Good afternoon again, everybody. My name is Rick Wise. Thank you all for being here. And I'm particularly pleased to welcome the team from Masimo, Micah Young in the center, Chief Financial Officer, to his left, Mike Poznanski, Senior Vice President of Finance, and to his right, VP of Business Development and Investor Relations, Eli Kammerman. Welcome to you all. Thank you for being here. Really appreciate it, as always.
Thanks, Rick.
Micah, just to start off in an unusual place, maybe, just because I'm sick of asking about COVID first to start every conversation. I was just reflecting last night about this, and obviously, you saw that the MCIT got repealed despite the bipartisan request from the, I think, 10 senators. What's this mean for Masimo in general, in your view? What's it mean? How do we think about it in context of Opioid SafetyNet and the future there?
Yeah, Rick, I think we're still hoping that it'll come back. But we think it's best for patients to get these technologies in their hands quickly and improve patient care. But I think until we have clarity around that, I mean, this is going to be Opioid Safety Net's going to be very dependent on reimbursement, as you know. We do believe there's a self-pay market, but I think that adoption curve will be much more shallow. I think we're still very excited about this product. We think it can save lives. And we're launching it outside the U.S. right now and initially self-pay there. But whether it's in the U.S., once we get approval through the FDA, hopefully that'll come soon, or OUS, where we're trying to market it and pilot everything out there. It's going to take probably two to three years to get reimbursement decisions on it.
It'll probably take a couple of years of collecting clinical data. We got to work with the payers and CMS in the U.S. to understand what data is going to be required in terms of patient outcomes and results, and once we have clarity, then we will work to collect that data and submit it, so I think of it as a two to three years before probably reimbursement, which will be more of an event that could drive more meaningful revenue and adoption of a very large market opportunity for us, but it'll take some time in a self-pay market until then.
And just again, at a high level, sort of not a fair question, but we were all excited about it. You were excited about it. Investors were excited about it and the potential for growth acceleration. Your growth is accelerating anyway, and lots of shots on goal, obviously. But do I feel disappointed for growth or anxious as I contemplate the next couple of years without Opioid Safety Net? Or no, there's so much going on. It'll be fine if it's another two or three years.
No, I think one thing is important to highlight is we kind of get bucketed in as a COVID play. Last year was a strong year for us. We grew revenue over 20% and 22% last year, and if you look at it, I think we're more of a post-COVID play. If you look at the catalyst from COVID, it's really driven more demand for broader patient monitoring, and that's kind of going even more into the general floor areas of the hospital, lower acuity settings. It's highlighted the importance of our SET pulse oximetry when patients need it the most with those chronic disease illnesses, and whether it's respiratory, cardio-type illnesses, so broader patient monitoring, that's been a big driver here. We've also seen more demand for hospital automation too and more connectivity in the hospitals and really helping hospitals become more efficient and more productive.
Right now, we're seeing nursing shortages. And I think that that's highlighted the importance of these solutions. And over the last two years, we've seen an increase. We've been connecting beds with Patient Safety Net and Iris Gateway for nearly 15 years. And that install base is a large install base that grew 50% over the last two years. And if you look at our Root, our connectivity platform, and also Root with vital Signs, I mean, Root has grown. It's more than doubled in the last two years in terms of the install base. And we've been installing Root since 2014. So this is we're seeing a lot of demand around not only expanding into lower acuity settings, but also hospital automation. And I think the other thing is we're seeing more demand around home monitoring and telehealth. And COVID's been a catalyst for that.
So we've got a lot of great things happening with the company. And I think we're more of a post-COVID play, especially the fact that our sensor volumes track with overall patient and hospital admissions. Elective procedures definitely impact the overall admission numbers. But you've seen the sensor growth over the last couple of years. And we're building up a much stronger recurring revenue stream. And as electives come back, it's only going to help drive more volume for the company. So there's a lot of throughput that comes through with elective procedures versus a COVID admission where you've got a patient sitting in a bed for two to three weeks. So you get a lot more throughput of volume of sensors related to electives. So that will be a tailwind as we move into next year.
So I'm going to pause there, Rick, and let you move to the next question.
