Medtech M&A and Deal-Making Perspectives

Speakers

John Babitt

John Babitt

Partner - Life Sciences, EY
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Michael Robinson

Michael Robinson

Managing Director, Healthcare Investment Banking, Medical Devices, Jefferies
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Azadeh Nasibi

Azadeh Nasibi

VP, Business Development, Medtronic
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Matthew Schopp

Matthew Schopp

Director, Business Development, Philips
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Matthew Vessa

Matthew Vessa

VP, Business Development, Hologic
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Antonio Sánchez-Cordero

Antonio Sánchez-Cordero

WW Vice President, Business Development, Peripheral Intervention, BD
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Let's find out directly from major strategics on what deals they are hunting for and hear their outlook on M&A activity in the coming year.

John Babitt  0:03  
Hello, everybody. Good afternoon. And thank you for joining us for certainly one of the most interesting topics that we'll talk about during the conference, mergers and acquisitions. And we've got a great panel with perspectives from Becton Dickinson from Medtronic, from Hologic and an investment banker to keep them all honest. So, with that, I thought what we could do is just talk about the agenda, what we're going to cover today, you know, 2021 was a record year for mergers and acquisitions in medtech. And we'll go through some of the data, but just spectacular results. And all these guys participate in that. What we're going to talk about are the strategies that they utilized to be successful in the market conditions that we saw in 2021. And then last and most important, we're going to turn to 2022. And see, you know, what are the real dynamics that are going to take place over the next year? So with that, I want to just get the panel introduced. Azadeh maybe you can lead us off.

Azadeh Nasibi  1:09  
Sure. Good afternoon, everyone. It's very bright. So yeah, some blinking Azadeh Nasibi with Medtronic neurovascular operating unit. I lead strategy, business development and integration had been in the space for almost 12 years and really excited to be here with all of you. Thanks for joining.

Matthew Schoop  1:31  
Thank you. Good afternoon, everyone. Matthew Schoop, working connected care under Philips and business development focused on sleep and respiratory patient monitoring, some ambulatory monitoring diagnostics, and our emergency care business as well.

Matthew Vessa  1:50  
Good afternoon, Matthew Vessa, Vice President of Strategy business development for Hologic working within the breast and skeletal health business. Incredible focus and franchise within breast cancer care and growing from there.

Antonio Sanchez-Cordero  2:04  
Antonio Sanchez-Cordero responsible for business development integration for Becton Dickinson, pray for intervention. Glad to be here. And looking forward to the discussion.

Micheal Robinson  2:14  
And Mike Robinson, I'm a managing director with Jeffrey's part of a group of about 110 healthcare investment bankers that are based around the world, I'm focused exclusively on medical devices. And I've been in the business about as long as John has. Yeah, that means we're all that's what it means. But I

