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2024 Wells Fargo Healthcare Conference

Sep 5, 2024

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Okay, good morning. Welcome back. I'm Larry Biegelsen, the medical device analyst at Wells Fargo, and it's my pleasure to host this session with the management team from Intuitive Surgical. With us, we have Jamie Samath, the CFO, and Brandon Lamm of Investor Relations. In terms of format, it's gonna be a fireside chat. If anybody has a question, please raise your hand. We'll call on you. Jamie and Brandon, thanks so much for being here.

Jamie Samath
CFO, Intuitive Surgical

Happy to be here.

Brandon Lamm
Head of Investor Relations, Intuitive Surgical

Thank you.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

I know, before we jump into questions, Brandon wanted to read the forward-looking statement.

Brandon Lamm
Head of Investor Relations, Intuitive Surgical

Thanks, Larry. As a reminder, comments in today's meeting may be deemed to contain forward-looking statements. Actual results may differ materially from those expressed or implied as a result of certain risks and uncertainties. These risks and uncertainties are described in detail in our SEC filings, including our most recent 10-K and 10-Q. Investors are cautioned not to place undue reliance on such forward-looking statements. Thanks.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Great. So Jamie, let's start with da Vinci 5. In the second quarter, I'm sorry, you placed 70 systems, which were well ahead of expectations and accounted for almost half of your total system placements in the U.S..

Jamie Samath
CFO, Intuitive Surgical

Yeah.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

What about da Vinci 5 is resonating most with surgeons?

Jamie Samath
CFO, Intuitive Surgical

Yeah, so I'd say the 70 systems were actually in the range of our manufacturing output plans. It was at the higher range, but that was kind of within our plans. What you have so far in terms of where we've placed systems, it's with experienced da Vinci surgeons. We did that intentionally because we wanted to have surgeons that could provide good feedback on the launch. And so what we've heard so far is, customers really respond well to the level of integration, the surgeon autonomy they get from integrated insufflation, from the way they can control certain aspects directly where they are operating the console, like integrated energy, precision, imaging, ergonomics. Those are where we see the strongest reaction so far.

We have technologies also with this launch in force feedback and Case Insights. And those are areas where Intuitive will develop that capability over time. We have supply constraints on force feedback in particular. And what we hear from those experienced surgeons is great interest in what they're seeing and experiencing so far, a recognition of the potential of that technology. And of course, we'll have to mature those technologies over time. We'll refine them. We'll add capability. But early feedback on those two technologies are the real long-term potential, which is consistent with our own expectations.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

That's helpful. So how should we think about the ramp in the U.S.? What... On the call, Q2 call, you talked about modest increases quarter by quarter. What, what does that mean, and do you expect da Vinci 5 to be greater than 50% of your U.S. placements in the second half?

Jamie Samath
CFO, Intuitive Surgical

Yeah, I would answer it the same way you asked the question, which is second half. We'd expect modest progressive increases in supply. I don't think we'd get more specific than that. In the second half, as we've said on the last call, we do have a planned hardware and software upgrade. That's something that you wanna do actually quite carefully to manage the customer experience. You have to obviously be ready from an engineering and manufacturing perspective. And so we've said modest increases in supply second half. With respect to then what that does to mix in the U.S., I wouldn't be that specific at this point.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Jamie, what are those planned software and hardware upgrades that you mentioned?

Jamie Samath
CFO, Intuitive Surgical

Yeah, so they include the integration of our Hub technology into the vision tower. Hub is our kind of media management capability, allows you to take images and video during the procedure. You can use that to integrate into the hospital's PACS and EMR systems, and it also has telepresence capabilities. We're gonna integrate that into the system, and we're gonna integrate the skill simulator capability into the surgeon console. That's where, when the system is not in use, surgeons can actually, using virtual reality technology, actually practice skill drills to enhance, refine, and develop their technique. The software changes are really response to feedback that we've heard from the surgeons so far, and they're mostly around usability.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Jamie, the telepresence software?

Jamie Samath
CFO, Intuitive Surgical

The telepresence capability-

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Capability.

Jamie Samath
CFO, Intuitive Surgical

In Hub.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Yeah. Historically, that was used. I think you had a third party supplying that. Is this the same vendor, or is this an in-house telepresence capability?