Yeah. No, that was a great summation. And let's stay on this notion and perception of Masimo as a COVID beneficiary. You have been a COVID beneficiary. And I guess I'd take it just a step further, Micah, and say, but part of that being a beneficiary has built a larger installed base. So as COVID wanes, will that urgency to expand on the general floor or expand into the ambulatory setting, is that lessened, do you think? Should we be worried about some of these big drivers lessening? And just I'll throw one other part in. Do we imagine sensor use, the math of sensor use accelerates as all things equal as electives come back, or the math is more muted because COVID hospitalizations are waning? I think I know the answer to some of this, but I'd rather hear your perspective.
Absolutely. Yeah, Rick, our install base, we're up over 2.2 million drivers now, or around 2.2 million drivers in the field, and that's grown 25% over the last two years, and we've seen, actually, now that hospital census has kind of rebounded back up this year, we're seeing our sensor growth and our revenue growth in line or better this year than our install base growth over those two years, so I think not only are we seeing a growing, large and growing install base, our shipments last quarter, we shipped 75,000 drivers, it's up 20% on what we averaged back in 2019, and we see ongoing demand there. I think that hospitals still focus their budgets on patient monitoring. I think it's an important area, and it's probably a lower-cost line item than most capital on most of the capital budgets, so I think the demand's still there.
And I think just the new customer wins. I mean, we've been continuing to gain share and gain new business at a record pace of the last 18 months. And I think that's also giving us more confidence at these new levels that we're seeing on the drivers this year. I mean, we're guiding to 280,000. We did 246,000 pre-COVID in 2019. So the momentum's there. Install base is growing. We're seeing stronger recurring revenues. And I think the recurring revenue, the revenue per driver is going to only expand from here, especially as we pull through more than just SET. We pull through Rainbow. We pull through SedLine, O3. And we start to bring in more hospital automation service revenues. I think we got a lot of tailwind opportunities here.
Yeah. One aspect of COVID that I just heard about nonstop during the quarter and so far in our Stifel Healthcare Conference is just I know you've been asked about it, but supply chain, chip shortage, transport costs, raw material costs. Now, since I think maybe the news came after you all reported, maybe, I think, about the third quarter inflation rates. Micah, I remember vividly when you came to Masimo, your laser focus on cost reduction and margin expansion. Can you keep doing that and achieving? I know those are priorities for you. Can you do it in the face of these outside headwinds?
Yeah. I mean, we definitely are focused on continuing to take out costs in terms of lowering our product costs, becoming more efficient, leveraging our back office, some of our overall spending over time, and some of the investments we've made and driving return on those investments. If you look at some of the things you mentioned, I mean, we've got a lot of supply chain challenges across all companies. I mean, they're all facing it right now, whether it's a chip shortage or just getting product that's sitting at the port, and you can't even get access to it right now. So we've been able to, the operations team here has done a great job of navigating through those, knock on wood, and hopefully we continue. But we've seen a lot of those costs too hit us last year. And they've kind of stayed in our P&L.
I think I've mentioned before, we've probably had 150-200 basis points of headwinds in our gross margins alone due to COVID-related costs. Those have continued. We've guided those into this year. I think it's kind of set us back a couple of years on our expansion, that 100 basis points a year. I think we've re-baselined now. Now it's a matter of we got to work through this planning process, this budgeting cycle. We're trying to drive the cost reduction initiatives with our engineering and manufacturing teams to help offset any future headwinds that may come as a result of supply chain or different things like that. So far, they've done a great job navigating. We've been through chip shortages before for the company's history. Our leadership team reminded me of that when it first started happening here.
And we had to go out and secure longer-term commitments. And they've been successful in the past. And so far, they've done a great job of navigating through it. So we're going to do everything we can to deliver that 50 basis points of gross margin improvement and continue to expand our margins there.
Do you feel more anxious about your ability to do it given what's happened even in the last month or two on this topic, or?
