed a little bit. You had talked about seasonality, some issues-
Yeah
... with financing partners, and potential underlying demand softening. Do you think you could unpack that a bit and talk about how each of these issues is impacting growth?
Yes, yes. Okay, let's talk about seasonality first, okay? The medical aesthetic has some seasonality effect. The first quarter is strong. The first quarter is strong, but not as strong. The second quarter is a little bit better because people prepare themselves for the summer. The third quarter, which is the summertime, usually people don't do aesthetic procedures during the summer, except in September, and the fourth quarter is the strongest one. So what happened in 2020, 2021 and 2022 is the, the, I call it the, the corona effect, just because we had corona in the beginning of the year, so the second quarter was not strong. Then the third quarter was a little bit stronger than the second quarter, which is not typical to the medical aesthetic industry. Okay?
So in 2023, seasonality came back, and then Q3 was typical seasonality, quarter, which again, in the previous two years, it was not because of the COVID. In addition to that, we're experiencing some slowdown in the economies, mainly because of interest rate. Now, interest rate affect also the financing the doctor need to pay when they buy a system.
For example, when a doctor buy a system in the United States for $120,000-$130,000, he basically buy it with a five years lease package, which is, on average, the interest rate up until the beginning of, up until the end of the first quarter of this year, was around 6%, 7%, 7.5%, 6.5%, depend on the credit scoring of the doctor. Today, the interest rate for leasing is around 14%-15%, and in addition to that, it's become very difficult for the leasing company to approve doctor. What it used to take three days to get approval for typical doctor, not, I would say, not the, not the richest one, three days after he signed the PO, today, it take three weeks.
Now, if you talk with reps, if you talk with salespeople, they will tell you that time kills deals. Why? Because if you sign a PO and now you have to wait three weeks to know if you got the finance or not, in those three weeks, all the competitors are jumping on this doctor. He may think twice, "14% is too high. Maybe I need to wait a little bit." And all the emotional type, you know, sales, I mean, disappear. So we have some difficulties. We had some difficulties on the third quarter from financing, from the time, the process of approving doctor, the slowdown in the economy. The good news, the good news is that procedures-wise, we're not coming down. That mean that existing doctors who has equipment continue to perform the treatment.
In the third quarter, we sold over 220,000 disposables of fractional Morpheus, BodyTite, FaceTite, AccuTite, where you need a disposable one-time use. So that mean that this year we will over 1 million procedures, compared to 700 that we did last year. If you compare third quarter of 2022 and third quarter of 2023, as far as disposable, as far as one-time use disposable, we grew 28%.... So the good news is that those doctors who still have the system, who own the system, not still, who own the system, continue to make procedures. In the first months of this quarter, we sold close to 100,000. So, so on one hand, the capital equipment is a little bit more difficult for us because of financing, because of interest rate, because of the long time take to finance.
Doctors don't have $120,000 cash. They need to have some kind of a financing package in order to buy the system. Although they make money. For example, if a doctor in the U.S. buy it for $130,000, in 2022, the average cost per month on a five year lease package is about $3,500, $3,300. If he does five treatments a month, and the cost of disposable is another $2,000, so the total cost for him is $5,500. He make $25,000 because he charge at least $5,000 per procedure in his clinic. So he pay back the system in seven-eight months.
But the psychological effect of the doctor to see that he's not getting financed or he need to pay 15% interest, make it difficult for him to make decision. But we will overcome it. It will come. We are doing some procedures right now, working with the leasing company, buy down some of the rate or making some pool of financing with them to make it easy for them. We'll see. I don't think it will end in, in at least not in the first six months of 2024, because I heard the Federal Reserve Board chairman said that, he's watching the inflation, and he did not yet decided whether he's going up on the rate or not. But we're a strong company, and we will overcome it like we, like we overcome the COVID time.
Can you talk about how much financing you've done in the past and how much you might do in the future with your balance sheet versus using partners?
We used to do in-house financing-
Mm.
Between 2%-3%. Now, we will probably go to 5% in-house financing, and in addition to that, if we create a pool with the leasing company, then we put 6% of the revenue in the pool to support them in case the doctor will fail to pay. So it depend how you count it.
Do doctors have bad credit?
No.