Jamie Samath
CFO, Intuitive Surgical

No, no, actually, our telepresence capability for some time has been in-house. We primarily use it for case observations, but that's been in-house for some time.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Okay. Sorry about that. How should we think about, you know, the limited launch you said is gonna go into early 2025 , I believe. How should we think about customers pausing new system purchases ahead of the full rollout in the U.S. and outside the U.S.?

Jamie Samath
CFO, Intuitive Surgical

Yeah. So in Q2, what you saw with the 70 placements, and the overall capital placement performance for the quarter, we placed 341 systems globally. That's up about 18% on a net new basis. So if you adjust for trade-ins, which have been coming down because we're at the end or towards the end of the da Vinci Si trade-in cycle, that capital placement performance we characterize as relatively healthy. So we didn't see in the U.S. any discernible impact from customers pausing to evaluate da Vinci 5. We can't say that that will be the case in the second half. I think it's too early to tell. You are, in a little way, skewed in Q2 by, again, customers that are early adopters and IDNs that wanna have access to the latest technology.

And so we'll see how that progresses in the second half. OUS, I'd just say, in Europe, we did see placements in Q2 be actually lower than the year ago period. That was mostly a reflection of pressure on government health budgets that then trickled down to healthcare budgets. We saw that in Germany and the U.K. in particular. But it is the case that in Europe, they have obviously awareness of da Vinci 5, and they may choose to evaluate da Vinci 5, and they also have now the opportunity to evaluate SP, given that's cleared in Europe. And so there may be some impact we saw in Europe. It's not clear. In the other OUS markets, no impact that we would discern, but I think we have to watch what happens in the second half.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Jamie, when are you gonna start accepting trade-ins for da Vinci 5?

Jamie Samath
CFO, Intuitive Surgical

Yeah. Generally, I'd say we'd wait until we get into broad launch, which we've said is the middle-ish of 2025. That gives them customers obviously greater exposure to da Vinci 5. Many of them will have had da Vinci 5 placements as incremental systems. They'll have some experience with it, and that gives them the opportunity now to evaluate their programs in terms of, based on their procedure mix, their site of care strategy, and what they see as the economic benefits of da Vinci 5, how would they like to start to progress in any particular trade-in cycle? I think that will be different customer by customer based on their strategy and their economic objectives. At this point, I'd see the trade-in cycle as being something that's progressive over time.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Jamie, I just wanna make sure we don't miss the forest for the trees. Big picture with da Vinci 5, any surprises, good or bad?

Jamie Samath
CFO, Intuitive Surgical

Nothing, nothing yet I'd say of significance. I do think so far, customer reaction to efficiency benefits and what they're seeing in terms of reduced console time. I think that's been quite positive, and I'd say slightly surprising.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Positive. On the positive side?

Jamie Samath
CFO, Intuitive Surgical

On the positive side, yeah.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Okay. And Jamie, sticking with systems, you said on the Q4 call that total system placements would likely be down year-over-year. So far, system shifts have been up about 2% year-over-year. Do you still expect systems to be down year-over-year in 2024? And if not, what has changed?

Jamie Samath
CFO, Intuitive Surgical

I'm gonna, I'm gonna turn that to Brandon.

Brandon Lamm
Head of Investor Relations, Intuitive Surgical

Yeah. No, I, I think, you know, when we kinda entered the year, clearly there's uncertainty around the timing of da Vinci 5 launch and, and what that could mean for customers who potentially are looking to acquire the system. And, and in some cases, there could be customers who pause to evaluate da Vinci 5 as, as they kinda make their considerations for capital. At this point, you know, to your point, we, we haven't seen much in terms of customer pausing just yet, but I think still looking into the, the second half of the year, we'll have to kinda see how this plays out. And so I wouldn't update those comments. At, at this point, I think those comments, in part, just reflected kind of our viewpoint starting the year.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Got it. Is there any evidence that the haptic feedback is bringing new surgeons over to robotics?

Jamie Samath
CFO, Intuitive Surgical

We don't. We can't say that yet, mostly because those that have used the force feedback instruments so far have been really experienced surgeons. And generally, what you see in experienced da Vinci surgeons is that they develop what's called visual haptics. They actually, by looking through the endoscope and seeing how tissue moves, they kind of develop a substitute for force feedback. But what we've heard from those surgeons is that they can imagine that surgeons now being trained on da Vinci, whether it's a surgeon that's chosen not to adopt robotics or it's a new surgeon, developing their skill, they see that force feedback relative to developing visual haptics could be an opportunity to both be the final step that causes the holdouts to convert, but also, shorten the time to proficiency in the training period.

