Welcome to the First Quarter 2020 Stryker Earnings Call. My name is Christine, and I'll be your operator for today's call. At this time, all participants are in a listen only mode. Following the conference, we will conduct a question and answer session. During that time, participants will have the opportunity to ask one question and one follow-up question.
This conference is being recorded for replay purposes. Before we begin, I would like to remind you that the discussions during this conference will include forward looking statements. Factors that could cause actual results to differ materially are discussed in the company's most recent filings with the SEC. Also, the discussions will include certain non GAAP financial measures. Reconciliations to the most directly comparable GAAP financial measures can be found in today's press release that is an exhibit to Stryker's current report on Form 8 ks filed today with the SEC.
I would now like to turn the call over to Mr. Kevin Lobo, Chairman and Chief Executive Officer. You may proceed, sir.
Welcome to Stryker's 1st quarter earnings call. Joining me today are Glenn Boehnlein, Stryker's CFO and Catherine Owen, VP of Strategy and Investor Relations. For today's call, I'll provide opening comments, followed by Catherine with some perspectives on our mix of deferrable and capital businesses. Glenn will then provide additional details regarding our quarterly results and liquidity position before we open the call to Q and A. As you know, Catherine will be shifting out of a role on June 1, so this will be her last Stryker earnings call.
While this is not quite the finish she had in mind at the end of February, I did want to take a moment to express my gratitude for her outstanding work the past 13 years. She has been a great help to me and the management team of Stryker. Also, if you include her time covering Stryker as a sell side analyst, this will be her 97th Stryker earnings call. She has seen a lot, but nothing quite like what we are going through right now. On today's call, we will review our Q1 results and provide additional details regarding the impact of COVID-nineteen on our businesses in March and into the Q2.
And we will also highlight many initiatives underway to ensure we maintain strong cash position through stringent cost controls to manage through this unprecedented environment. For Q1, we achieved organic sales growth of 2.4%, reflecting strong momentum through the 1st 2 months of the quarter and into March, followed by a marked slowdown tied principally to a deferral in elective procedures. We took a number of steps in March to aggressively limit travel to ensure the safety of our employees and customers, while ensuring our essential personnel were available to support healthcare workers around the world. These efforts, along with other cost controls, helped to mitigate some of the impact on earnings from the slowdown in sales, resulting in adjusted per share earnings of $1.84 a decline of 2% versus the prior year. The sales drop became more pronounced towards the end of March and in the last week of the month, our company sales declined 30% versus the prior year.
The biggest declines were in hips, knees, spine and endoscopy, offset by our other businesses. By geography, Japan, Canada and smaller countries in Europe and emerging markets performed well, while China was clearly the weakest. In Q2, we expect a recovery in China, but most other geographies will get worse given the spread of the virus. For the month of April, our company sales will decline by 35% to 40% versus 2019. Looking at the remainder of the quarter, we are encouraged by the planned gradual resumption of elective surgeries in the U.
S. And abroad. Our portfolio of products are being impacted by COVID-nineteen in numerous ways. Clearly, we are seeing a deferral in elective procedures, particularly within our orthopedics and spine businesses. We fully expect given the chronic and progressive nature of the conditions impacting these patients that the vast majority of them will be treated in the coming months, recognizing that the exact timing of a broad resumption of elective procedures is too fluid to predict.
And as hospital needs to treat COVID-nineteen patients escalated sharply in March and into April, we saw a significant increase in the demand of products across our roughly $2,000,000,000 medical portfolio, which Catherine will discuss in more detail. In response, our manufacturing teams have been aggressively ramping capacity of much needed products, while also ensuring we scale back other plants where demand has been negatively impacted. Overall, given our mix of businesses and the cost control initiatives underway, coupled with our strong balance sheet, we believe we are well positioned to manage through this slowdown. Given the fluid nature of the current situation, we are not providing Q2 or full year guidance. However, we expect to maintain the cost control efforts for most of 2020.
We are also setting ourselves up to respond quickly as customer demands return. We are providing financial assistance to hold our sales forces in place and continue to invest in our pipeline of new products. We are proceeding with integration efforts regarding Wright Medical and given the impact of the virus on competitive hiring, we are expecting a minimal level of sales force attrition. As was publicly announced, Wright held its shareholder meeting on Friday, April 24 and the deal was approved. This reduced the tender threshold from 95 percent.
The tender offer was extended until June 30, which is customary as we continue to work through the closing conditions. We expect to close around the end of Q3 2020. Please note beyond this update, we have no new information to share with you regarding Wright Medical and we will not be taking any questions on this pending acquisition during today's call. Before I turn the call over to Catherine, I would like to take a moment to thank all of our employees around the globe for their commitment to ensuring the safety of their colleagues, their families and our customers. Our sales forces across our businesses who are essential to supporting doctors and caregivers have demonstrated unwavering commitment during this pandemic.
Our manufacturing teams have worked tirelessly to optimize the plant network and to ramp capacity where needed, and we have created rapid innovations in response to the pandemic. We will continue to support our employees and our customers as they work to meet the needs of the many patients that will need treatment. While our many year growth momentum has been temporarily derailed, the Stryker spirit is alive and well and we remain poised to capitalize as the situation improves. And now over to Catherine.
Thanks, Kevin. My update today will focus on providing greater granularity around our mix of businesses that are particularly impacted by the COVID-nineteen virus. Overall, we estimate that 40% to 50% of our total global This includes primarily our orthopedic businesses, including hips and knees, extremities, as well as spine and Neurotech's ENT. There are also procedures within our endoscopy portfolio that can be deferred, including some of the scoping procedures and sports medicine. Additionally, with many states and countries having implemented or recently come out of stay at home orders, we have seen a slowdown in trauma.
This can be attributed to fewer people out driving, a slowdown in construction and general decline in overall activity that traditionally drives trauma procedures. Unlike truly elective procedures, the patients deferring surgeries addressed by our products will not improve with time, rather their underlying conditions generally continue to deteriorate. So while the exact timing of the resumption of elective procedures to more normalized levels is difficult to predict at this point in time, we do anticipate the vast majority of patients treated by our products will return. We also assume the resumption of procedures will continue to vary by country, state and municipality as they increasingly move past the peak impact of the virus. In contrast to the impact we are seeing from deferred surgeries, other parts of our portfolio are experiencing significantly heightened demand as Kevin noted.