I mean, there's definitely challenges we got to work through, but we also think there's some great potential moving forward to take costs out of some of our equipment, some of our monitoring equipment, our boards, and different things like that that can help us navigate through this over time, but we also think that we should see a healthier product mix moving forward that could help us get through this. Then we've got a large install base, and if we can continue to leverage the cost of that install base that we've already put out there by driving more revenue per driver, those are some of the things I think we can continue to perform well. I think, like I said, we've re-baselined, and I think we can expand from here, so.
R&D spending has trended up. It was sort of mostly upper single digits a few years ago. Now you're more recently in the low double-digit range. I mean, I'm confident that you're spending it on growth, enhancing, exciting things. I'm sure we have not seen everything yet that's going into spending. Is this the new, right, sustainable R&D spend for Masimo going forward?
Rick, this is the most excited I've ever been with our pipeline of products. We have been, like you said, I mean, we've been spending between 11%-12% of revenues. We were spending 9%, I think, the year before I came. And the team's done a great job of really identifying projects, opportunities, new addressable markets. And I think we've got a strong pipeline. We're continuously looking even more towards how do we help patients in the home. And we've come out with a lot of wearable technologies. And we're continuing to expand on those platforms. And I think the next 12 months, we've got a pretty exciting pipeline that we'll be able to talk about.
I'm thrilled to hear it. I think I asked Joe something about it on the call, and it pushed him a little bit, and he seemed to hint, suggest that maybe by year-end, I'm sure we won't see everything, but start to see that flow. Is that still a reasonable thought that we might start to see some of that pipeline that you're so excited about?
I didn't catch his year-end comment, but I've always said kind of early as the next maybe six months to 12 months, we'll see some exciting new products.
Come on, Eli, back me up here.
Rick, you know I'm a little bit more conservative with my commitments there. But yeah, we'll see how it plays out.
Like the excellent CFO that you are.
Thanks.
When we think about just, I was reflecting on the general floor comment. Just, in recent months, you've said many times and appropriately. You've penetrated because of COVID-19 10%, now more like 30%, and I appreciate what that means, and that's excellent. Where do we go from here on the general floor? I mean, are we going to see solid, measurable? Am I going to be asking you in six, maybe 12 months from now, and you're now at 35% and then 40%? Help set our expectations there.
Yeah. I mean, COVID has definitely accelerated some of the adoption of patient monitoring on the general floor. And like we mentioned, it's gone from 10% pre-COVID. We think it's 20%-30% now. And I think what's really highlighted is the need to monitor more patients who are taking opioids on the general floor, who are under respiratory distress or have cardio-related issues. And we've got data that shows there's better outcomes. And you can actually reduce the cost of care by lowering the ICU transfers and some of the related costs around that are created by some of those diseases of the patients you're managing.
So, I think what we could see is it's hard to make a decision on if you're a hospital and you've already got half of your beds that you're monitoring. It's hard to say they wouldn't. How do you pick and choose which patients you monitor? And I think with the clinical data that we have, especially with the Dartmouth-Hitchcock studies and those longer 10-year studies, it shows the benefits. And I think that that's what can be a catalyst for greater adoption. I think it could you could see an environment where we get up to 70%-90% of penetration over the long term. But I think it's going to be a steady adoption over time.
And I also think that it's that last, call it 10%-30%, maybe where you got to reach those smaller, more community, rural community hospitals where they're more budget conscious. So there's a lot of work to do ahead. But we've definitely seen a lot more demand for it.
Yeah. Turning to Masimo Safety Net, which you've referenced a couple of times. Gosh, I know it's the earliest possible moment of thinking about this opportunity and where we could go. But where do you again, what's ahead? What should we expect over the next couple of years? Is this going to be driven by maybe the new products that are coming out? And just at a general level, maybe if you could update us. I think last I recall, you were in like 200 hospitals have these kind of programs. What's next? What are the key catalysts there?
Yeah. When we pivoted on Opioid Safety Net and launched Masimo Safety Net for really COVID patients during the pandemic, that's when we started to get the adoption through these hospitals, and we have, I think, over 200 now, as you mentioned. A lot of these hospitals are even more interested in these longer-term chronic disease type management programs. I think the utility of Masimo Safety Net is really managing things like COPD, CHF, and the home environment and really helping these institutions manage those patient populations, so right now, and then more near to midterm, I think that that's got a big opportunity for it because it's not as tied to reimbursement as Opioid Safety Net is. If you think about it, these disease management programs with these hospitals, as they start to implement these things, they can manage that through a DRG code for the patient.
