ResMed Inc. ($RMD)

Hello, everybody. My name is Brandon Vazquez. For those of you who I haven't met before, I'm 1 of William Blair's medical device analyst, also cover animal health for the firm. I am required to inform you for a complete list of research disclosures and potential conflicts of interest go to williamblair.com. And with that, I am happy to say that we have the ResMed team here. We have Mick Farrell, the CEO; and Aaron Bloomer, the new CFO. Happy to join us here. They're going to give us a corporate presentation as many of the -- as we've been doing all day. We will actually stay in this room for the breakout session, so at the end, I'll come up here. I might give us like 5 minutes to let people trickle in if they're coming from another session. And then we'll do Q&A here. With that, I'll turn it over to Mike.

Excellent. Well, thanks. And I've got the time here, so I'll stick pretty closely to the 29 minutes they got me here on the presentation. Look forward to a lot of questions and a good discussion around sleep health, breathing health and the health care technology delivered at home. Forward-looking statements, you can read on your own. Yes, ResMed is the global leader in the field of connected health and digital health. We have over 26 billion nights of medical data in the cloud. Over 30 million 100% cloud connectable medical devices sold in over 144 countries worldwide. I think 1 of the takeaways from this slide is over our performance since our IPO on NASDAQ in '95 and then on the big board in the New York Stock Exchange in '99 and dual listing in Australian Stock Exchange and in 1999 is our bottom line performance. We'd be in the top quartile plus of S&P 500 with our GAAP and non-GAAP operating margins north of 34% and 36%, respectively. So we're a high performer, fast grower and strong leverage through the P&L in huge markets. But the primary reason, I think, to consider us at a growth conference, like here at William Blair is that, number one, we're in a huge underpenetrated market. And number two, ResMed has the smallest, the quietest, the most comfortable, the most cloud-connected and the most intelligent devices and software solutions. So innovation leader. And number three, just incredible financial performance that we've had, not just in the past, if you look back over 4, 8, 12 quarters. Look over 1, 3, 5, 10 years and then project that forward because given our huge markets, given our market leadership position, we are not changing any of that. And in fact, I'll talk to some megatrends that we believe will bring our company to even greater success on that top and bottom line growth. I think I'll just say this as well, just recognizing the stock and where it's at today, where health care is what, 2 decade loads and medtech are at 15-year lows maybe relative to S&P. I think fadeaway of 15 to 16 on ResMed. I've been with the company 26 years. This is a once in every 2.5 decades opportunity to get into a growth story like ResMed. And we think -- I personally think we should be 5, 7 turns higher than that based on our profile of history and future. This is the history. I won't go into the 5-year performance on top line and bottom line. I think 1 of the particular elements to take from this is not only the leverage we get through the P&L, primarily from gross margin, but also the free cash flow we generate. Really important in a market like this to have cash, and I'll talk to you about our uses of capital back into R&D, back into sales and marketing, but also into tuck-in M&A, and I'll talk through 1 particular acquisition that we just completed yesterday actually. So this is the primary point I talked to on the first slide. We are an incredibly large, incredibly underpenetrated markets. Obviously, this Venn diagram, the 1 that draws you to the center is our core market of obstructive sleep apnea, over 1 billion people worldwide suffocate many times per hour of sleep every night of their life. And left untreated will lead to much greater increases in solid cell tumor cancer than the average patient, will lead to a 37% increase in all-cause mortality and a 55% increase in cardiovascular mortality. And when treated completely reversal on those mortality numbers. The other circles here to look at, insomnia. I'll talk a little bit about our first play there with a software product, but I think there's lots of opportunity there for hardware in the future. Our COPD market, where our high-level bilevels, STs we just launched on our Air 11 platform for the U.S. is targeted at that overlap syndrome as well as core COPD patients with new CMS changes. And then restless leg syndrome, which is the third biggest sleep disorder, 400 million people worldwide, 7% of the adult population. And I'll talk about a technology that we literally just acquired completely drug-free, completely reversible and noninvasive. Sleep doctors write the prescriptions, it goes through our