This is most noteworthy for our medical business, which had sales of roughly $2,300,000,000 in 20 19 or approximately 15% of total Stryker revenue and is comprised primarily of capital equipment. It's important to recognize that our capital equipment portfolio, which represented about 25% of our total sales in 2019, includes both large capital and small capital at about 9% 16% respectively. Our large capital equipment offering includes Mako, Bevs and Structures Within Medical, Endoscopy's communication portfolio and spine's enabling technology, which includes Mobius and navigation. Turning to smaller capital equipment, this bucket includes medical emergency costs and defibrillators, endoscopy's cameras, instruments power tools and waste management and neuro powered instruments that are reported within neurotechnology. Of note, small capital is typically used in the OR and as such tracks more closely to growth in procedures.
Against that backdrop, we are seeing strong demand across essentially the entirety of the medical offering, including beds and stretchers, physio, emergency costs and Sage. We are also seeing meaningful increase in demand for instruments flight personal protection offering, which is included in their base product portfolio within surgical technologies. Across the board, we have ramped capacity to meet the current demand and what we anticipate will be ongoing demand as hospitals look to better position their capacity and stockpiles going forward. In late March, we developed the Stryker emergency release bed, which helps emergency responders manage patients efficiently during this critical time. We started manufacturing this low cost bed at the end of March, which broadens our medical offering beyond ICU and med surg beds to better meet customer needs.
Other efforts to assist with responding to COVID-nineteen include the production of face shields for healthcare professionals and a new patient protective covering product, which attaches to our ambulance structures. Overall, while the slowdown in elective procedures has and will continue to impact our top line, we are able to leverage our unique product portfolio and offset part of that impact through demand for our medical and instruments offering. We expect this trend will continue into Q2 with an ongoing gradual increase in elective procedures. With that, I will now turn the call over to Glenn.
Thanks, Catherine. Your comments are as insightful as always. Today, I will focus my comments on our Q1 financial results, related drivers and certain liquidity matters. Our detailed financial results have been provided in today's press release. Our organic sales growth was 2.4% in the quarter.
These results included U. S. Growth of 2% and international growth of 3.3%, recognizing that approximately 75% of total sales, our business is significantly weighted in the U. S. As a reminder, this quarter included 1 additional selling day as compared to Q1 2019.
Pricing in the quarter was unfavorable 0.4% from the prior year quarter, while foreign currency had an unfavorable 0.9% impact on sales. During the quarter, our growth was significantly negatively impacted by reductions in elective surgeries that occurred in the last 2 weeks of March. This impact was most pronounced on our joint replacement procedures. In light of the current environment, we wanted to provide additional detail with respect to our businesses and geographies. For the month of April, our U.
S. Orthopedics and spine sales were down roughly 65%, while MedSurg and Neurotechnology posted declines of roughly 25%. Asia Pacific declined roughly 20%, while Europe was down nearly 55%. Our Latin American business was solid delivering 20% growth for the month of April. Our adjusted quarterly EPS of $1.84 represents a decline of 2.1% from Q1 2019.
Our Q1 EPS was negatively impacted by $0.02 from foreign currency, which was slightly higher than our previous expectations given currency fluctuations. Certain other factors resulted in disproportionately negative impacts on EPS, including the loss of higher margin sales and a loss of leverage related to manufacturing and operational fixed cost. In addition, the lack of share buybacks in Q1 2020 resulted in a higher than average share count outstanding. I will now provide some brief comments on segment sales. Orthopaedics had constant currency and organic decline of 1.2%.
This included U. S. Growth of 0.3%. This growth included positive impacts from knees, trauma extremities and Mako. Internationally, orthopedics had an organic decline of 4.3%, which primarily reflects an earlier downturn in certain geographies.
MedSurg had constant currency growth of 7% and organic growth of 6.3%, which included a 5.6% increase in the U. S. Instruments had U. S. Organic sales growth of 10.8%, driven by gains in their surgical cutting blades, waste management, SteriShield, surge account and smoke evacuation product lines.
This performance was particularly impressive given the tough comps from Q1 2019 and further validates our decision to split the sales force into orthopedic instruments and surgical technologies. Endoscopy had a U. S. Organic sales decline of 2.9%. This reflects positive growth in its core video and general surgery products, offset by a slowdown in its communications and sports medicine businesses.
The medical division had U. S. Organic growth of 9.1%, reflecting strong demand across its bed and emergency care businesses, which accelerated meaningfully in the latter part of March owing to demand tied to COVID-nineteen. Internationally, MedSurg had organic sales growth of 9.1%, reflecting a slower impact to capital businesses in key geographies. Neurotechnology and Spine had constant currency growth of 1.5% and organic growth of 0.3%.
Our U. S. Neurotech business posted constant currency growth of 0.2% and a 0.6% organic decline for the quarter. This reflects a slowdown in procedures in the latter half of March and some temporary supply disruptions during the quarter. Internationally, Neurotechnology and Spine had organic growth of 9% and reflects balanced growth across most geographies and businesses.
Now I will discuss operating metrics for the quarter. Our adjusted gross margin of 65.3% was unfavorable 50 basis points from the prior year quarter. Compared to the prior year, gross margin was unfavorably impacted by price, acquisitions, business mix and fixed cost absorption, the latter 2 of which were more pronounced during the second half of March. Adjusted R and D spending was 6.4% of sales. Our adjusted SG and A was 34.8 percent of sales, which was 40 basis points unfavorable to the prior year quarter.
Compared to the prior year, SG and A was unfavorably impacted by business mix, deleveraging of selling and marketing costs and foreign exchange, and this was partially offset by operating expense savings actions taken during March. In summary, for the quarter, our adjusted operating margin was 24% of sales. Given the current environment, we enacted measures in March covering most of our discretionary spending. These included curtailments in hiring, travel, meetings, consultants, as well as the idling of certain manufacturing lines and facilities, including furloughing the related workers. Subsequent to March, we also have enacted salary reductions impacting most of our leadership positions.
Related to other income and expense, we saw a benefit in investment income, which was partially offset by increased interest expense related to the Eurobond offering that was completed late last year. Moving forward though, given an unexpected decline in investment income earned on deposits and the impact of other rate changes, OI and E will increase by approximately $5,000,000 to $8,000,000 per quarter. This does not include the impact of any additional debt issuance for Wright Medical. Our first quarter had an adjusted effective tax rate of 14.3%. Included the benefit related to stock compensation expense and other discrete items.
Turning to cash flow and liquidity. We ended the Q1 with cash and marketable securities of $4,000,000,000 and generated approximately $591,000,000 of cash from operations in the quarter. This is ahead of our internal targets and significantly more than in Q1 2019. This reflects increased earnings and a reduction in working capital primarily driven by accounts receivable during the quarter. As I noted in January, we did not repurchase any shares in Q1 nor do we plan to do so during the remainder of the year.