John Babitt  2:33  
think the other thing that we're going to accomplish with five panelists and moderators, we're going to have the highest person to panel ratio here until people get back from lunch. But with the great weather and being from Minnesota, I have to say I wouldn't come back. But everybody wants to talk about mergers and acquisitions. And what we thought would make sense is just to start with some framework from what we saw in over the last year. And, you know, certainly in the med tech sector, there was a lot to be really super happy about, you know, revenues approached almost a half trillion dollars growth of 10% over 2020. And yeah, there was a lot of interruption, but there was also a lot of a rebound. And really showed a lot of opportunity and resiliency across the industry. Public evaluations, at least for the end of the year, had really performed pretty spectacularly especially high growth, med tech, and you know, outperforming pharma and biotech, which is always the pure group, so a lot to be positive about that, obviously, over the last three months, that's taken a little bit of a correction, one of the things that we're going to talk about here today is what are the implications for M&A coming out of that. And then, as you can see, all the way up in the right, and this is one of the things that the industry was really proud of is that during the pandemic, you know, R&D spending actually increased almost 17% across the industry $24 billion plugged into research and development. And, you know, a lot of these companies were, you know, part of that, whether that was diagnostic tests, whether that was ventilators, you know, really responding to, you know, the pandemic. And you know, on the bottom left, it did not go unnoticed from the the private capital market or the equity markets. $34 billion raised, which was a record 9 billion in venture capital also record SPACS $4 billion raised, we're going to talk about that as well because you can't have a discussion without SPACS these days. And what we also saw was a lot of strategic investment into data, you know, really using digital as the currency to move care from the acute say in the hospitals into you know, ASCs and into the home. Also a lot of discussion around connected care and we've got some panelists, as you heard, that are participating in those sectors. So, when we kind of sat and looked at the universe, you know, what does it bode for 2022? We said, you know, look, there's some, there's some tailwinds, like, you know, unbelievable firepower sitting on, you know, all these guys balance sheet, it's over 600. And that's not a million, it's a billion. So over half trillion dollars that seen on the balance sheet ready to be deployed, whether its internal programs, or external to things like mergers and acquisitions, and a lot of need to build capabilities, especially when you look at the the introduction of all these digital capabilities of AI, you know, connected care, there's a lot of gaps that need to be filled. But, you know, we weren't, you know, just coming to the table with rose colored glasses. There were a lot of, you know, potential headwinds, you know, not the least of which is certainly the public markets volatility these days, you know, COVID variants, you know, seem to pick their head up, you know, that leads to hospital shorting, hospital staffing shortages, and just things that, you know, just give a little bit of indigestion across the industry. But, you know, the facts don't lie. I mean, if you look at last year, 2021, 64 deals over $100 billion in m&a, it was a record year by all accounts. And, you know, one of the dynamics that we saw kind of creeping into the calculus as we exited 2021 was that high growth med tech in this, this represents the multiple forward revenue increase, you know, from from, you know, roughly 10 times revenue at the before the pandemic to almost 14 times revenue, forward revenue, you know, kind of coming out. And, and so that's that those valuation and now these have come down, I haven't while on this forward to 2022. Obviously, it'll look a little bit different, as we all know, but still, they're they're trading well above their, you know, historical highs. And if you look at the bottom graph, where Where have the m&a valuations been, you know, over the last 10 years, it's roughly three and a half times forward revenue. If you look at the last year, it kind of creeps up to almost 10. And so, you know, as you can kind of do the rough math 14 is greater than 10. You know, how are these guys developing strategies to be successful in their m&a endeavors? And that's one of the things that we're going to unpack. And as I alluded to before, no, no m&a conversation would be complete if you didn't talk about SPACs certainly the talk of the town 2021, we'll get some perspective here today, about how people are participating in those and what the expectations are for 2022. I think the bottom line is, you know, 71, active SPACs, average capital raise of 200 million, but 77% of those are trained below their, their, the initial value, and they get their experience and upwards of 41% redemption rates. And so, you know, a lot to unpack there. I think one of the other things that we'll talk about is, you know, will that capital if it's returned to the shareholders, will that recirculate in other corners of the, of the med tech sector? How will that occur? So, you know, with that, we're gonna open it up to our panel, and get their thoughts and I think we can, you know, really dig right into it. And we have two Matthews on the panel. So we're gonna go affectionally by Matthew v. And Matthew s, and we'll start out with both the Matthews but, you know, it would be interesting to get your guys's perspective and we went through a lot of the data 2021 off the charts. '22 starts off with a, you know, a real, I think, you know, a lot of velocity Quidel, OCD, Stryker, Vocera, Medtronic, Affera, but it seems like, you know, since we've gotten a little bit that bit of this public company, or public trading volatility that maybe a little bit of the foot on the gas is has come off. But you know, as you guys look at, you know, kind of where you guys are today, is the m&a still full full force ahead. Like what we what we saw Matthew V. If we can maybe go there first.

Matthew Vessa  9:26  
Yeah, I would say definitely no relief in terms of how we're looking to deploy capital, very strong balance sheet. And in terms of where Hologic sits today. You know, we've been building a pipeline for for more than a couple of years and steadily and methodically doing the transactions that make sense for us, but certainly not moving unnecessarily quickly, just because of the fervor in the market.