So it just becomes an operating expense. Our technology has become an operating expense line item for the hospital. And there's a lot of interest right now. So we're working through some pilots right now. And hopefully, that'll translate into some contracting we can talk about here soon.
So we might hear at some point there will be some press release talking about contracts like that. And just in simple terms, is that potentially incremental growth as we contemplate 2022, 2023? Or is that too soon to expect something like that?
Yeah. I mean, going back to kind of our long-range plan, we've set 8%-10%. That's really the core parameters. So all these hospital automation, home monitoring, Opioid Safety Net, a lot of these are additional shots on goal above that growth rate. They can definitely grow faster than what the growth we're seeing overall in the business today to help contribute.
That's well said, and where do you think we are now with hospital automation? I think there, again, I'm saying this maybe I'm more vague. It's like you're in 4,500 accounts. How big an opportunity is it, and again, same kind of question. What are the next steps forward for Masimo in this space?
Yeah. I mean, we're still early in the adoption of hospital automation. We're very well positioned. Still, our revenues are only about 2% in hospital automation of our overall revenue. So it's not a big we're still a long way to go to penetrate that large market opportunity. And we think the market long term is $1.5 billion is what we sized up at the last Investor Day. So right now, we have not only as we gain new customers, we try to bring them onto hospital automation and service revenues that come out of that. But we have a pretty large existing install base today that, as I mentioned before, we've been connecting beds with Patient Safety Net for nearly 15 years. And that install base grew 50% over the last two years.
And if you look at it, just our existing install base, we're only 20% penetrated with service revenue. So we've still got a lot of opportunity just with our existing install base, let alone as we gain new customers. So we saw hospital automation contribute about a half a percentage point to growth as it grew well above our 10.5% last quarter. And we think that that's going to be a nice tailwind of growth for us for many years to come.
Yeah. A lot of folks these days are talking about Connected Care. I know you've been asked about it on calls, and you've answered it, but from another angle, I was curious, as I turn to capital allocation, one aspect of it obviously is going to be M&A and tuck-in technology or tuck-in deals. Should I worry? Are you worried that all these folks thinking they're Connected Care companies are going to be more competition and drive prices up or get in your way as you try to add to the Masimo portfolio of technologies?
I'd actually encourage competition. And the reason is I think it's just more marketing for it just shows that it's relevant in the hospitals. There's utility. And it can drive better outcomes for patients. It can drive more efficiencies for the hospitals and the systems. And we've always been a company that's had pretty open arms where we connect and play. I mean, we welcome co-opetition. And that's what we're seeing with two of our kind of primary competitors too in the hospital automation world is Philips and Hillrom, for example. And they've got great connectivity platforms as well. And we definitely interact with those platforms and cooperate with those platforms.
So I think where we differentiate ourselves more is going beyond connectivity and just getting the information in the EMR, but being able to manage that data flow coming from the patients in real time, all that information throughout the hospital. And we can distribute to any endpoint in the hospital, whether it's a central nursing station, whether it's alarm management escalation through our Replica software so nurses can interact better and respond to those patients. Or it's back in the OR room where we can centrally display on our UniView software that the care team or the surgical team needs to see, that's right in front of them where they don't have to look on these small monitor displays. And then we've got the advanced algorithms. What we do best with the data is really taking the data and doing analytics, scoring, decision support.
That's some of the things, the elements we'll be able to roll out over time to continuously improve. That's going to drive more competitive advantage for us over time as we deploy those algorithms.
And so back to this notion of capital priorities, how are you thinking at a time when rates could start going up and your balance sheets in superb shape and LiDCO integrations underway? How are you thinking about the year ahead and your priorities?