In addition to the discretionary spending controls I previously outlined, we've also taken steps to conserve cash, including reductions in planned capital expenditures and project spending, focusing on opportunities and accounts payable and slowing M and A activities. Considering our cash holdings and available credit lines, from a liquidity standpoint, we are well positioned. We currently have available credit lines, none of which are drawn on at this time of approximately 3,000,000,000 dollars In addition, our investment grade credit rating supports good access to the capital markets and we would anticipate taking advantage of historically low rates to complete the funding for Wright Medical. In terms of future capital requirements, our quarterly dividend is approximately $215,000,000 and we have $13,000,000 bond maturity due in Q4. As it relates to guidance for Q2 and the full year, we reaffirm our previously announced decision to withdraw guidance given the significance of uncertainties at this time.
We will continue to evaluate operating circumstances and the market environment for stability prior to reinstitution of guidance. And now I will open up the call for Q and A.
Thank
Your first call comes from the
line of Bob Hopkins from Bank of America. You may proceed.
Thank you very much and thanks for taking the questions and congrats to Catherine, 97 is a big number. Couple of two quick things. 1, first, Kevin, for you, I'd love some help in how to think about your capital businesses. I'm just curious, are there scenarios where you think the increase in demand that you're seeing last more than a few quarters? And then just generally what could happen to growth on the other side of the demand surge?
So Bob, I'll take that the first and then I'll pass it to Catherine. As it relates to large capital, I think Catherine provided you a breakdown of our large capital in her prepared remarks. The beds and stretchers are the ones experiencing kind of a spike in demand. And at this point, it's really too difficult to ascertain whether that's pull forward or whether that's just extra demand because there is this need to build stockpiles. There is this need to have beds, a certain number of beds and an expansion of beds primarily related to coronavirus, but it may not be something that's just pull forward.
It may be additional demand. As it relates to the other large capital communications Mako and those other components, those that's going to start to slow down as you probably would imagine. We're not seeing orders being canceled, but there is a bit of deferral going on and that I would expect would continue to pick up in the future. And maybe I'll turn it to Catherine to talk about small capital.
Yes, Bob. First of all, thank you. It's I would say if you look at small capital, that's about 16% of the total and it does tend to track with surgeries. So that business has not benefited anywhere near to the same degree as the medical, particularly beds and stretchers have. So I think you're going to see that be more in line with that elective procedures come back on.
And some of it is going to be tied to hospital liquidity. And keep in mind, through Flex Financial, we have a lot of ability here to help hospitals think about different constructs to finance those purchases. So it's very different from the Great Recession in terms of how medical business is being impacted. But I do think there's going to be continued uncertainty around the pull forward because we just don't have a strong sense yet what the new norm is going to look like for stockpiling.
And I guess just one quick follow-up sort of another big picture question. Devin, a few of the other medical device CEOs have offered up that they think growth could return by the Q4. And I'm just curious if you from what you're seeing in the world and in terms of what you're seeing from your customers, do you share that optimism or are you a little bit more cautious? Thank you.
Well, thanks, Bob. As you can imagine, we've run a lot of scenarios and I don't have a crystal ball, but certainly that is a scenario we think could very well happen. The pent up demand is there. I think the recovery will probably come in waves. So you have a number of employees that are furloughed that would love to get their procedures done now, while they have healthcare coverage, worried about what could happen in the future.
That could be a first wave of resumption of procedures. And then you also have people who have taken time off and that may not be able to take the time off later. So that could cause a slight dip and then a resumption again. But it really is going to relate to how the overall economy recovers and how the virus evolves in the future. But that certainly is a scenario that we believe could happen.
But again, this is uncharted waters, so we'll see.
Your next call comes from the line of David Lewis from Morgan Stanley. Please proceed.
Good afternoon. I echo Bob's comments, Catherine. Congratulations. Just a couple of quick questions for me. I wanted to follow-up a little bit on maybe a different way of focusing on Bob's question.
But there's a view, Kevin, right now that amongst some of your peers, the economic exposure to recon is somehow different. So that's versus other device procedures, it's somewhat less that are more or less deferrable, orthopedics is sort of more deferrable. What are your thoughts around the economic sensitivity of hips and knees? It's sort of perception that they are very economically sensitive, but the data is not exactly clear. And this is leading to a notion that people think ortho would recover after other types of medical device implantable procedures.
What's your view on that economic exposure in your recovery relative to other med tech?
Well, David, I mean, obviously this is uncharted waters as I mentioned at the end of my answer to Bob's question. But what I would say is the hospitals are very motivated to do our procedures. If you think about orthopedics and spine procedures, they are moneymakers for hospitals. And the hospitals who are treating coronavirus patients now are bleeding in their P and Ls. So there's a financial motivation.
Also patients certainly that are suffering would like to get those procedures done. So I'm not in some of the other spaces of other elective procedures. So it's hard for me to do a compare and contrast. But the hospital CEOs and the surgeons that I've spoken to are all absolutely gearing up to start bringing back their patients. And the surveys they've done with patients have suggested that patients are very comfortable coming back as soon as the hospital is safe, it's going to be safe for them.
I think those patients will be coming back. So I don't believe that there's something unique about orthopedic surgery that would cause that to be pushed to the back of the line. On the contrary, given its economic impact to the hospitals, I think it could be moved earlier in the chain.
Okay. But very helpful. And then just a related question. Just Glenn gave us some numbers on the percent decline in April 4 for your procedure. So a couple of questions there were just have you seen in recent days or rolling 7 day average a recovery or any kind of bounce off the trough for your orthopedic procedures?
And there's been a lot of discussion around inpatient versus outpatient. Have you seen a difference in terms of how procedures are recovering if they are in inpatient versus outpatient? And is there an opportunity to use this particular pandemic as a way of pushing more procedures to the outpatient market? Thanks so much.
Yes. David, there's a couple of questions in that. I think the first one, the percentages that I gave you are absolutely up to date. And so I don't have any sort of further data or information that would support a bifurcation of that. In terms of looking at what's going to outpatient or what's inpatient, I think it's still too early and it's still dynamic and it's evolving in the moment.
So it's something that we obviously are watching very closely. And as soon as we have data or monitoring on it, we would provide that. But I'll let Catherine comment on that as well.
Yes. I just would follow-up, David. Just keep in mind, the shift to recon procedures in the ASC setting is already underway. This probably continues us down that path, but there's only so much capacity. There are about 300 ASCs in the U.
S. That are doing hip and knee procedures. They are essentially running at full capacity. Now they may be able to do more by staying late later or working weekends. But that is really dwarfed by the number of hospitals in the U.
S, which is about 5,000. So I think you're going to see the shift continue, but I wouldn't expect some massive seismic change in the trend because the capacity just isn't there to absorb it.
Your next call comes from the line of Vijay Kumar from Evercore ISI. Please proceed.