I think we have to get to broad launch. We have to get the system into the hands of those newer surgeons or those surgeons who have not yet converted, and I think we'd look to actually generate evidence to that fact.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Jamie, in Q2, ASPs were up about 4%, year-over-year, rounded. Should we expect mid-single-digit increases in the system ASP going forward from da Vinci 5? I know we know what the, you know, the ASP increase is, but just on an aggregate basis, if you will.

Jamie Samath
CFO, Intuitive Surgical

Yes. I'll let Brandon take it.

Brandon Lamm
Head of Investor Relations, Intuitive Surgical

Yeah. I think at this point, you know, I wouldn't necessarily kind of see hold what you saw in Q2 and kind of run that forward. The system ASP that we report is reflective of purchase systems only. And so, you know, if I just look at this last quarter, about 70 placements of da Vinci 5, only 11 of the 70 were outright purchases. And so there'll be a kinda mixed component that will affect the kinda that reported ASP. So we'll have to kinda continue to see how that progresses looking ahead.

Jamie Samath
CFO, Intuitive Surgical

If you look at economics, aside from whether it's an upfront purchase or a lease, then you have two dynamics that kind of play out over time. The pricing of da Vinci 5 is, of course, ahead of Xi, as we've described. And so, as da Vinci 5 becomes a greater proportion of the system mix, both as you get into broad launch and as you expand into other geographies, then you have a positive impact to unit economics, whether upfront or over time in a lease arrangement.

But I think the second factor to just consider from a modeling perspective is as you get past broad launch and as you start to see trade-ins pick up, trade-in credits from a Xi to a da Vinci 5 will be quite a bit larger, at least in the first couple of years, relative to recent periods where you're upgrading from Si to Xi. And so you have two competing dynamics there that affect unit economics, whether system ASP is upfront or over time in a lease.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Historically, an Si trade-in, I think you've said maybe $500,000 credit.

Jamie Samath
CFO, Intuitive Surgical

In recent periods, no, it's been more like $200,000-$300,000 .

Larry Biegelsen
Medical Device Analyst, Wells Fargo

$200,000-$300,000 credit.

Jamie Samath
CFO, Intuitive Surgical

Right.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

So the Xi credit, are you willing to say what that might look like?

Jamie Samath
CFO, Intuitive Surgical

Not, not yet. I think it's too early, and, I think we wouldn't say it because customers may be listening, and so that's subject to negotiation, but quite a bit higher.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Quite a bit higher. Jamie, while we're on it, again, I don't wanna miss the forest with the trees. Capital, equipment, environment, any color on that?

Jamie Samath
CFO, Intuitive Surgical

Uh,

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Big picture.

Jamie Samath
CFO, Intuitive Surgical

Yeah, I'd say U.S. has been stable and relatively healthy, less exposed to capital budgets, per se, because I think last quarter, 77% of placements in the U.S. were lease arrangements. And so in most cases then, they're kind of bypassing the capital budget process, so a little less sensitivity in the U.S. In Europe, we did see some stresses, but placements were down year-over-year, I think five systems. That was predominantly government budget related. Again, I think I said this, trickling down to kind of healthcare budgets. So we'll see how that continues, but there's certainly some stressing in terms of budget deficits in Europe. I think we've talked about China, very dynamic.

Placements have been a little lower in recent periods versus when the anti-corruption effort started, when domestic competition started to have a greater impact. The rest of Asia, I think, has been healthy so far.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Would China bounce back to 14 systems in Q2, and 14 is where you were before anti-corruption?

Jamie Samath
CFO, Intuitive Surgical

Yeah, I wouldn't call it a bounce back per se. I think, given the size of the remaining quarter, I think 14 reflects delayed tenders, particularly from anti-corruption and, kind of a slowly increasing win rate from domestic competition. So I wouldn't characterize it as a bounce back per se.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

The anti-corruption challenge, you know, initiatives, which are almost a year ago, still having an impact? I think a year ago, you thought it would probably be done by the end of the second quarter.

Jamie Samath
CFO, Intuitive Surgical

Yeah, there was some indications from written government documents that it would be through June of this year. Our team on the ground in China are saying it's now extending into next year in terms of that set of activities.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

For anti-corruption initiatives?