DME channel. I'll talk about all the synergies associated with it. The only other takeaway I'll put here is that I flip those numbers around, I say 80% to 85% of the U.S. market is unpenetrated. And I don't care how you cut TAM and SAM, 80% to 85% in front of us in this country which is the most penetrated in the world is a huge opportunity. But then you look at Europe, where 90% of the opportunity is in front of us. And you look at Asia Pacific and Rest of World, where it's more than 95% of the market is underpenetrated and unpenetrated in our core markets. And I'll talk a little bit about these megatrends. I mean I think awareness about sleep and sleep health is probably the highest it's been certainly in my 26 years in the company, probably in the history of our industry. Sleep is just becoming more and more aware. And it's not just the Apple Watch and Samsung watch, the Galaxy Watch from Samsung that have the ability to actually not only track your sleep, but detect sleep apnea and warn you if you have suffocation episode. But it's also Oura, and I'll talk about our engagement with that #1 ring-based wearable provider and what we're doing with Tom and his team there. But it's also Whoop. It's Garmin. It's Google's Fitbit. These wearables are driving people to care about the 33% of their life that they should be unconscious in full regeneration of mind and body. Slow-wave sleep and REM sleep is where your body resets, the synapses from any stress of the day through REM sleep and regeneration of muscle. Whether you're into sports or whatever you do, your muscles need to regenerate and that happens during slow-wave sleep. If you have untreated sleep apnea or if you have untreated RLS or if you have insomnia, you are not getting deep sleep, slow-wave sleep and REM sleep. It's going to impact every aspect of your life, including your length of life, but most importantly, your quality of life. I'll talk about GLP-1s a little later and talk about how this megatrend, this new drug portfolio -- drug profile, I think will have similar impact to blood pressure meds and statins in terms of cholesterol control. This weight prevention is very important, I think, as a group and as an industry. It's going to be a huge tailwind for ResMed over the next 1, 3, 5 years. I'll talk about the kinetics of that and about how those adds from a player in this field. I don't know if Lilly is at this conference, but when you look at what they're going to invest in the Don't Sleep on OSA campaign, it's going to bring more patients into the funnel than we could have ever afforded or any of the players, including the other pill makers and device makers, and we're going to talk about how we're training in the middle of funnel for our doctors, for primary care doctors and our sleep doctors to best respond to that and bring patients into the funnel. The only other mega trend here is, obviously, you watch the valuation of the sector in tech and semiconductors and Gen AI. I believe that AI can only actually provide value as applied to each vertical. And our vertical of health care, particularly our vertical of med tech is completely untapped in terms of the efficiencies and capabilities that AI can bring in terms of reducing costs and improving outcomes and frankly, improving the engagement of our customers, but -- which includes the doctors, but also the patients and involving them even more in their care. Just to talk really briefly about the strategic lines that we announced just last week with Oura. Obviously, they're going through a process of -- it's now public of going towards an IPO. One thing that we found is that partnering with people of a similar approach to sleep health has been very beneficial for us. And we obviously have partnerships with Samsung and with Apple and the data can go back and forth from our system to Apple Health or Samsung Health, however, you manage your health record. But I think particularly not everyone wears that watch to bed. Very few people actually wear the watch overnight. The battery life isn't there. And so in the field of sleep health, we actually feel that ring-based wearables and some of those other Whoop, Garmin, sports-based wearables are probably a better play to fully understand your sleep health. And from the data that we get from that 33% of your life that you should be in this beautiful unconscious regenerative state, many of you are not. And sometimes, it's a sleep disruption due to breathing issues. And if it is, you're going to see it and you're going to start to see those data. And then our job is to follow this path and make sure that you get a referral to a primary care doctor who's educated in the field of sleep health and ultimately to a sleep specialist who can write a prescription for our products for life and to become a ResMed patient. So this is the whole value change from Stage 1, which is just 8 billion people on the planet to Stage 7, which is