Hey, guys. Thanks for taking my question. And maybe one on the robotics side. I know it falls into the large capital bucket. Is there a view that either hospitals see this as a differentiated investment as a way of differentiating themselves from peers?
So when we think about in the post COVID world, the demand should normalize for something like Mako? Or just maybe give us some color on how we should be thinking about Meijer? Because there is a view of that as systems are capacity constrained, maybe utilization of robotics might lag a little bit here.
Yes, thanks for the question. I would say that those surgeons that are believers in Mako or believers in robotics will resume their normal amount of work. We had terrific momentum. You can even see if you look at in the line of other orthopedics, it performed very well in the quarter. We did see a bit of a slowdown in some of the Mako orders being delayed a little bit.
So liquidity of the hospitals is important when you're outlaying large amounts of money. But we see tremendous signs of continued interest. No orders being canceled, just being delayed a little bit until elective surgeries resumes. And yes, hospitals do see it as a differentiator and we continue to be very bullish about the prospects of Mako. Underscoring what Catherine said earlier about Flex Financial, I think that's something that we're going to use even more probably as ASCs want to acquire Mako's, they don't typically have the same size of capital budgets, but we have a number of different vehicles to help them finance their capital.
And so we do expect Mako to absolutely resume the trajectory we're on once the elective surgery comes back in force.
That's helpful, Kevin. And maybe one for Glenn. On the cost structure, fixed versus variable, how should we think about decremental margins here as you think about the next, call it, 2 to 12 months? Thank you.
Yes. At this point, just given sort of the fluidity of the situation and looking forward, I'm not sure that I can guide you to an exact sort of margin number. I will say that to the extent expenses are discretionary, but I've mentioned travel meetings,
manufacturing
employees manufacturing employees that are at facilities, where we've slowed down or stopped certain lines. It's really difficult to sort of predict our exact operating state. I do think some of those expenses obviously will come back as we ramp back up. But at this point in time, as I think about our future cost structure, I do anticipate that many of these things will be impacted and we'll feel the impact from them throughout the remainder of this year and frankly on into 2021.
Your next call comes from the line of Matt Miksic from Credit Suisse. You may proceed.
Hi, thanks for taking the questions. Just one follow-up, if I could on ASC for Catherine, your comments on the number of orthopedic oriented sort of ASCs out there. Could you talk a little bit about the potential impact on spine? And then I have one follow-up.
Yes, sure. I can take the first part of that. Okay, sorry, Catherine, I'll start that. So spine procedures are done in the ASCs, but they tend to be the more basic procedures like ACDS. So it's not an enormous part of the overall spine market.
And we think we're well positioned there to be able to deliver the products needed for those procedures. Sorry, Kathleen, go ahead.
No, nothing additional. Just to say it's probably low single digits, the percent of spine procedures that are done in the ASC setting at this time.
Got it. Okay. And then on just some of the to your point about the bulk of the lift here in terms of returning to elective orthopedic procedures, sounds like from your description needs to happen in acute care centers. What are the next steps that you see happening there? What are the constraints, I guess?
States are just starting to open up. Is it the middle of May? Is it some percentage of utilization that we start to see? What would be the things that you expect to see over the next several weeks to help us understand if that's happening and to what degree?
I think it's going to be very gradual. We're seeing states and not just in the U. S. Overseas, they're moving slowly and it really just depends where they are in meeting guidelines, where they are in peak cases. So we don't have a perfect formula to tell you what it's going to look like.
It just seems to be pointing in the direction and this is uncharted territory, but pointing in the direction that we're going to continue to see more and more states resume elective procedures. Those patients need to be treated. As Kevin indicated, it's a profitable procedure for hospitals. And so I think it's just going to be gradual. So we're probably in a better position months from now than we are today, but it's also very much a wait and see as hospitals get increasingly comfortable and start to recognize the new norm of how they deal with COVID patients, while also recognizing they have to treat the broader spectrum of patients.
Yes. The only thing I'd add to that comment is a lot of hospitals are actually gearing up to be able to work extra hours even on weekends. They won't do that day 1. Obviously, they're going to gradually start to bring patients back, but that's something they're planning for in the back half of the year. And so I do expect, as I mentioned before, seeing this recovery come back in waves is pretty likely.
Your next call comes from the line of Larry Biegelsen from Wells Fargo. You may proceed.
Thanks guys. Thanks for taking the questions. One product question and one kind of big picture question. Just on the April trend of negative twenty 5%, I think for neurotechnology and spine, did that apply to your neurovascular business as well or has that been more resilient? And I had one follow-up.
Yes. Hi, Larry. Yes, that did include our neurovascular business as well in that statistic.
Got it. And Kevin, just taking a step back, what do you think the long term implications are of this of coronavirus for MedTech? And how are you positioning Stryker for success in a post coronavirus world? Thanks for taking the questions, guys.
Well, thanks. That's a big question. I would tell you that I think we're very well positioned given the diversification of our portfolio. Obviously, elective surgeries are very important to us, but we're not only an elective surgery company. And the fact that MedSurg is the largest of our 3 segments certainly helps protect us and insulate us from the full effect.
I think that diversification will serve us well, but and we believe still in our strategy, this is not going to cause a change in our strategy of category leadership and leading positions in all the segments we choose to play in. It's not going to take us off our approach to M and A. We will emerge from this and we believe the fact that we've stayed in conservative fairly conservative balance sheet has really helped us. And even with the upcoming Wright Medical acquisition, we have a very good strong financial position. Things will change.
There will be a lot less travel. I could tell you that we've learned a lot about technology. The way we're engaging with customers through this has been amazing for me to watch, surgeon engagement, hospital engagement, and even our employees. We tend to be a high touch culture and we're learning that technologies, you can do a lot of really amazing education things with technology. So that I think will become a more permanent thing.
And our R and D teams are learning how to work very, very effectively, including surgeon collaborations virtually. So those are the things that will be more, think, more permanent. The trend to ASCs will only accelerate, but as Catherine mentioned, a long way to go still. That pace will increase. Those are probably the 2 things I would point out to.
But other than that, I think we're just going to be getting back to the regular offense that we had before.
Your next call comes from the line of Pito Chickering from Deutsche Bank. You may proceed.
Good afternoon, guys. Thanks for taking my questions. I want to echo thanks to Catherine for lots of your help over the years. First question is, as several states are moving to allow surgeries to start happening again, what is your sales force in those states telling you about what the doctors are planning and how does OR block schedules look in those states?
Thanks, Tito. I don't have any definitive data because it really does vary. You have hospitals, even in New York, where we know they're gearing to resume procedures, elective procedures, hips and knees in particular in May. I think it's really going to depend on the type of hospital or teaching institution or where they're located geographically. So they may be doing more procedures over the weekends, more procedures in the evening.