Yeah. Now, as far as capital allocation, number one priority is M&A. We definitely have an active pipeline. A lot of the targets you've seen of the deals we've completed have been more tuck-in, smaller tuck-in acquisitions that I love those because we can take great technology and leverage our commercial footprint. We're in our share of the market in pulse oximetry approaching 50%. We're in over 150 countries. We've got a large clinical footprint. TNI, Connected Care, LiDCO acquisitions, all those, they were limited markets that they were in. One was in Germany. One was in the U.K. We can now take that and leverage it across all of our global commercial footprint and drive even greater results than what they could on their own. We'd like to take great technologies, integrate them well, and leverage that commercial footprint.
That's the ones that have been mostly through our pipeline. We're not afraid to do a larger deal if it's strategic and it meets a lot of our criteria that we take it through. But valuations have been tough over the last several years of getting some of those bigger deals done.
Yeah, I can believe that you're not alone. One question I often get is related to your potential focus on the consumer aspect of monitoring, and you touched on it several times in different ways in this conversation. What do you say to somebody who's worried and anxious that Masimo might not have the expertise or the people or the capability to do in the consumer side of the monitoring world what you've done in the hospital side?
I would say we've hired some very talented people in the area of consumer from some of the large companies, and they're on our staff now, so we've got a lot of great expertise that came in-house over the past two years. We've got a consumer marketing leader who's phenomenal, and I think we're advancing a lot of our marketing capabilities, especially as we start to gear towards more home health and consumer and health and wellness, so I think we're positioned well there, and we've got a business inside the hospital that we've already got a lot of that built out, and that continues to kind of run, and so we feel good about where we're positioned right now, and we've got a lot of exciting new products to talk about here soon.
That's great. Just out of curiosity, flu season the last couple of years hasn't been a big deal. People seem to over-focus on it, I think, relative to Masimo. But how are you thinking about the setup as people take their masks off? And how are you going to talk about and dial that into your thinking as we think about the finish to this year and, more importantly, the start to next?
Yeah. It's still early to determine how the flu is going to play out this year, especially with whatever protocols are in place at the time as we get further into the winter months. But I think flu season may contribute 0.5 percentage points to growth in a heavier year. And we've been kind of thinking about it as kind of just an average year so far. But we'll see how it plays out. It's just early to really talk about the flu season.
And just last, Micah, just as a big picture, what are the major puts and takes that you're thinking about as you look ahead to 2022 at a high level?
Yeah. I think one thing as we're working through the planning process, I mean, I'm excited about some opportunities with some of our newer market, which is LiDCO. Taking LiDCO's as I mentioned before, they were only in the U.K. Now we're starting to launch that product in the U.S. this year. And you start to combine LiDCO's cardiac output measurement with Rainbow SpHb and PVi, you now have a pretty comprehensive solution for hemodynamic monitoring because you've got cardiac output, fluid responsiveness, and oxygen delivery. So I think those combined can give us a great opportunity to really drive that market and really gain some share there. And I'm pretty excited about it. I think that's a near to mid-term, medium-term opportunity for us. And I think it could contribute to our revenues next year. And I think another opportunity is just, as I mentioned before, home monitoring.
We'll see how well those pilots go, those programs, and see if that translates into some contracting that could contribute as well next year. So those are a couple tailwinds that we're looking at. I think anything tied to elective procedures will be a tailwind opportunity as we go into next year as well. Because if you think about our products, it's really SpHb. It's Rainbow. It's PVi. And it's also SedLine and O3, and those have been compressed over the past during the pandemic. And as procedures get back to pre-COVID levels, that's going to be a tailwind for us moving forward. And then just the last couple of things is still trying to work through the gross margin expansion, trying to meet those commitments that we put out there in our long-range plan and offset any potential supply chain headwinds we have. And currency.
Currency is another thing we got to look at because dollar strengthened quite a bit. So when I look at kind of what the analyst expectations are out there, I'd say it's probably implying a 10% constant currency growth rate at least already. So yeah. So I think that's something that is a headwind as well we got to consider, so.
On that note, sadly for me, but happily for you probably, we have to leave it there. Micah, Mike, Eli, thank you so much for being here. Really appreciate it and all the great information. And clearly, it's going to be an exciting year ahead for another one for Masimo. Thanks again.
All right. Thanks, Rick. Take care.
All right.