John Babitt  9:50  
Yeah. And Matthew S maybe some perspective from from your lens.

Matthew Schoop  9:56  
Yeah, I think just just to echo that, it's, it's the same at Philips right. We have fully divested the businesses that were not healthcare related or health tech related. So we we have a strong balance sheet as well, and are open to large acquisitions as well as continuing to execute on our pipeline and work tokens to augment what we already have.

John Babitt  10:22  
Yeah. Great. Um, Mike, you might have maybe a different kind of perspective. I mean, are company's still, you know, pursuing with the same vigor and, you know, maybe even more importantly, to the, you know, emerging companies in the audience, are we seeing the the number of sales kind of, you know, processes kind of come to the market?

Micheal Robinson  10:45  
Yeah, I don't I think the volatility of the equity markets, definitely have an in will have an impact on m&a activity. I mean, for one thing, when the markets are this volatile, there is no IPO market. So that as an alternative that's kind of shut and will remain. So. I think until, you know, the VIX, the volatility index, kind of gets below 20 and stays there, SPAC market is highly correlated to the IPO market. So SPAC alternatives kind of off the table. So you know, I think one of the the implications of this volatility is the balance of power has shifted towards buyers, to people up here on this panel, with their giant balance sheets, and also private equity, for sure. So, you know, we would expect to see the buyers being more aggressive. We haven't really seen that yet. I mean, I think the last three weeks with, you know, the invasion in Ukraine, everybody sort of pauses a little bit, it's hard to really lean forward. Right into that, but I certainly think the, the environment is, is set for a lot of activity, a lot of capital to be deployed, but it's starting a little bit slow. And it may be, you know, for that reason,

John Babitt  11:59  
And then, as the day maybe we round that out, because Medtronic off to a fast start with the affair deal. How are you guys, you know, viewing kind of the current situation?

Azadeh Nasibi  12:11  
Yeah. And affair was outside of sort of the neuroscience deals, but I think similar, you know, we, we have our steadfast strategies and priority areas, and while you know, COVID, and what's going on in the markets will cause potential blips and, you know, perhaps, you know, some some reconfiguration or readjusting of focus and strategies. But when you think of, you know, what's important short term versus midterm and long term, you kind of have to, you know, keep that in mind. And, and it really hasn't changed much from an neurovascular stroke perspective. And our priority areas, I mean, we do a lot of tuck ins, because it makes sense for us. And, you know, we had stuff that was in flight, just as COVID happened. And we still stayed steady and went through and went on to other things as well during the last couple of years. So, I would say, from from where we look, and what we see, it's, it's still healthy. For

John Babitt  13:14  
some more the more of the tailwinds to come and more 2021. To continue. And Matthew is on the, you know, one of the themes that we saw in 2021 was, you know, the Connected Care, and obviously, big deal with with biotelemetry. I mean, you know, just maybe, you know, again, with a lot of entrepreneurs in the room, you know, how should they be view in the Connected Care space? And where are the big gaps that you guys are kind of seeing on that front?

Matthew Schoop  13:43  
Yeah, and our biotelemetry acquisition, and for those of you who don't know, they, they're one of the main players and cardiac monitoring for mobile, cardiac telemetry and Holter monitoring. And they provide both the product to do the monitoring, as well as the service then for, for the clinicians. And, you know, in 2021, that was really a another business for us to acquire. And since then, we've been looking to build upon that with, with the acquisition of cardio logs, which, which just closed this year. It's not just about the product or the service, but it's also about how much data you're getting and gathering, and how can you better process and use that data, both to help the clinicians and help the patient at the same time? So a lot of what we hear from clinicians is it's it's so much data, and we don't, we just can't handle it. So being able to help both the patient with a better product, as well as the clinician with some AI and some data capabilities is really what we're looking to do across all of our businesses.