Um, usually-
Usually not. Some of them, it can happen, but not that much.
Specifically, why is it taking that much longer? Is that just a processing thing?
Yes, that's the processing. They ask for more document. They want to see the tax return. They want to see how much business they did. I don't know what else, and that they have some issue that, you know, make the process longer. I'm not a finance guy, but I see that on the market.
I can tell you, just tell you from on the ground why it takes a little bit longer. As soon as they ask for more documents, you need compliance from the doctor and his accountant. That's why it starts to take weeks. I mean, you can still do it in days, but because they ask more, then it takes weeks to get it from the doctor.
Yeah.
That's-
It's just the back and forth.
Yeah.
Yeah. Okay.
They are more cautious. They are also, you know, knowing that the market is slowing down, maybe the doctor will not have as much as he want patient and, you know, it's a snowball started with the interest rate all the way down.
I guess now in retrospect, and having seen, you know, Esta and Sientra and Allergan talk about a softer market, how much of the Q3 softness do you think was seasonality versus the financing versus underlying demand?
I would say that seasonality is about 10%-15% down always 10%-15% below the second quarter. And in addition to that, I would say we left something like another $10 million on the table because we didn't reach financing on the third quarter.
Okay. Has anything changed sequentially outside of... It sounds like you're gonna do more, but have you seen anything external change?
Well, we hope to get it improve. I mean, and that's what we're doing on the fourth quarter now.
Okay.
The fourth quarter is relatively stronger, so it will help.
How much should we expect from the relaunch of Define and from some of the other new products that you have coming up for next year? Like cellulite-
For what? For 2024 or for 2023? For 2024.
Well, for 2023, I assume it's gonna be small, right? So-
Okay, for 2023, it's very little. I would say that we expect that the Define and the Envision in 2024 will contribute at least $50 million.
Okay.
Worldwide.
It was a long time ago, but you said in the past that you thought hands-free could potentially get to 20% of your sales-
Yeah
... versus it's around nine or eight today, right?
Yeah.
Do you think that can still happen now with the newer relaunches?
We came up with Define, is basically the new Evoke. Evoke was the first generation of the hands-free for face. With the Define, what we did with the Define, is we combined the hands-free with Morpheus on the same platforms. So now we are developing protocols for the doctors to do combined treatment, which again, hopefully will make it more popular. We're going to do the same with the Evolve, which is the body hands-free. We were going to combine it with the, with the Morpheus 3D body, up to seven millimeter, combine the treatment, which will come on the third quarter or of next year, the new Evoke-
Mm
... which combined with some new modalities, which hopefully will bring it to the next step. Hands-free was very popular during the COVID, and it is a little bit, you know, we thought it will stay. Hands-free was very popular during the COVID because of the social distancing that people requested. They wanted to do something without anybody in the room, so we sold plenty of them. Right now, we stopped them, but it will come back again.
Can you talk about the cellulite application?
Yeah. Yeah.
When that could come out, you know-
Yeah.
Should we be excited about that?
Cellulite, cellulite is a very tough indication. Many people and many companies have tried to treat cellulite with all kinds of energies. We are doing now a study combining the BodyFX and the Morpheus Body to see. We have three sites in the United States, and so far the results look very promising. So if that will be the case, in 2024, we will probably develop a platform which will be only cellulite. Only cellulite, combining between several modalities, not only one. And that's also. But yet to be proved and get the FDA approval in a way that our study will complete, once the study is complete.
Do you just want to see more results to be more convinced because it's a tough-
Yes.
- application?
Yes.
Yeah.
Yes. Yes. Yes. I mean, you cannot, you cannot treat cellulite and say, "Hey, the treatment is forever." The clearance that the FDA will give you is treatment of the appearance of cellulite, not treatment of cellulite.
Mm-hmm.
Because women will develop cellulite after the treatment, so you have to do some maintenance as well. That's the procedure.
Gotcha. I know you said the majority are leases. I've gotten this question a lot, actually. What percentage are leased versus purchased versus some other format?
95% is lease.
Okay.
95% is lease, all kind of lease. I mean, and I include in the leasing also if a doctor go to his bank and get a better, a better deal as a loan, that's for me, it's a lease.