Jamie Samath
CFO, Intuitive Surgical

Yes. Yeah.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Got it. And the stimulus, you-- I know I asked about that on the Q2 call. You don't think that's something that's gonna benefit robotics?

Jamie Samath
CFO, Intuitive Surgical

Our team has not seen an impact or a benefit from that, and they are not predicting that there'll be a benefit. So, I know other players have indicated there may be a benefit, but we don't see that.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

On utilization, it was about 2% in the first half, I believe. That's a little bit lower than, you know, the mid-single digit that you point us to. Is there a reason? Do you expect it to bounce back?

Brandon Lamm
Head of Investor Relations, Intuitive Surgical

Yeah, I think, yeah, both Q1 and Q2 utilization about 2% growth there. You know, I think for, you know, what that really is reflecting is really strong procedures growth in the first half of the year-ago period. And so in Q1 last year, 26%, Q2, 22%. And so I think you had kind of a strong comparator there. I think looking ahead, we would expect utilization growth to start to revert back towards more historical averages in the low- to mid-single-digit range, as you start to see those procedure comparisons start to normalize as well.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Understood. And you had 17% procedure growth in Q2, as you mentioned, after 22% growth a year ago. And you raised... You know, the question is, what gave you the confidence to raise the bottom end of the guidance range for procedure growth?

Brandon Lamm
Head of Investor Relations, Intuitive Surgical

Yeah, I think the increase in the bottom end of the range really just reflects the procedure performance that we saw in the first half of the year. So if I kind of took Q1 and Q2 together and look at that, we're sort of close to that midpoint of the guidance range that we provided. So I think that's sort of what was kind of contemplated there. Obviously, in terms of the range as a whole, we've also contemplated scenarios for what happens with bariatric procedures, procedures in China and Korea, given prolonged physician strikes in Korea, and then the delayed tenders impacting capital in China, and therefore, procedure growth. So those are sort of the scenarios or things that we've kind of contemplated in the range.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

U.S. bariatric was down mid-single digits in Q2 after, I think, being flat in Q1. Jamie, when do you think it drops?

Jamie Samath
CFO, Intuitive Surgical

You mean, when does it-

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Bariatric, yeah.

Jamie Samath
CFO, Intuitive Surgical

When does it stabilize?

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Yeah.

Jamie Samath
CFO, Intuitive Surgical

So this is a conversation we have regularly with our bariatric KOLs, and the sum of it is they can't predict when it will stabilize. I've heard commentary from others that they think it's stabilizing. That's not the indication we're getting both from our field and from our KOLs, and so I think at this point, we're saying it's just too early to predict.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

And you're still doing better than the market. So the market is worse than down mid-single digits.

Jamie Samath
CFO, Intuitive Surgical

That's right. I think it's down in the teens.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Yeah, mid-teens sort of range.

Jamie Samath
CFO, Intuitive Surgical

Yeah.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

So, too early to call.

Jamie Samath
CFO, Intuitive Surgical

In terms of when that market stabilizes, and then therefore, when it stabilizes for us, we don't have any basis for calling the stabilization.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

But obviously, the comps are gonna start to get easier.

Jamie Samath
CFO, Intuitive Surgical

Yeah, it will.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Okay. Okay, and then, I guess the big surprise really on the Q2 call, besides the da Vinci 5 placements, was also the margins. So maybe talk about what drove the strong margins, particularly the gross margin, and why the gross margin takes a step down in the second half of 2024, please.

Jamie Samath
CFO, Intuitive Surgical

Yeah. So Q2 gross margin on a pro forma basis was 70%, and that was quite a bit, a bit ahead of our expectations. We did have some one-time recurring items that we described on the call. If you adjust for that, it would've been 69.5%. That's still relatively strong performance. We did see, relative to expectations, better pricing for components from our suppliers, and we also saw better freight rates and logistics costs in the quarter. That's been an area of focus for the teams. We didn't expect it to materialize that quickly. If I just take a first half, second half view, first half pro forma gross margin was 68.8%, implied by the midpoint of the range for the year. Second half would be 68.8% also, so flat-ish.