John Babitt  14:54  
Yeah, no, that's data is the new frontier, for sure. And I think it's been interesting to see, you know, a lot of your organization's in Medtronic include bring on, you know, new Heads of digital. And, you know, it'd be interesting to see kind of where those investments are going to really land. Antonio. You know, BD was extremely active and I think caught a lot of people by surprise, because there are a couple of big deals that you guys were still digesting, but a number of tuck ins, you know, Will that continue to be the strategy at BD?

Antonio Sanchez-Cordero  15:32  
Yeah, definitely. John, I love to be a bit original and disagree with my panelists. But truly, we have a very clear strategy. We have a pipeline. In our case, it's around smart connected care, it's about new care settings. It's about improving chronic disease outcomes. And we're going to try to do as much as we can in those areas that is strategic, and that is connected to our to our platform. So definitely, I think we continue to see activity from BD. Yeah.

John Babitt  16:00  
And, you know, one of the interesting areas where you guys played was in on the SPAC front and in 2021, and maybe tell the audience for those that don't know, you know, some of the, you know, areas that you guys have looked at, and or, you know, kind of considered because I found it, you know, intriguing for sure,

Antonio Sanchez-Cordero  16:18  
yeah, so I wasn't involved I was I joined BD a year ago. So I wasn't involved in the the Vicarious deal. But certainly, I think that we're talking about availability of capital, I think that also means there's a bit of a more open minded attitude, both from institutional from, from the stakeholders, and as well from from corporate. So I think that, that that creativity, it's going to continue, and we're using some of that creativity as we think about some scenarios where there might be, you know, Win Win opportunities to work with other players.

John Babitt  16:47  
Yeah. And, Mike, interesting, interested to get your perspective as being the, you know, the banker, where does I mean, obviously, it's SPACS for all the talk in 2021. But, you know, now we're here in 2022, you know, do do they, do they gain some sort of momentum? Or, you know, and then what happens if, if all that cash goes back to you know, the original investors?

Micheal Robinson  17:11  
Yeah, I mean, I hope they gain momentum. If they do, that means that volatility has come down, and the IPO market has opened up. I don't think we're optimistic about that right now. I mean, when you look at the performance of IPOs, in 2021, it's it's actually pretty rough, you know, IPO is all sectors, down something like 45% from their issue price. In med tech, it's also negative, you know, biotech is really negative. Do you have to see that turnaround before IPOs and SPACs can become relevant again, when you just can't lose money in these things in Vicarous is trading around five bucks. And you know, these are really good companies. But there's been a real pullback, in terms of appetite for risk. So we don't really see the crystal ball doesn't show us when you know, SPACs are gonna be a player in doing deals. As far as the the second part of your question, John, the capital flowing back. But it remains to be seen, I think most of the explorations are really happening in the fourth quarter. So it's going to be back in. So I don't think it's going to have a big impact in 22. Maybe it'll have an impact in 23. You know, on the other hand, a lot of the shareholders of the SPACs that guys have traded out. And it's often you know, just pure hedge funds who aren't necessarily healthcare people. Yeah. So little bit up in the air, but it's so much capital that even if a little flows back, you know, you'll feel some some effect. And I think it's more of a 23 dynamic at this point. Yeah.

John Babitt  18:51  
So, so maybe turn the page to capital allocation, I think one of the more interesting dynamics in med tech right now is, you know, the real funding and introduction of healthcare IT into the environment and, and then also kind of layering on that need to have product innovation. And, you know, Azadeh, maybe you can take us through, you know, your your business because I think it's an interesting subset and certainly illuminate for these, the a lot of the, you know, audience around, you know, you know, when do you kind of look at m&a. And when do you look at partnerships like what your, your group has done historically?