And then one of the newer things that you've been talking about is actually refreshing the core platforms.
Yes. Yes.
That's also significant because a lot of them are kind of near the end of that five year-
Yes
... lease. So maybe talk about the significance of that. What are you doing to the platforms, and how much of a-
Mm
... kind of an upgrade cycle could that drive?
Okay. Okay. Well, the first and the most important technology is the minimally invasive technology. So we're now developing what we call a new minimally invasive RF technology, which, if you know, the current technology is based on two cannulas, one on the top of the skin and one inserted into the subdermal fat. We're now developing the same technology with one cannula, which will make it more user-friendly for the doctor. It will probably come... We're doing some study right now, and we believe that that's something that doctor will love, especially the plastic surgeon. And if it will be very user-friendly, also dermatologists and other doctors can use it. So we're developing one cannula technology for minimally invasive radiofrequency-assisted lipolysis, and it will come soon.
The second technology that we're improving is the Morpheus. The first thing that we did, it's already on the market, is what we call Morpheus Body 3D. So, I don't know if everybody familiar here, but the Morpheus has needles. For the body, is 40 needles. When you apply energy on the 40 needles, you want to make sure that every needle will have the same level of energy. Okay? But just because the return electrodes is on the skin, and some of the needles are close to the return electrode, it was not spread evenly. So now we're developing a technology which we call 3D, which will make sure that all the treatment will be done, and the energy will be spread or distributed evenly. That's another technology.
In addition, we develop what we call a burst. So, with the Morpheus, if you go into the skin, you give one pulse in 7 millimeter. Automatically, it will go to 5 millimeter, you give another pulse. Automatically, it go to 3 millimeter to give another pulse. So basically, in one punch, you treat three levels of the skin, which is very important. So these two technology now are being upgraded, and in 2024, we will bring it to the market.
How do you make it bipolar with one cannula, and then does that make it a lot easier-
Yeah
... to do the procedure?
No. How do you make it? Assuming that this is a cannula-
Yeah.
You have one electrode here, in the middle, a piece of ceramics, and one electrode here.
Okay.
The Bipolar is between them.
Does that make it easier?
But I give you all the secret now.
Is it easier to remain? So you're saying you can expand the derms then? Is it easier to remain kind of planar in the different tissue levels? How does it make it easier?
It make it easier to operate.
Yeah.
I mean, for example, you know, there was a company called Apyx, which is with the J-Plasma or Renuvion. They have one cannula, but they don't control the temperature, so they had a lot of adverse effects. But somehow, doctors like the fact that this is one cannula.
Yeah.
It's a different technology. It's a evaporation of helium. So we're trying to develop something which will become more user-friendly to the doctor for treatment for face, for body, for neck, one cannula. It's much easier than you have the two cannula, one on the skin and one internally.
Yep. Maybe we could switch gears and talk a little about capital allocation.
Mm-hmm. Yeah.
I know you got a nice letter recently. You've expressed your views publicly on buybacks.
Yeah.
Does the stock price make you feel differently about that at all? And I guess if not, maybe talk a little bit about your acquisition strategy?
Well, I know that this question will come. I mean, we're not against buyback. I mean, it's not a secret, we have more than $700 million cash. But we tried to do buyback with $100 million, and it did not help the stock to go up. Maybe for two weeks, and after that, everybody forgot that. Second, we look around, and we see other companies who are buying back, who are doing a buyback, and also we analyze few of them. One of them is even from our industry, HydraFacial, Beauty Health Company. They announced $100 million of buyback, and the stock went down 25%, six weeks after. So, buyback is, it's interesting. I know everybody calculate that one - if you do buyback, the EPS will go up. That's correct.
But we believe that in order to do an organic growth, we need to do acquisition. And we believe that now, just because economies are slowing down, we will see some more opportunities. We had. We gave two proposals to two companies, but it didn't work out with them. Maybe we gave lower price than what they expected. We're exploring another two companies right now to see if we can do an acquisition. We want to wait until the end of the year and to see if we can do an M&A and not buyback, because we believe that an M&A will give more value to the shareholders. That's our strategy today.
Great. I think we have to end there. We're about a minute over, but thanks so much for your time, and thanks for your interest in InMode.
Thank you, all.