people adherent to our therapy for over a year. We're very excited about the fact that we have 33 million patients within Stage 6, 7, right? They're in our ecosystem. We have them in AirView and myAir. But if there's 1 billion people worldwide, 33 million is 3.3% penetration, and you add in all the competition, it's only 5% penetration. So the question is, what else can we do to improve top of funnel, Stages 1, 2, middle of funnel, Stages 3, 4, 5 and our bottom-of-funnel retention, resupply, re-PAP in Stage 6, 7. One thing we have done in these last couple of years is use the incredible free cash flow we have to invest in some strategic acquisitions. We bought VirtuOx, which is a home sleep apnea testing provider, the #1 provider of home sleep apnea tests within the U.S. so that we can help that primary care physician, if they want to refer someone from a home sleep apnea test, they can refer to VirtuOx, and they can take care of it. One click is the goal there, that they're 1 referral and then that patient can be screened, diagnosed and prescribed. On Stage 3, we bought NightOwl. I didn't bring the sample with me, but I don't know if Mike has 1 in the audience. We can do it in Q&A. You can pass around for those of you here in person, a home sleep apnea test, that's literally the size of my fingertip, which is this NightOwl product. It's technology from Belgium. We wanted to challenge -- we don't necessarily want to be the #1 diagnostic player in the planet, but we want to challenge the diagnostics players to say, shouldn't it be the size of a fingertip and as easy as Bluetooth into your phone and the data go to your sleep doctor? That's what NightOwl does. That's the Ectosense acquisition. We also bought Somnoware, which is software for the sleep doctors as they manage their practices, so they can be more efficient and for their data to go back and forth to Epic and Cerner more easily. And then, of course, we bought Brightree, which is basically an ERP or an EHR or both for HME customers. So our U.S. HME customers, the vast majority of them run on Brightree. And it's kind of like, I don't know, how you guys use Bloomberg or whatever your financial terminal, that's how DME's use Brightree. It's everything. That's what they first turn on in the morning. That's what they turn off at night and it helps them run their businesses, lower costs, improve efficiency and improve outcomes. One extra area that we've applied there in terms of acquisitions in the value chain is Snap technologies. That was an add-on to Brightree that helps with resupply. So think every 3, 6 or so months, you need a new mask, you need your tubing, you need your filters. This is the system that allows that to happen. And Snap helps engage with the consumers, with the patients to help bring them through the system. What we just launched in the last 12, 24 months with Snap, it's available not on Brightree. So even though the vast majority of HMEs are on Brightree, those that aren't, we wanted the resupply technology to be there. So that's the Snap acquisition. And then AirView and myAir are homegrown, but they're the software, the cloud-based software for the doctors is AirView, and the cloud-based software for consumers is myAir, and we now have over 10.5 million downloads of myAir. So what have we done recently in terms of product launches? Well, look, we launched a brand-new technology on our AirCurve platform. This is the ST and ST-A lines. Think of this as using in that Venn diagram for overlap syndrome and COPD. CMS just changed its reimbursement criteria that bilevel ST product like this can be used as a primary treatment for COPD, chronic obstructive pulmonary disease, 480 million people worldwide, many tens of millions here in the U.S. COPD is the #2 cause for rehospitalization within the U.S. And so we're not only saving lives, we're saving money for the health care system as we treat COPD with these ST, ST-A products. These are incredible margin products for us, but more important than that, they're incredible for the health care system. So we're really excited to have these high-end bilevel noninvasive therapies, noninvasive ventilation therapies on our high-volume AirCurve 11 line. So watch this space as they just get launched this quarter in the U.S. But our portfolio is much beyond that. It is the smallest, quietest, most comfortable devices. But if you look in the bottom left-hand corner here, it's also about that most connected and most intelligent therapies. We're making sure that consumers patients can be gamified in the way that Instagram or Facebook or X or whatever social media platform you're on wants to engage you for ads sold to you. We want to engage you for use of the device and improvement of your life to save your job, to save your marriage, to save your life. And the way we do that is driving adherence rate. I don't have the clinical data in this deck, but you can get it from Mike, our