Azadeh Nasibi  19:33  
Yeah. And specific to healthcare it here. So just to give a little bit of background, I didn't provide this in the introduction. So the neurovascular business within Medtronic, it's our stroke business, right. So we have acute ischemic stroke and hemorrhagic stroke and the devices that go through the vessels right up to the brain to pull they're very much mechanical, mechanical devices, mechanical therapy, so no have sort of data and whatnot associated with it. But that's just for the procedure and the intervention. When you look at the overall patient journey and the care continuum opportunities for that patient, that's where we, from our perspective, see a lot of opportunity for data and AI, and especially as you go upstream to the procedure and say, Okay, how can more strokes and more patients be triaged better and faster, to get to the therapy and to the intervention, which, again, is benefits the patient, the the physicians, the community, as well as you know, the companies in the space. So, you know, we're but that's not a core competency of ours. So, so where we've started is with partnerships, like Viz.ai, where they offer a cloud based mobile platform. For any stroke system, if you're on it, essentially, your physician can be on call at home at a soccer game, you know, wherever, and they get an alert and a stroke is identified. And they, you know, essentially, start the triage for the whole system before they don't even have to pick up a phone. And so that's where we've partnered started in US now it's in Europe, as well, as we think about where else should we play in the care continuum for our patients? So that's an example.

John Babitt  21:19  
No, that's it's a fantastic example. And I think it's going to become more relevant. As you know, a lot of these technologies don't make sense to acquire, but they make sense to have to be from a capability perspective. And Matt V. You know, in 2021, it wasn't as much about capital allocation, but it was seen on all the COVID cash and how to, you know, double down and kind of deploy it. So walk us through sitting on some of those decision makings, you know, how did you guys kind of survey the landscape? And, and, you know, decide, you know, the right choice was to go down m&a, versus r&d or returning cash to shareholders.

Matthew Vessa  22:01  
Yeah, so, you know, coming coming through COVID, we were definitely one of the beneficiaries is as a diagnostics company, and having, you know, one of the top COVID enabled technologies. You know, coming back to your initial question, though, around how we're thinking about m&a, it's forced us to think about bigger opportunities, obviously, it's also forced us to continue with our tuck in strategy, because I think as we'll talk about value creation, effectively is more tied to tuck ins. But the nice thing is having that leisure to and not leisurly but the leisure to look at some of these bigger, potentially transformational opportunity is not like Bard and BD coming together, but the, you know, the sort of methodical nature that these deals won't happen overnight. Just because this is the year that that we're looking and shopping and doesn't mean we won't do a deal maybe in the following year. 2023. So it's, it's been very much a full court press, you know, all hands on deck, looking through a lot of potential opportunities, reviewing strategies, what if this than that, but, you know, as as, as they talked about, there's still this, we've got deals and gaps in our portfolio we need to consider, but to your other point, the make by ally, strategy is always in the forefront of our minds. As we think about software, as we think about new devices and imaging systems. We have a lot of those capabilities built in. But I think it's about appropriately and fairly measuring where we are versus a, an earlier stage company that can do things faster or be more in tune when you start, you know, from zero and build your software to today's protocols.

John Babitt  23:48  
Know that that's that's certainly a admirable and enviable problem to have. And you get company. We don't have Thermo on the panel, but certainly them going out and acquiring a billion dollar CRO. Yeah, it's the art of the possible. Mathhew S, you know, just one last thought maybe and, you know, capital allocation between because obviously, Phillips, you got the heavy iron side of the business, you got the technology side of the business. I mean, how do you guys kind of divide and conquer, to make sure that you've got kind of adequate coverage or that the best opportunities are kind of getting adequately funded?

Matthew Schoop  24:28  
Sure. Again, it all starts with, like, all the other panelists have talked about with with the strategy. It starts with the clinical problem. It starts with understanding what does the patient need was the clinician need, what capabilities do we have in house? So you know, there's a constant evolution of the strategy and looking at different ways that we can execute on it. And if it makes more sense to do it organically, then we'll do that. If it makes more sense to do it in inorganically, whether that's putting a few seeds in the ground with investments and looking to grow for for a couple of years from now, we'll do that. And if it if it makes sense to go out and buy right now then then we'll go and do that.

John Babitt  25:12  
Yeah, certainly, it gives a lot of opportunity for the guys and gals in the audience, for sure. Hey, Antonio, maybe one thing that came up around supply chain, and I know you had a great phrase when we were prepping a COVID-proof deal, and maybe explain to the audience, you know, what, what your guys's kind of definition of that is? Because I found it a bit intriguing.