I think they're all going to be highly motivated. We do know that their wait list of patients is pretty high. We are hearing that the patients, I know there's some concerns, will they be willing to go back to hospitals. What we're hearing when we talk to customers is their wait list remain healthy and patients are listening to their doctors. They listen to them when they said don't have the surgery right now.
And when they tell them it's safe to come back in and they realize they're not going to be going in to get their hip and knee done through the emergency room where their concerns are much greater, they're comfortable with it. But there's no perfect model to say this is how they're going to deal with it. I think there's going to be flexibility in a number of different methods that take place to address the backlog of these patients that need to be treated.
Great. And then for neuro, like you mentioned that there are some supply disruptions that you saw for neuro supply. Can you go look in that a little more and talk about which other facilities you idled and the carryover, the inventory levels for those products? Thanks so much.
Yes, sure. We had you probably heard an earthquake in Salt Lake City, which is one of our manufacturing facilities for neurovascular that caused a slight disruption in that business. And then we also had a bit of supply challenges with the neuro powered instruments portfolio. And those again are temporary in nature. This happens to us from time to time.
Over the years, you hear this in one quarter, we might have a slight disruption in supply. And so those are the 2 things that hit the neurotechnology business, both of which are largely resolved or will be resolved certainly by the time we get to Q3, Q4.
Your next call comes from the line of Caleb Krum from SunTrust. You may proceed.
Thanks guys for taking our questions. So you mentioned that you've made several cost cutting adjustments. So my question is, if demand does return sort of fairly quickly in the 2nd part of this year, Are you comfortable that you have the infrastructure supply and manufacturing employees in place to support that demand?
Yes. Thanks, Kayla. It's one of the things that literally we are meeting almost every other day on in terms of how do we need to position ourselves to ramp back up and getting a good feel for what products will be in demand and where are we from an inventory standpoint with those products and also how are we preparing for our employees to come back to work so that we can meet that demand. So I do feel like we are positioning ourselves very well and we have a pretty good understanding of where we think demand will peak and we're doing all we can to be ready for that to happen.
Okay. That's helpful. And then, you guys mentioned you're slowing M and A activity. So does that effectively mean we shouldn't expect any M and A activity outside of Rite for the rest of the year? Or what would be sort of a catalyst to push you guys to be more sort of opportunistic on M and A in this environment?
Thank you.
Yes. And you mentioned right, we actually have the biggest M and A going on right now that we've ever had ever. So that's one thing that we obviously are focused on. I guess I would say that business development remains sort of an ongoing part of our long term strategy. And obviously, we'll balance potential opportunities with our liquidity position and where we want to be even next year and the following year on liquidity.
But I could see that we would get back to smaller tuck in acquisitions. We have slowed it. We have paused it. We have not turned it off. We're keeping close to the market just to understand.
But I think in some ways, it will allow us to have more time over target and be smarter about where we are choosing to execute on M and A opportunities.
Your next call comes from the line of Robbie Marcus from JPMorgan. You may proceed.
Great. Thanks for taking the question. I wanted to ask about MedSurg. You gave some great clarity into the areas that are benefiting. And Kevin, I think you said it really well, you don't have a crystal ball, you don't know what's going to happen.
But maybe in the two scenarios, one where there is a second wave, one where there is not. Is this a business that you think saw stockpiling or acceleration of purchases here? Or do you think there's still a lot more to come through the rest of the year? Should we see another wave of infections?
Yes. I think the demand we're in some of our categories, we're selling everything we can make right now. So I would say we're a long way from having filled up any stockpiles. So I think if this coronavirus continues at an accelerated pace or if there is a second wave, I would expect a commensurate increase in the sales of those products, be it the pipe protection system and instruments or the majority of the medical portfolio.
Great. And maybe on the financial side, how should we be thinking about free cash flow this year relative to earnings? Are you going to be building inventory here? Anything that we should pay attention to that would change the conversion rate materially from free cash flow from net income to free cash
flow? Thanks.
Yes. I think, Robbie, the single biggest thing we're going to feel in the coming quarters related to free cash flow is just going to be reduced earnings. And frankly, if there's less sale, there's less accounts receivable to collect. And so that will be the single biggest impact I think that we'll feel. We obviously with manufacturing slowed and certain manufacturing
We're
we're very selective in terms of how we think that will come back. So I really think given the uncertainties that we will be facing, we're making very prudent decisions relative to cash conservation.
Your next call comes from the line of Rick Wise from Stifel. You may proceed.
Hi, Kevin, and congratulations, Catherine, we'll miss you. First, Kevin, maybe you could expand on your comments on the international business generally. You highlighted obviously China was the weakest in the Q1 internationally And you gave us the April down 35% to 40%. I think that was a worldwide I wasn't sure if that was worldwide or U. S.
But regardless, are you seeing any signs of recovery in some of the weakest international markets? If yes, maybe you could just give us a little additional color about how you expect those weaker international areas to recover and whether that informs your thinking at all about the U. S?
Yes. Hey, thanks, Rick. What I would say is, certainly, China was the most negative in the Q1. The 35% to 40% number I gave was a global number. So that's what April is finishing.
I don't have the exact number because this is the last day. We haven't closed a month, but it will be in that 35% to 40% range. What we saw in the Q1, certainly China was very negative. That is recovering. I think they're back to roughly 60% to 70% of where they normally were prior to the virus.
So and it's sort of gradually improving. So China is getting healthier. Japan, we had a terrific Q1 in Japan, and I think that will get marginally worse in the second quarter, but they've done a very good job managing it. Same thing with South Korea, we had a very good Q1 and we're not seeing South Korea slowdown. The big wildcard in the international market is Europe and even Australia to some degree where Australia had initially said that they were going to cancel all elective surgeries for the entire quarter and now 2 weeks later, 25% of the procedures are now back and being scheduled.
So that's how fluid it is. Just in 2 weeks, they went from nothing for the whole quarter to back to 25%. So all this to say, it's going to be difficult to predict what happens in the UK, what's going to happen in Germany. And so Europe is the wildcard area. I think it's certainly going to be worse than it was in the Q1.
And how much worse, it's hard to say right now. I think for us, Europe was something in the 55% down range in April. And I think that's likely going to continue throughout this quarter. It should get better towards the end of the quarter. But again, it's hard to predict.
And just as a follow-up on the knee business, maybe you could just again give us a little more color on your high level thinking. I know we don't have all the numbers yet, more to come, but your U. S. Knee business held up relatively well, I mean, honestly. And maybe talk about some of the initiatives that you're pursuing to sustain what would have seemed to be likely outperformance in the Q1 and even under challenging conditions in the second quarter.