And so what you see in the second half is increasing depreciation expense, then partially offset by those things I mentioned in terms of improved supplier performance and improved logistics costs. You also see a little bit of impact from a continual growth in the proportion of the revenue mix, those new products that carry lower margins.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Jamie, thinking about next year, what are some of the, you know, puts and takes we should consider, maybe starting with the top line?

Jamie Samath
CFO, Intuitive Surgical

Yeah, I'd just say overall, in terms of, let's say, areas to watch that could be a headwind, I'd highlight four things, and none of them are a surprise. Bariatrics, we have to continue to watch. As we said, we don't know when that's, if and when that stabilizes. The China market continues to be dynamic. We don't have great visibility in terms of then how that plays out over time. We don't know enough yet to see when that may change. We have increased depreciation that we've talked about, both in the second half and on a more significant basis next year, again, given our CapEx. And then maybe we're starting to see some yellow flashing lights with respect to the macro. The market's a little volatile right now.

We're reacting to kind of every economic data point, and so I think we'll watch the macro carefully. In terms of then what could drive our business in positive ways, obviously, we'll take da Vinci 5 to broad launch, and our newer platforms, Ion and SP, are getting clearances in a set of geographies. And so we'll drive then the launch and over time, the adoption of those new platforms.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

The Korea strike, if it ends, could there be a bounce back?

Jamie Samath
CFO, Intuitive Surgical

We would expect so. We think a fair portion of those patients haven't been treated, so there's probably an accumulating backlog there. I think those patients would've intended to and would like to get da Vinci surgery, and so you could see some recovery for when that strike starts to resolve. We don't have indications yet from the field that we can predict when that might be, but yeah, that could be a benefit. It's a smaller market, but yes.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Ion’s approved in China now?

Jamie Samath
CFO, Intuitive Surgical

Ion's approved in China. We're in a couple of tenders right now. We have not placed our first system, but we expect to in the second half.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

You've been providing a lot of disclosure on Ion procedures and systems. Is there a plan at some point to provide more disclosure on, on the contribution?

Jamie Samath
CFO, Intuitive Surgical

We are looking at what we would do for next year. We haven't decided yet. We do that each Q4. So we'll provide you that update in terms of whether it now becomes big enough for it to expand our disclosures, but haven't decided yet.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

And Jamie, on 2025, sticking with that, maybe on the P&L, what are some of the considerations like you went through on the top line, if you can?

Jamie Samath
CFO, Intuitive Surgical

I think beyond the ones I've described, I'd just reiterate that the depreciation expense is significant. We spend just over $1 billion of CapEx based on this year's guidance, just over $1 billion the prior year, and so that's gonna now really start to show up in depreciation expense. Not yet ready to say directionally what happens to gross margin. We'll do that in January. When we finish our planning process, we'll obviously provide the outlook in January, but there's a period where you have elevated depreciation expense. Much of that CapEx is for facilities that provide us capacity on a manufacturing basis over a multiyear period, and so you have to grow in and then grow into and then leverage that depreciation expense.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Is there any way to look at your CapEx spending and to try to estimate what this increased depreciation could be, or is that impossible?

Jamie Samath
CFO, Intuitive Surgical

... You probably could, but I would recommend against. I would just say, give us till January. Let us work through the details, and let us provide you the update in January. And I think we'll look to give you some sense of incremental depreciation as part of describing our outlook.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Are there offsets to that?

Jamie Samath
CFO, Intuitive Surgical

Progressively, in gross margin, we're looking to improve product costs in Ion and SP. That's a multi-year plan. We've seen some improvements so far this year, but that continues over the next couple of years. But how that all shakes out in terms of gross margin for next year, again, I'd wait till January.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Right. But you're not saying one way or the other, up, you know, stable or down.

Jamie Samath
CFO, Intuitive Surgical

Yeah.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

I mean, depreciation's obviously a headwind, but there could be offsets, so it could be flat, it could be up. You're not saying one way or the other?

Jamie Samath
CFO, Intuitive Surgical

Not gonna say it now, we'll say it in January.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Right, but it could be all three of those scenarios. Is that possible, or are you saying directionally, it's probably stable to down?

Jamie Samath
CFO, Intuitive Surgical

Yeah, I'm not giving you the direction yet.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Okay. I'm just... Yeah, it could be all three of those.

Jamie Samath
CFO, Intuitive Surgical

That's right.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

I just wanted to confirm.