Antonio Sanchez-Cordero  25:39  
Yeah, I think that the last couple years have been sort of unprecedented in a number of ways. And with our portfolio being large enough and comprehensive enough that we have sort of a natural hedge, right, because when COVID was getting worse, our diagnostic business, but it get better, those that, you know, businesses that depend on elective procedures would obviously see that see the pain. I think from a strategy perspective, and from a deal perspective, we started thinking about, you know, are there are there deals in other areas that are sort of COVID proof? I think, as we as we coming out, hopefully, out of this COVID pandemic, that has it transformed my bed into more understanding the effects of supply chain? And are there assets that are more attuned, that are more protected from supply chain disruption, because it feels this is here to stay? I don't know, if three months, six months or three years, but it certainly doesn't feel it's going to go away easily. So certainly, we're trying to understand when we look at targets now, how susceptible are they to supply chain disruption? Is there something that we can do about that? Yeah.

John Babitt  26:37  
And Mike, I'd be interested to get the the banker perspective, are you seeing any processes kind of get delayed? Because they they can't get product to market? Or that? You know, just that supply chain element kind of creeping into the m&a?

Micheal Robinson  26:56  
Yeah, I would say actually not. I think in m&a, there's typically a mindset and an approach and a comfort level with, you know, making adjustments to results, whether they be COVID adjustments, or anything that can be sort of positioned as a one time type of item to Antonio's comment, to the extent that we think we're gonna be having these one timers for three years that that's a different story, because that's not a one timer anymore. But I think, at least over the last couple of years, we haven't seen deals not get done, because there's a problem, there was a hiccup in the supply chain. At the moment, acquirers are willing to sort of look beyond that, make an adjustment and look at the, you know, the opportunity on that basis. Okay.

John Babitt  27:46  
Now, I think that's the general consensus, it'll be interesting to kind of pay attention to and does this latest, you know, wrinkle, kind of maybe throw more than just a ripple in the water, which hope hopefully not, you know, maybe just taking a step back and looking at, you know, COVID and, you know, your your priorities and how you think about the the portfolio, as they did it really kind of change or influence, you know, kind of any the thinking around your, your portfolio.

Azadeh Nasibi  28:21  
Honestly, it didn't, and we have somewhat of a COVID proof portfolio within within the stroke business, because it's not, you know, highly, it's not a very elective or wait and see type, procedure or patient population for most of our therapies and devices. I think the we did get better as we look at deals to think, more granularly about certain risks, especially with, you know, supply chain and other things and just have better mitigation plans and think about those little perhaps a little bit more depth than we did before, because, you know, we didn't think that, oh, certain raw materials are going to be on backorder for literally 50 weeks, you know, for for some of these companies. And then how can we then as Medtronic leverage sort of our scale, and even sort of buying power and negotiation power to actually alleviate some of some of those risks that some of the smaller companies that we're interested in, are, are experiencing, so really, the long term strategies remain? And it was, you know, having figured out how to even do diligence in a remote type of way, you know, we figured out some FaceTime stuff, video stuff when everything was, you know, no travel whatsoever, complete shutdown. And I think it's actually kind of made us better and more flexible and how we think about risk and execute deals.

John Babitt  29:49  
Do you think that that'll stay the standard or not? Because this is like the first time I've been to like a conference? So I mean, will that will that stick or do you think it'll go back? to where it was, or somewhere in between?

Azadeh Nasibi  30:02  
Yeah, I think there will be somewhere in between, I think that you can never replace, like, if you're doing a site to visit and walk through, you can never sort of fully replace that that in person. But we've certainly learned how to how to manage without it. And so in fact, could we then be faster and better, because there's some things we can do more remote and not having to be in a place? And yeah, you know, augmented with a follow up visit. But I think it's been good experience and good learnings for us as we have gone through some deals, and

John Babitt  30:37  
it has certainly been like, yeah, for sure. And then maybe just a couple thoughts on the regulatory front. And Matthew S maybe, you know, anything that you're seeing that is an m&a impediment, or that people should be paying attention to whether it's the FDA, or some of the, you know, the FDA has the new cyber czar, or the FTC, just any any regulation that that you're seeing, or you guys are paying attention to, on that on that front?