Some of the detailed initiatives that you're undertaking with surgeons using Mako, just any additional commentary would be very welcome. Thank you so much.
Okay. Thanks, Rick. I'll start, maybe Catherine can add to it. What I would say, there's nothing magical about our Q1 knee. It's the continuation of the trend of the last 4 years or 5 years, where we've been consistently taking market share.
I'm very proud of the work that our team has done on Mako as well as cementless, both of which, as you saw over the last 2 or 3 years, have had steep increases in their adoption rates. And that continued in the Q1. I can tell you at the end of February, we were feeling really, really good about our knee number. And then just like everybody else, there was a fall off that occurred about midway through March. The fact that it's still ended the quarter in a positive territory for U.
S. Knees is pretty incredible. We're really pleased with that. And so again, it's just continued amazing momentum with Mako and with Cementless, which are both huge portions of the knee sales that we have. And the surgeons are very, very loyal to both Mako and to Cementless based on the great outcomes they're getting with their patients.
Your next call comes from the line of Matt O'Brien from Piper Sandler. You may proceed.
Good afternoon. This is Patrick on for Matt. Thank you so much for taking the questions. I'd like to start on your spine business. In 2019, you made a lot of good progress integrating K2M and getting that business up and running.
So prior to the COVID-nineteen disruptions, I'd love to hear more color as to the dynamics that was happening within that business in January February? Thank you.
Yes. I'm very pleased with how our spine business is progressing. Certainly, in the international markets, you see very good numbers. We even posted pretty good numbers in the Q1. That's a continuation of what we saw last year.
In the U. S, we started to see the improvement really in the November, sort of December timeframe. That was continuing into January February and a number of new products were launched in the Q1. Unfortunately, that got derailed just like everybody else's spine business around the middle of March and we're not immune from that. But I would say I feel as good as I felt about our spine business since the acquisition of K2M.
Every day, we sort of continue to build momentum. And even the Mobius business, which we acquired towards the end of last year, is seeing tremendous demand as some hospitals are actually using it to do X rays of the chest for the coronavirus. So we're actually trying to ramp our capacity of Mobius, which is, as you know, a mobile CT scan and really the only one on the market that's mobile and they're using it for coronavirus. So we're actually ramping that capacity. So overall, the outlook for the future for spine is positive as positive as we felt kind of entering the year.
Great. That's really helpful color. Thank you so much. And I have a quick follow-up, if you don't mind. I'd like to talk about clinical trials.
We're hearing from other MedTech peers that they're seeing anywhere from 6 months of delays on some of their trials. I know Stryker has had a great track record of new product introductions and has a lot of clinical trial catalysts. So is there anything material we need to think about from a clinical trial or new product perspective? And is 6 months the right way to think about some delays due to coronavirus? Thank you.
Yes. I think we're actually pretty fortunate that we don't have any major launches upcoming that are contingent to clinical trials. It's always a timing issue. If you just look at where our neurovascular or our PMA products portfolios are in their lifecycle, We really don't have anything major pending. I think 6 months is a good way to look at it.
We do have some minor delays in approvals. So some products, just getting them approved. If you think about our aspiration products in neurovascular, getting them approved in Europe, they are approved in the U. S. And we had limited launch in the Q1, which is proving very successful, but those aren't yet approved in Europe.
So Europe is just overwhelmed with UMDR and other product approval. So that's more probably in the 3 month timeframe than 6 month. But what's affecting us, at least in the short term, is more around getting products approved outside of clinical trials. And there really isn't anything major that's holding us back from a clinical trial standpoint.
Your next call comes from the line of Kristen Stewart from Barclays. You may proceed.
Hi, thanks everyone for taking my question and I'll echo the commentary on Catherine. It's been really great knowing you both from the sell side perspective and on the company's perspective. You've done a great job just in your role on both on the IR and on the business development front. So I guess, Glenn, I just wanted to go back to the question on this MedSurg and Neurotech down 25 because I would imagine a lot of different moving parts within those 2 kind of categories. Is there any way just to kind of give us a little bit more detail there to just kind of help us understand some of the puts and takes out of imagine on the medical side you're seeing quite a bit of a benefit, probably within the neurovascular as Larry was kind of saying, it's probably one that's pretty defensive.
And then maybe within some other areas within med surg, you're probably seeing a little bit more of a downtick just as some of that's more kind of capital. So any way to just kind of frame some of those moving parts or quantify some of the benefit that you're seeing from COVID that would be really helpful. Thank you. And I have one follow-up.
Okay. Yes, I think, while you did a pretty good summary, but I guess what I would say is, as you look at the number, you're right, medical is showing fairly strong positive numbers. I would say across the rest of the portfolio, it was negative and it ranged anywhere negative from 20% to as much as maybe 40% or 50% depending on the business. Capital is a little lumpy too. So some of the capital businesses were able to deliver and make deliveries during the month of April and so they saw a little more favorability.
I do think that as we move into May, we'll continue to see some of those downturns in that similar trend that we saw in April. It might be a little more pronounced as some of the capital businesses trail off.
Any way to quantify medical? And then my follow-up would just be on gross margins, how should we just think about as some of the plants are seeing lower throughput and you have some sitting idle, are you going to be expensing some of those, the manufacturing absorption costs as period costs or will some of that be capitalized into inventory and will that be a drag that will just kind of sit there and be recognized through cost of goods sold in future periods? Thanks.
Okay, sure. Yes, on the medical, I mean, let's leave it that it's positive. And in the short term, we do sort of see that demand will still be heavy. Moving out, I think medical will be impacted, especially their beds and stretchers business to the extent that that's large capital and there could be liquidity issues with hospitals. On the gross margin question, you're absolutely right.
The single biggest thing that will probably be a big impact in Q2 will be fixed cost absorption. And right now, we don't see that we would be capitalizing that in the balance sheet. We would only be able to capitalize to the extent we actually produce the inventory. And so you'll see that flow through the P and L and that will be more significant and more pronounced than it certainly was in Q1.
Your next question comes from the line of Raj Denhoy from Jefferies. You may proceed.
Hi, thanks. I just really had one question, just a with COVID is that perhaps more volume will shift there over time. And so one of the things I was curious about is if you could maybe just ground us in kind of what pricing environment is, the profitability environment is for you guys when you sell joints into that channel?
Yes, thanks. Right now, the profit profile is very similar to what we see in the hospitals. Most ASCs are affiliated with hospitals. Hospitals have a partial ownership, of course, in the ASC, and they tend to buy the implants on the same price contract that we have for their hospitals. So for us, the profit profile is very similar to what we see in the hospital.