Jamie Samath
CFO, Intuitive Surgical

Yes. Yes, yes.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Okay, and you know, what about just in recent years, you've grown OpEx slower than procedures. Is there any reason why that might change next year? Sometimes when you've had big launches, you've chosen to grow OpEx faster.

Jamie Samath
CFO, Intuitive Surgical

Yeah. I'd say that we have a priority to continue to prioritize R&D, and that's because we balance the opportunity for growth, which we think is significant in terms of, from a strategic perspective, robotics and computer-aided interventions. We think that's a strategic opportunity for us. The opportunity is large, and so we're balancing growth and profitability, and we'll prioritize R&D. From an SG&A perspective, subsets of SG&A continue to have the opportunity to leverage. And so I'm not gonna say yet whether that means that the what you described changes in terms of what you've seen recently. Again, we'll do that in January. But kind of those are the two net dynamics that we're prioritizing.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

You know, you've talked about, you know, having top-tier margins between 35% and 40% over time. By our math, you know, you don't guide to the margins, but we get to about 35% for 2024. Do you feel like you're in the, you know, solidly in the 35%- 40% range, or is there anything that could cause you to go backwards? And maybe it's some of the factors you've already articulated today.

Jamie Samath
CFO, Intuitive Surgical

Yeah. So maybe framing, last year, 2023, op margin was 34%. First half of this year so far is 35%. If you look over the medium term, not 2025, medium term, let's say three to five years, there's kind of three drivers. You have the opportunity to drive trade-ins at some point from the launch of da Vinci 5, once you get past broad launch. Secondly, we have said we have an aspiration to get gross margin to 70% versus where it's at today, let's say in the 68.8% range. So that then obviously falls through to operating margin. And over that period, we continue to see the opportunity again for subsets of SG&A to drive some leverage.

For 2025, again, I think the key thing to consider is depreciation expense, and a portion of that depreciation expense will be in operating expenses.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

The Xi trade-ins, Jamie, is that a good guy or a headwind to the margins? You mentioned three things, one being-

Jamie Samath
CFO, Intuitive Surgical

Yeah.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

The first thing you mentioned was trade-ins. Are trade-ins a tailwind or a headwind to margins?

Jamie Samath
CFO, Intuitive Surgical

Over a multiyear period, they become a tailwind because you get the incremental revenue. There's periods where you have to obviously contemplate what's the degree of trade-in credit that likely declines over time. But if you look at kind of the midterm, it's a tailwind to margins.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Got it. And I lost my train of thought, but shoot. All right, I'll come back to it. Oh, da Vinci 5. What? Remind us of what you've said on when that I assume right now it's dilutive to the gross margin. What have you said on timing, when that can be. Or you know, I don't know if it's ever accretive to the gross margin because it's capital, but when does it become kind of consistent, call it, with the gross margin of Xi?

Jamie Samath
CFO, Intuitive Surgical

Yeah. It's actually within the 70% objective over the next three to five years. In that period, we think we can get the da Vinci 5 gross margins to be similar-ish to Xi. And so that's different than saying similar-ish to the corporate average, because capital generally is below the corporate average.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Right. Right.

Jamie Samath
CFO, Intuitive Surgical

At target and close to Xi, in the next three to five years.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Right now it's below. It's a drag?

Jamie Samath
CFO, Intuitive Surgical

That's right, yes.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

It's below Xi.

Jamie Samath
CFO, Intuitive Surgical

Yes.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Okay. And Jamie, we didn't-

Jamie Samath
CFO, Intuitive Surgical

On a percentage basis.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Right. Got it. Understood, and we didn't talk about procedures, just maybe remind us of what the, you know, the key growth drivers are, where you are. Hernia has been probably the biggest in general surgery in the U.S. What inning are we in, in the big procedures, and what are some of the new ones that are coming on?

Brandon Lamm
Head of Investor Relations, Intuitive Surgical

Yeah. I think growth drivers, kind of as we see it, are pretty consistent with what we've described before, which are really in the U.S., focused in general surgery, to your point. When you look at some of the large categories that we've talked to, we're really in that second quartile of adoption across many of those categories today. So that includes things like cholecystectomy, hernia repair, colorectal procedures, and even bariatrics. And so I think there's still opportunity to see further adoption in those procedures. And in addition, you start to see early-stage growth in some other procedures, like appendectomy, fore gut procedures, other kind of liver procedures as well, which is encouraging. I think outside of the U.S., our focus really is procedures beyond urology, particularly those malignant procedures.