Matthew Schoop  31:07  
Yeah, you know, I think COVID certainly had some some positive and negative impacts, you know, the timelines for regulatory seem to be taking longer than than usual, which everyone has adjusted to the new normal there. But it also brought some reimbursement and virtual care opportunities to the table. I think we're still working on figuring out and everyone's waiting to see whether those will stick and be made permanent. Yeah. And a lot of people hope that they that they are, but we still don't know yet. And on the on the other hand, then, so looking at SAMD data, or software as a medical device, and the regulatory there, that's continuing to evolve, but it's definitely gotten a lot clearer when it comes to using data and the regulatory pathway there. Yeah. Which has been great, great for us in the Connected Care business.

John Babitt  32:05  
Yeah. Matthew V, anything that you guys are paying attention to, at whole logic.

Matthew Vessa  32:12  
So a few things, you know, the it used to be that you would launch a medical device in, in Europe first, because the regulatory hurdles were easier. And then we've we've moved to the US being a little bit easier. I think it's being conscious of both of those markets. Obviously, there's, there's pros and cons to, to establishing commercial footprints and both of those markets, but you know, we're looking at, at deals where with the more encumbered European CE process, we're thinking about how that impacts the deal model, how does that impact, you know, the traditional m&a metrics? And then just, you know, a related point as it relates to, to FTC. We know there's a tough FTC today, you know, there's there's close examination for any big company doing a deal, especially around areas of innovation, where there's a, effectively a concentration in share that can potentially disenfranchise customers. So that's an important thing that we watch when we look at transactions.

John Babitt  33:17  
Yeah, I think it's going to be interesting, because it seems that the, you know, there's no problem with big companies like Baxter buying Hillrom, but there's a lot of angst about big companies buying small companies, which, you know, impacts that this audience, you know, pretty pretty directly. We're coming down to, you know, maybe some of the last thoughts here, I guess, you know, with all the international considerations that are going on now, and, you know, Mark high growth markets, like like China, and I know, for Philips, that's, that's been a high growth, as well as Medtronic, you know, how are you guys thinking about m&a, m&a, maybe outside of, you know, the United States, or just the the overall, you know,  OUS and or China's strategy, as they I don't know, if you have any thoughts or share there.

Azadeh Nasibi  34:12  
Yeah. And for first stroke and neurovascular, China is one of our largest markets. And, you know, value based pricing is just starting to happen for our our business there. But, you know, not quite to the extent that it's been happening in in other segments, so, and there's still a lot of under penetration in terms of the actual therapies and patients getting the therapies they need for stroke. So huge opportunity and lots of local competition. I mean, there's so much capital that's been deployed in China for local startups that are now competing with multinationals. So far, they still haven't quite gotten to sort of the level of evidence and performance with with you know, the with our therapies in the multinational therapy, so there's still an advantage, but they're going to catch up. Right? So we certainly look at any global m&a we do a deep focus on what does this mean for China? What would it look like? And also have a look at alternatives? Strategies for, you know, does it make sense to do something for China only in something in particular. But it definitely always has the spotlight in any of our m&a strategies, because it is such an important market and high growth and, and on the regulatory front, too. There's some things there with that actually has because of EU MDR has brought to light and I won't get into too much details, but there's some I'm sure if you haven't run into this yet, you might but animal derived materials, and you know how to work around that, because that's actually not been allowed in China for a long time. But it hadn't. It hadn't been known for many components until EU MDR forced it to be known. So it has had some ripple effects there. But so there's a lot going on with how to be in the China market and product in there. So

John Babitt  36:09  
yeah. Matthew, any anything to add? From Phil's perspective, I think you guys have a unique lens on this.