Keep in mind that the biggest savings that they have, they make more money in procedures in the ASC. The surgeon usually has a part of ownership, so they're very motivated. But the EBITDA of ASC is higher than hospital and the big reason for that is the savings in the facility costs. That's really why they make more money in the procedure. They don't need to drive down our implant prices to be able to drive that higher degree of profitability.
Obviously, there are different kind of facilities. You have to make life easy for them in terms of buying. We've created an entire offense around the ASC that I'm really excited about. If you asked me 3 or 4 or 5 years ago, I was kind of concerned about ASCs, not sure how it would be for Stryker's business. Now I'm actually believing that it's going to be a very good thing for us because we have the booms, the lights, the operating tables, the Makos, all the capital, power tools, Neptune Waste Management, everything that they need for the surgery, we can help them.
And we have the disposables and the implants. And wrapping that up in a financing solution gives us a really tremendous advantage as more and more procedures go to the ASCs. So really as of this point, we haven't seen much in the way of severe price pressure.
That's helpful. Thank you.
Your next call comes from the line of Richard Newitter from SCD Silicon Valley. You may proceed.
Hi, thanks for taking the questions. I wanted to ask on the any protocol changes that are happening or that you're hearing about from your customers with respect to reps and the way you deliver your implant businesses to the physicians being allowed in the ORs and the hospital? How is that going to change if
at all? And then I
have a follow-up. Thank you.
Yes. So far, we haven't really seen any change. As you know, today, many of our reps are in the hospitals, our trauma reps, our neurovascular reps. So today, and even if you think about revision surgery or oncology surgeon within joint replacement, Our reps are in the operating room today arm in arm with the medical staff doing those procedures. And so we've heard some there could be some testing required for our sales reps in some places.
That's it's very, very early, making sure they have the right PPE that they were equipped correctly to make sure that they're not transmitting the coronavirus. But other than that, we haven't heard really any discussion about blocking access or limiting access. Again, it's pretty early hospitals are preparing their plans, but mostly what we've heard so far PPE and are they trained and do they know how to put the proper PPE on and potentially having some degree of testing. The same expectation that they would have for their own staff who would be attending those surgeries.
Great. Thank you. And then just on the big ticket capital items, I'm just curious, you said no one's really canceling as of right now, it's more a postponement. I'm curious, what are they saying that they're going to need to see as you have the conversations? What do they need to see to potentially resume their decision making process?
And are you getting the sense these are 6 to 12 month delays or truly just indefinite?
Yes, I think they're temporary delays. I don't think they're indefinite. Look, there's a lot of uncertainty right now. They don't know if they're going to get a bolus of new patients for coronavirus. And the hospitals that are, let's say, New Jersey, New York, those that are at the epicenter or even Detroit, they lose a lot of money while their hospitals are not having elective surgery and while they're treating coronavirus patients.
So obviously, the first $30,000,000,000 has been doled out to the hospitals. The next $30,000,000,000 is coming. The general allocation method didn't provide extra money to those patients, those hospitals that were treating coronavirus patients, dollars 10,000,000,000 of the next $30,000,000,000 is going to be disproportionately pushed to those hospitals. So waiting to receive the money and seeing how much hospital get is very important to their overall liquidity profile. And then as they resume elective surgeries, as I mentioned earlier, that is really going to help up their financial situation.
And so that's what they're waiting for. If the governors declare delays in the elective surgery ramp, their financial situation deteriorates just like ours does. And so that's the that uncertainty has to be sort of wood lifted. And even if they're not back to 100%, if they're back doing elective procedures and they have some line of sight to financial stability, then they'll be inclined to start to make those purchases because they do want to differentiate themselves. They do want to deliver great service to their customers.
And so it's just the uncertainty around their financial stability and their liquidity, which is which they're waiting to resolve.
Your next call comes from the line of Joanne Wuensch from Citibank. You may proceed.
Thank you very much for taking the question and Catherine congratulations. I have two questions that are related. How do you think about the recovery and the procedures that have been postponed? Another management team thought that maybe 0% to 15% would come back in the back half of this year. Can you comment on that?
And then big picture in your portfolio, which ones of your procedures come back first? Thank you.
I'm not sure I got the first part, Joanne. It was 0% to 15% of
Those procedures that have been delayed. So if you had 100 procedures that have been delayed in the month of April or March, what percentage of them come back this year or next year forever?
I think in the procedures that we operate in, virtually all of these procedures come back. I mean these are the osteoarthritis is a degenerative condition. These people are going to need these procedures. And so I would expect that they would come back at least in hips and knees and spine. What we're seeing a little bit in the stroke area, which is kind of sad is a lot of patients are afraid of going to the ER.
And so we thought that that would be largely protected just like trauma cases. That's actually not true. And so they're not they're actually suffering with strokes at home. And so part of that is actually elective, which I would never have guessed. As they get more comfort and as the incident rates and death rates start or continue to decline, which they're doing in many locations, they'll start to get more comfortable going to the ER and you'll see that volume resume.
But me, 0% to 15% seems like a historically low number. We would expect a lot more to come back. What I can't predict is how fast will they come back?
I'm sorry, that 0% to 15% had to do with those coming back in 2020?
Yes. Again, I believe to me that seems awfully low. I mean, with the surgeon surveys that are surgeons and hospitals that I've spoken to, the patients are on the waiting list. They're not they don't want to leave the waiting list. They would like to get their procedures done.
But the big wild card is just how deep is this recession and how to if there are more layoffs, will those people get their procedures? Those are things I can't predict. But to me that sounds low in my view. Again, I don't have a crystal ball, but that sounds awfully low to me. I don't know, Catherine, if you'd want to add anything.
No, I agree, Kevin. I think we just have to wait and see how it plays out. If this is a V or a U shaped recovery, there's different implications. But I don't think we could give any more granularity or specificity.
And then of your procedures, which ones come back first? Thank you.
Again, can't really answer that because it really depends on the locations, the hospitals, are they equipped, can they have a separate facility that's separate from their coronavirus patients. If they can, they'll do whatever procedures they've got the equipment for in those ORs. So for us, I'm hearing a lot of pent up demand certainly in the orthopedic side. Those a lot of those physicians are not employed by hospitals. They might have an affiliation with the hospital, but they're not employed and they are eager, I would say very eager to get back to work.
And they are very lucrative procedures for hospital. So I do believe those procedures will come back fairly quickly.
Your next call comes from the line of Ryan Zimmerman from BTIG. You may proceed.
Great. Thank you for taking the question. I just want to follow-up on Raj's earlier question. It's really around pricing. MedSurg came in positive the first time in I think 8 quarters on pricing.