So our focus there really is in hysterectomy for cancer, thoracic procedures, and colorectal procedures, which is where we're seeing a lot of traction.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

So appendectomy, we, we've heard that talked about before, but not a lot from Intuitive. I mean, just, you know, more from physicians. That's an emergent procedure, and so I'm curious, how big is that? Remind us. There's a lot. I mean, it's a big category, and what are you seeing there, in the U.S., given that it's an emergent procedure, and what are the economics? Is that, you know, is there an economic consideration there?

Jamie Samath
CFO, Intuitive Surgical

You take the market size, if you have it. Do you have the market?

Brandon Lamm
Head of Investor Relations, Intuitive Surgical

Yeah, I don't think we've been specific just yet on kind of what that market is. But to your point, a portion of that is coming in emergent, and so maybe only a subset is applicable in terms of being addressed robotically, but we haven't been specific on the size.

Jamie Samath
CFO, Intuitive Surgical

We've seen our footprint expand in the acute care setting, so then providing the opportunity to have emergent care be treated through with da Vinci. That's both cholecystectomy and appendectomy. Appendectomy is growing at a fast rate, but from a small base. In terms of economics, if I just do a CMS reimbursement reference, actually the reimbursement on the CMS is generally about the same as a cholecystectomy, and so therefore, the economics are similar to a cholecystectomy. It skews a little bit to more complex cases at this point because both are in earlier stages of adoption, particularly appendectomy. But I think given now you have a growing footprint that's available to emergent settings, you're seeing that being used at an increasing rate.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

That's helpful. And while we're on procedures, obviously, we're trying to figure out if there are new procedures that da Vinci 5 unlocks. Are we seeing any evidence that you can speak of right now, that it's bringing, you know, opening up new procedures?

Jamie Samath
CFO, Intuitive Surgical

Yeah, it's too early. Our initial focus is driven by our view that da Vinci 5 and its capabilities actually allows us to go deeper in the procedures we're in. And as Brandon described, in many of those procedures, we're in the second quarter on the U.S. and much earlier stages of adoption in our U.S. markets. And so we think we can go deeper in that existing set of procedures. Over time, we will look for additional indications, given the capability of da Vinci 5. Not ready to describe what those may be, and they'll likely take a little bit of time, but certainly, we do see the opportunity for that over some period.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Jamie, lastly, the competitive environment. Maybe walk us through what you're seeing in Europe and in Asia, please.

Jamie Samath
CFO, Intuitive Surgical

Yeah. So in Europe, particularly when competitors first started to enter the market, we did see selling cycles extend a little bit because they now started to participate in tenders that previously had been mostly Intuitive. If you look at, though, our win ratio in tenders in Europe, it stayed high and consistent. So I think we're actually quite pleased with that win ratio and the fact that it's not changing. In Japan, you see a local manufacturer, the Medicaroid system. Again, we like our performance there in terms of success rate or win rate. The place where I'd say we're seeing in a relative basis, more impact from competition is, as we've described in China.

There's a growing number of players that now have a system cleared, and again, there's this, local provincial preference you see for those, players that are headquartered, in particular, in those provinces. But outside of China, I think, the impact of competition to Intuitive is stable, and we like our win rates.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

You're going to be manufacturing locally in China? I know there was some development there recently.

Jamie Samath
CFO, Intuitive Surgical

We are. We started late last year manufacturing a local system in China, and that was in part so that we could participate in tenders that required a domestically manufactured system. One of the things that we're seeing in tenders is a requirement to have the system be manufactured in the province. And so then, that's not an instance where we're likely to put manufacturing facilities in every province so that we can participate in those tenders, but it is what it is.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

That's helpful. Jamie, we're almost out of time. We are out of time, but I wanted to give you the last word. Any closing remarks?

Jamie Samath
CFO, Intuitive Surgical

No, I think the company feels good about our relative competitive position. I think we're excited about the launch of da Vinci 5 and getting da Vinci 5, Ion and SP to either broad launch and/or additional geographies. Thank you for all of you, for your time and your support.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

Thanks for being here.

Jamie Samath
CFO, Intuitive Surgical

Yeah. Thank you.

Larry Biegelsen
Medical Device Analyst, Wells Fargo

All right.

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