Head of Investor Relations, who's here today, leading us today. And we have data that shows that general adherence to CPAP, IPAP bilevel therapy, if you don't use any of the digital, it's sort of in that 60%, 65% of patients at day 90 are adherent to therapy. If you just add on the doctor using our AirView system, the cloud-based data, that goes up to 70%. But if you go further and gamify it with the consumer, the patient is using myAir, it goes up to 87% adherence at day 90. And this is sort of the adherence rate that a pharmaceutical company would dream of for a drug that all you have to do is take a pill, we're asking you to put a medical device, turn it on and put a mask on and keep it on for the majority of the night to be defined as adherent. We get up to 87% adherence. So when you hear about our ecosystem, it's not just about being tech and driving -- putting the tech back into med tech and writing the sort of AI wave, this is about actually lowering costs. We see a 50% cost reduction for the labor costs of setting a patient up on CPAP when they're using the digital portfolio, myAir for the patient, AirView for the doctor. We see that improvement in adherence up to 87%. So watch this space. The only other takeaway from this slide is on the right-hand side, bottom right, may not look like much from your seat, but that difference between liquid silicon rubber and fabric that has been in a multicavity high-temperature, high-pressure tool adhered to it so that the consumer, the person, the patient feels fabric touching their face, not a medical device, but it feels more like the pillow or the sheet in the bedroom and it becomes more consumerized and more of a normal thing to happen at night. We still get all the efficacy. We still keep the tongue off the uvula, prevent suffocation episodes and treat your obstructive sleep apnea, but now we do it with fabric. This is a first from ResMed. It changes the basis of competition. I think it's as important as heat and humidification or as what we did in digital 10 years ago to have fabric-based masks at scale at the level that ResMed can provide. So there's only 3 in the market right now. The N30 is about 1.5 years in, doing incredibly well, 1 of our best launches ever. But the F30, which has just launched in the comfort and clear areas and the comfort 1 has fabric all the way around the head. Watch this space on those. I think it changes the basis of competition. If you think of our industry as razor and razor blades, we just launched some of the best razor blades in the history of the industry. I won't go into details on this. In the U.K. market that we've launched another part of our pathway to engage people within the NHS system. And this is less about lowering costs, the NHS cost, what it cost. It's more around driving efficiency so that you can get a 70% reduction in the time that a home care provider, a health care provider has to spend per patient, that frees up for higher volumes of patients coming through NHS. And so within a fixed reimbursement system like in Northern Europe or in the U.K. here, we think providing efficiency is really important to help those health care systems find efficiencies and get through the bureaucracies to help people find their pathway to therapy. So watch this space as that's launched. So this is the acquisition I talked about earlier. This is a company called Noctrix. This came out of the Stanford bio design group and Shri and his amazing team of MDs, PhDs have had what I would call an incredible noninvasive drug-free completely reversible therapy that's able to solve this problem that happens to 7% of adults. So you probably know someone who with or without knowing is kicking their leg all night. It's called restless leg syndrome. Sometimes it's so severe that it wakes them up, but it almost always wakes the bed partner up. But it definitely causes micro arousals and arousals that prevent them from getting slow-wave sleep and REM sleep, so refreshed sleep and waking up refreshed. Right now, all the doctors have is, frankly, ADHD-type drugs and opioids, opiates. And these are not good medicines, and they have so many side effects when being used to treat a limb that's moving at night versus a brain health issue or a pain issue. And so we think that even though this is FDA de novo classified as second line treatment after those pharmaceuticals, I think you're going to see many sleep doctors as ResMed launches this technology and drives it through our channel, who start to say this should either be combination or frontline treatment ahead of the medicines. We're not there yet on the standards, but watch this space, we'll get there. This was a pretty scarce and unique asset, and we're really excited. Sleep doctors write the scripts. It goes through the DME channel. It goes through the VA where we have incredibly strong relationships. It's completely noninvasive drug-free and reversible, and it