Matthew Schoop  36:18  
Yeah. So coming from other other large med tech companies that that always said global as a focus, and it really was, and moving to Philips, about a year and a half ago. Philips is based in the Netherlands. So if we don't come forward with a global plan, and we look US only we look like a fool to management. So it's it's a really strong focus. It's not to say that, that we won't consider technologies that are currently only in one market. But we definitely want to consider what does it look like to bring that global? Or what are the different solutions globally that may be needed based on specific market needs?

John Babitt  37:02  
Yeah. And, you know, Mike, maybe, you know, we've got a lot of entrepreneurs in the crowd, you know, they're shaping an m&a strategy. And I know that you can't have just an m&a strategy. But what are two or three of the arrows that they really need in their quiver that you're seeing that are kind of, you know, these guys, you know, must haves?

Micheal Robinson  37:26  
Well, I mean, I think, first and foremost, that it, you need to run your business to, to build it, and not to sell it. Because these guys can sense, you know, weakness. It's a little bit tougher now. And that, you know, is as we discuss the IPO market isn't available, sort of as a as an alternative that said, there was a fair amount of private capital out there available for late stage, and maybe many of the companies in here may be experienced in this. I know I am I've had private company clients that have gotten inbounds, you know, from institutional investors who want to put capital to work and, and I think, you know, that that's, that's, that's always a good strategy, right to have enough capital, raise the capital when you don't need it. So that, you know, you don't need it at a time when you can't get it. But I really think it's kind of fundamentally that I mean, just kind of, don't build to sell, you got to build it to build it and and do everything you can to take as much risk out of the equation as you know, as possible. Yeah,

John Babitt  38:34  
no, I think that's sage advice. We're down to the short strokes here. And I think it'd be a good time to maybe do a lightning round of what we think is one thing to watch for, kind of as we go forward and 22 with med tech m&a. And Antonio, we're gonna put you on the on the hot seat here real quick. Lightning round. What should we watch out for?

Antonio Sanchez-Cordero  38:57  
Yeah, I think I think Matthew mentioned before is the focus on clinical value, right? I mean, for us, when we look at, you know, we have our strategies, and we're trying to to help more patients have more healthcare professionals. And it goes down to clinical value. And I think in those conversations with with the startups with entrepreneurs, it's really understanding how that that value plays in the bigger picture. And we're very supportive of those discussions, but it needs to start in clinical value and not in cool technology. And so I think with that in mind, when the conversation starts there, it tends to go to a good spot. We're very, I think we're growing more a dial in our make by partners strategy, and so we can adapt. There's lots of things that we can do if there is clinical value, if there's no clinical value, sort of everything else doesn't matter. Yeah. Matthew?

Matthew Vessa  39:41  
Yeah, I would add on to that clinical value at the multi stakeholder level, so clinician hospital patient, and within the hospital thinking, you know, clearly about economics if reimbursement doesn't seem like it's an option, having a value creation story that's tied to something else that's measurable material and that customers care about

John Babitt  40:00  
Matthew S.

Matthew Schoop  40:02  
think, focusing not just on the better next product, but how do you make things cheaper? How do you make the lives of the clinicians easier? When they're running into staffing shortages? And they they need help? As much as the the patient's do?

John Babitt  40:19  
Yeah. Azadeh?

Azadeh Nasibi  40:21  
Yeah. So I'll focus more on on maybe types of deals. And from, from our perspective, kind of the moving into more of the the partnerships and structured deals and doing things that are maybe not your traditional, you know, outright acquisition or asset acquisition, in order to hit on some of the things that have been talked about, right. If something is early enough, you see the potential you see the signals, but how do you validate some of it through either a partnership or through investment with very key milestones? I think, at least from from our lens there'll be more of those types of activities in our space.

John Babitt  41:03  
Yep, I think so as well. And I'm gonna throw one bold predict prediction, I think we will get at least one deal over $10 billion. That's my bold prediction. So and I know Mike, and I would like nothing better than to see that and so that's right, exactly. Well, hey, everyone, we have hit triple zeros up here. Can you help me just give it a token of applause for our panelists, I thought was really great.

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