And it just seems that pricing is a little less pronounced right now. And is that a function of hospitals maybe taking their foot off the gas there? And kind of what are your expectations for pricing in the back half of the year, maybe when they have a little more time to focus on it? Could we see that increase a little bit? And then the second one is a follow-up to that.
And you didn't call out pricing in spine in the press release. I'm just curious if you could comment on some of the pricing dynamics there in that segment of the market. Thank you.
Sure. So first off, in terms of pricing and you think about our portfolio of businesses, generally on the orthopedic side, we have more pricing pressure than on the MedSurg side. And actually even within MedSurg, if you look at some of our businesses that largely sometimes have positive pricing, medical, it would be one of those businesses. So I would say that as you look at Q1 or you think about Q2, business mix is going to really influence where pricing is going to land. And if there's sort of less ortho and more med surg, I would say pricing would be a little muted.
I do think though moving forward, the same controls and pricing sort of procedures and functions that exist in hospitals will always continue to exist. We have always felt pricing pressure and I don't expect that that will let off at all. So I do think that it's not really a function of hospitals getting back to it. For us, it's really going to be a function of sort of business mix within our own sales line. And then on the spine front, I don't have any real specific guidance on spine pricing.
I mean spine is probably within orthopedics, one of the most sort of price sensitive lines that we sell. There's loads of spine companies. I would say if anything, maybe the current environment will drive out some of the spine competitors. And so with less competitors, maybe spine pricing will level out a little bit. But it's really uncertain at this point.
Thank you.
Your next question comes from the line of Josh Jennings from Cowen. You may proceed.
Thanks a lot. Just two quick questions. First is just wanted to check-in on development programs, particularly the Mako new indication development, spine and extremity, I think you have talked about historically, you haven't provided timelines, but does this crisis delay any timelines even though we don't know what they are at this point for 1? And then second, just Kevin being the Chairman of ADMEVENT, any core initiatives the group is pursuing to support the med tech industry? Thanks for taking the questions.
Sure. On the first front, I would tell you, if you look at the R and D spend we had in the Q1, it was very much in line with our normal spend. We are not taking our foot off the gas at all with respect to our R and D pipeline and that includes Mako and future indications. We aren't going to get specific about timelines yet because we're not really ready to do so and we'll keep you posted, but full speed ahead with all of R and D. As it relates to ADVAID, yes, it's been a very busy time.
I happen to be Chairman and this is my going into my 2nd year of my 2 year term. And so we're on weekly calls with all of our CEOs within the industry. I would say the first big focus was ventilators, as you could probably imagine. And now the major focus is on testing, because the diagnostic companies are also members of AvaMed. And really just working with the administration and FEMA in particular to make sure that they have a clear supply signal and trying to get them to get the demand signal so we can kind of have some kind of matching.
And obviously, it's not our job to define the protocols for when do you do live virus testing, when is antibody testing appropriate and serology testing and what companies should do. But we're in active discussions. And I would say testing is it's moved away from ventilators and PPE is still a common topic that we're talking about, but much more of the focus right now has shifted to testing as governments around the world are trying to figure out and states are trying to figure out how to bring people back to work. So that's the big focus right now on testing. And it's I'm really when you're part of that trade association, it really it makes you appreciate this industry.
It's an amazing industry does so much for people, especially in these kind of trying times. And I'm really proud of how the industry has stepped forward to really to help our customers.
Your next call comes from the line of Matt Taylor from UBS. You may proceed.
Hi, this is actually Young Lee for Matt. Maybe just one question. I was wondering, when it comes to your hospital customer finances, do you have a view of maybe how many of them are a little bit distressed in this environment? And how can that disrupt the recovery curve?
Yes. We I don't have insights into what hospitals may be distressed. I mean, my guess is that obviously their cash flow of most hospitals is under stress just because they don't earn as much money treating COVID patients as they might during elective procedures. I do think that between government grants, external financing once hospitals can demonstrate positive cash flow again. And even our own programs with Flex Finance, there's plenty of capital availability for hospitals.
And so I think that moving forward, once things settle down and we see sort of a trajectory ahead, then a lot of those programs will kick in and allow hospitals to sort of reinstate capital buying programs.
Okay. Thank you.
Your last question comes from the line of Kyle Rose from Canaccord. You may proceed.
Great. Thank you very much for taking the question. So just wanted to talk just a little bit about maybe the commercial structure, particularly with the backdrop of some of the cost changes you've discussed. Are you seeing any big picture trends with respect to changing, I guess, the support level or the requirements for what the sales rep does on a case by case basis? And I guess the secondary question is coming out of that is we've seen the potential for groundless models or maybe there's a virtual model in the operating room.
What does that do from the cost structure of what the SG and A line looks from a long term perspective?
So look, at this point in time, we're not really seeing any change to the way our reps provide service and support our customers. I think what we're learning about virtual tools is they can be additive to our offense. The idea of completely replacing our sales reps, you know companies have tried this in the past and it has met with pretty big failure. But I do think there is a role for technology. We are seeing a little bit of this in Japan.
And so I think technology can be an additional tool in our arsenal, certainly for training. And even in terms of support that it provides some benefits, potentially some benefits in SG and A, but I would say those are very modest at this time. It's very early. And I think as things resume, it's going to resume much more in the manner that we saw prior to coronavirus. And then potentially you could see acceleration afterwards.
I think rehab for sure, patients are very comfortable going home and trying to do their rehab at home and using virtual tools. I think you're going to see a lot more of that. There has been some movement that's increasing. I think the surgeon consultations that used to occur in surgeon offices, that's going to be a lot more virtual. That's happening now.
And certainly, the payers are a lot more comfortable paying for that, which they weren't before. But as it relates to the nuts and bolts of our procedures in the operating room, I don't see any dramatic change at this time.
Just one follow-up from a pricing perspective. I appreciate the earlier commentary around spine. I just you talked a lot about physicians in hospitals coming under financial distress. Just are there any expectations for potentially some increased price pressures specifically when you think about the recon side of the business?
We haven't seen any sort of step change impetus for price change within implants. This has been going on for some time. Certainly, our prices go down every year. They have moderated. There really isn't this is not a new impetus to drive significantly reduced pricing.
And so I don't expect I think our price outlook will stay very similar moving forward.
There are no further questions at this time. I will now turn the conference back over to Mr. Kevin Lobo for any closing remarks.
As I said in my opening remarks, I would like to once again thank the frontline healthcare professionals and first responders for everything that they have done and continue to do. I'm also proud of the efforts of our employees who are showing great resiliency in continuing to serve our customers in this difficult time. Thank you all for joining our call. We look forward to sharing our Q2 results with you in July.
Thank you, ladies and gentlemen. This concludes today's conference call. Thank you for participating. You may now disconnect.