feels and it looks just like the CPAP of 1989 or 1999 as ResMed was just ramping up. And I think this segment is completely underserved and we're the best owner of the asset, and watch this space as we begin to take this tuck-in acquisition and I think create not just value for restless leg syndrome patients, but maybe even a whole platform of product opportunities for ResMed to expand through the organic or inorganic approaches for noninvasive nerve stimulation to help with sleep health breathing, health and health tech at home. So I think PTSD, think depression, think insomnia as potential target markets for noninvasive nerve stems such as this Nidra product. Okay. To address, as I talked earlier about this new class of medicines, these glycogen like peptides, these are data that we're using to track. Well, what's going to be the impact on our patients and their pathway as they go through this? And so we're tracking over 2.1 million patients with both GLP-1 and CPAP or positive airway pressure, PAP prescriptions. And by the way, these are 99% plus latest generation GLP-1, so tirzepatide and semaglutide. And we actually ran the sell analysis to say, well, how much of each? And it's well north of 50% that are actually tirzepatide. So the most effective in terms of weight loss and improvements. And what we're seeing here is that patients with this combination therapy script, which by the way, was in Eli Lilly's own study show that the combo therapy was better than their drug alone. What we're seeing for us on our side is patients with the combination script actually start our therapy more than the average patient, about 10% higher probability of -- from that prescription actually setting up on day 1. But then we looked at day 365. And then we looked at day 1,000 and whatever, 3 years out. And we saw the resupply rates. So this isn't just I'm adherent to therapy. This is on buying a mask or a tubing or accessories at year 1 and year 3 were up 3% and 6% roughly, and it's almost a separation of the curve over the average patient. So in terms of our combination therapy, it's not only good from how the drug company sees it, it looks good from how the medical device company sees it. And I talked to a key opinion leader from University of California, San Diego about this, who was the PI on the Lilly study, Professor Atul Malhotra. And I said, why is this? Why are they using it more? If they're losing some weight, why would they use it more? And he said, "Listen, for 30 years I've been in this industry, I've always talked about loose weight, have that a diet and exercise and use your CPAP." He said, now I've got a drug helping with Part A versus just me talking to the patient and I'm seeing this improvement. I said, "Yes, but what goes beyond that?" And he said, "Well, maybe the reduction in weight reduces a little bit of that peak pressure, the peak grit just to keep the tongue off the uvula that you need at that REM sleep moment at 3 a.m. and has less arousals, less chance to wake someone up." So maybe that's why it drives higher adherence. We'll work on the mechanism, and I'm sure there'll be a peer-reviewed published paper that will talk about it. I'm just a simple engineer, not a medical doctor. I look at this and look at the black box and say, these 2 therapies together work well and have better outcomes in terms of adherence to our therapy. So we see it as a really good tailwind for the business. We also do the sub-analysis of 2.1 million patients and said, okay, imagine you're on a CPAP first, and then you get a GLP-1 prescription subsequent to that. Do these numbers change? And we looked at 2-year and 3-year adherence rates, and they were both higher, roughly 5% and 6% higher. So pretty much in line with these data. So we'll continue to look at this, and we'll do work with the companies for peer view published evidence as to why, but combination therapy seems good. These therapies seem to work better together. And the question is, once those patients show up to a primary care physician saying, what this injectable Don't Sleep on OSA thing, what does the primary care physician do? And this is where we're focusing in this middle of funnel to educate primary care positions, maybe reeducate them because they learn about sleep medicine back in medical school 5, 10, 15, 20 years ago. We're up to now 80,000 CME continuous medical education trainings by over 45,000 unique identified clinicians, mostly primary care clinicians. The best part of that training is 78% of them saying, well, I'm going to do something different about sleep now that I'm more educated. I understand the gold standard is CPAP APAP bilevel. Silver is probably this dental device and then bronze, right? So 100% treatment, 100% AHI treatment from CPAP APAP bilevel when used as directed, right? 75% treatment for the dental and then about 50% reduction, half treatment from an injectable like a GLP-1 or an implantable. So retraining on that's been really important. But 78% say they're going to do something, we've actually been tracking before and after training, how many referrals are there for home sleep apnea tests and how many referrals are there for that prescription for positive airway pressure? And it goes up, and we'll provide more and more data to show exactly quantified how much it goes up when the doctor has been trained, not just them saying they intend to change clinical practices, but they actually do quantitatively. So we'll update you as we go over time. Finally, I've got 4 minutes left, I'll end on capital allocation. I have my new CFO here. So any questions on this in the Q&A can go directly to Aaron Bloomer, our amazing new joined us from Exact Sciences and knows a lot about helping people get involved in diagnostics and med tech. We've got really disciplined capital allocation across our business. As you can see, this pie chart sort of breaks out where we put our capital. My best use, and I believe always will be of our capital is to put it back into the company. So we're investing 7% roughly of our revenues back into R&D, keeping the smallest, quietest, most comfortable, most cloud-connected and most intelligent devices. We're putting around 19%, 20% back in the sales and marketing to make sure that sleep positions, DMEs, but also primary care physicians are fully educated and we can get those prescriptions and we can help the channel be there. But we're also continuing our dividend, and we have a good dividend yield, and we've been increasing that over the years, and we think it's important for you as shareholders to get your cash back, so we'll continue to do that. And then the share repurchases, where we've talked about north of $100 million then we entered $150 million a quarter, went to $175 million a quarter, our last public call. Since we're on Reg-FD here, I'll talk about this quarter that we put over $200 million into share buyback, just here right here in this Q4. And our goal for FY fiscal year 2027, which for us starts on July 1, we're at June 30 end, we plan to continue and increase that share buyback. So watch this space, north of $200 million a quarter, north of $800 million for the year, but potentially above that. And Aaron and I will give you a detailed overview after our Q4 numbers that we'll talk about on our August earnings call. The other one, obviously, here is that M&A and what we're going to do with the dry powder there. So we talked about Noctrix, $340 million tuck-in acquisition that can create this new capability, watch this space for things around that order of magnitude for ResMed. Again, we have to be the best owner of the asset. It has to be in sleep health, breathing health, health tech at home, has to have a financial profile that's accretive to us on a growth level and gross margin level. And also, we have to be the best financial owner of the asset with a cultural fit and cultural stretch. Cultural fit is integrity, honesty, cybersecurity, privacy. The cultural stretch is something new, like nerve stem tech that you got from Noctrix. So watch this space for the appropriate sort of tuck-in acquisitions in that $100 million to $500 million range roughly. This is our outlook that we gave at New York Stock Exchange on our 25th anniversary there, 100 quarters on the big board. We talked about maintaining what we've had, which is high single-digit top line growth. And we talked about leverage through the P&L to get higher than that for NOP growth and obviously with share buybacks and beyond even more leverage down to our earnings per share. I'll close where I started with why is ResMed a compelling investment opportunity. The first 1 had 7 bullet points, but here's just 3. One, our target markets are huge and underpenetrated. The TAM is over 2.3 billion people. That's 1 in 4 people on the planet that have a sleep health, breathing health or health tech problem that ResMed is uniquely positioned to solve. Two, megatrends are in our favor. Apple, Samsung or Whoop, Garmin and Google Fitbit, they're going to bring patients into the funnel, and GLP-1s are going to do the same thing. This is a once-in-a-generation opportunity for us to see this level of patient flow, and it's on us to get that middle of funnel right, to get those patients prescribed and on our therapy. And third, and I think most importantly in this space, we've got the best products, the best innovation pipeline about what we're going to do to treat sleep suffocation, to treat insomnia and to treat any sleep disorder, including now restless leg syndrome. And we've got supply chain flexibility. No matter what's happening in the world right now, it's Strait of Hormuz and costs, we're going to be able to do what we do best, which is get these products to people in 144 countries worldwide. And with 19 seconds to go, I'm going to end and we'll go officially to Q&A, sir. Thank you very much.