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瑞信-美股-医疗保健行业-牙医调查显示:牙科需求仍然不足-128-30页.pdf
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瑞信-美股-医疗保健行业-牙医调查显示:牙科需求仍然不足-128-30页.pdf
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DISCLOSURE APPENDIX AT THE BACK OF THIS REPORT CONTAINS IMPORTANT DISCLOSURES, ANALYST
CERTIFICATIONS, LEGAL ENTITY DISCLOSURE AND THE STATUS OF NON-US ANALYSTS. US Disclosure: Credit
Suisse does and seeks to do business with companies covered in its research reports. As a result, investors should be aware
that the Firm may have a conflict of interest that could affect the objectivity of this report. Investors should consider this report
as only a single factor in making their investment decision.
28 January 2019
Americas/United States
Equity Research
Healthcare Technology & Distribution
Dental Update
Research Analysts
Erin Wilson Wright
212 538 4080
Charles Lederer, CPA
212 538 1822
charles.lederer@credit-suisse.com
Katie Tryhane
212 325 2713
George Engroff
212 325 2289
george.engroff@credit-suisse.com
CHANNEL CHECK
Survey says: Dental demand still lacks bite
■ 4Q Dental practice volume, revenue growth on par with 3Q trend:
According to our proprietary survey of 75 US dental practitioners, 47% of
practices experienced positive revenue growth in 4Q, rising 0.5% (weighted
avg.), consistent with our initial 3Q survey. New patient traffic (+1.0%) was
the most meaningful driver of practice revenues, followed by pricing
(+0.9%), bridges/implants (+0.8%), and preventative care (+0.6%). An
encouraging dynamic, respondents were incrementally more optimistic on
NTM trends with 71% expecting improving practice volume (vs. 65% in
3Q), which bodes well for all our dental names. As a caveat, this is our
second dental survey, and we expect more meaningful takeaways to our
dental coverage with greater historical context.
■ Equipment–Digital dentistry drivers w/ caveats: While respondents
were more optimistic on equipment purchasing over the NTM, with
particular focus on intraoral scanners and CAD/CAM, we note that
practitioners remain wary of larger cash outlays in an anemic demand
environment, with dentists likely less inclined to make equipment
purchases in light of growing macro concerns, as well as noted
reimbursement pressures. That said, we highlight positive commentary on
Dentsply Sirona’s (XRAY, Outperform) CEREC offering, noting its
convenience and ease of use, despite continuing low overall penetration.
While we view XRAY as a turnaround story LT and are optimistic on
innovation opportunities in an IDS year, we acknowledge execution risk
associated with salesforce, R&D, and cost structure initiatives. In terms of
promotional activity, several respondents highlighted more aggressive
discounting for ALGN's iTero, while XRAY equipment pricing was noted as
relatively unchanged.
■ Supply chain, Direct Dist., Amazon update: Henry Schein (HSIC,
Neutral) and Patterson Companies (PDCO, Outperform) were named as
primary distributors by 40% and 17% of respondents, respectively. The
majority (80%) is satisfied with its primary distributor, and 86% do not work
with GPOs, an unsurprising dynamic (differs from Vet). While only 6% of
standard medical consumables (e.g. gloves, cotton balls) are purchased
through Amazon today, respondents expect purchases through Amazon
could grow to 14% in 3-5 years. In terms of direct distribution, respondents
currently purchase 22% of consumables direct from manufacturers, with
12% expecting to purchase more directly over NTM.
28 January 2019
Dental Update 2
■ Clear aligners remain in focus: The majority (68%) of clear aligner users expect
demand to rise over the NTM, with volume likely supported by a rising base of trained
practitioners. Align Technology's Invisalign (ALGN, Outperform) remains the market
leader, with 60% of our entire cohort (88% of clear aligner users) offering Invisalign.
While concerns over competition, DTC, and ASPs have weighed on ALGN’s shares of
late, we view there is room for several players in a highly underpenetrated clear aligner
market, and we view ALGN is well ahead in terms of innovation, with several
respondents highlighting its recently launched mandibular advancement offering, an
underappreciated dynamic, in our view.
28 January 2019
Dental Update 3
Dental Survey Takeaways
We commissioned a survey of 75 practicing dentists dispersed across 21 states in the
U.S., with the highest number of responses in New York (13), California (9), Florida (9),
Massachusetts (6), and Illinois (5). Our respondents range across a number of specialties
including general dentist (48), orthodontist (15), periodontist (7), pedodontist (3), and oral
and maxillofacial surgeon (2), with an average tenure of 23 years. About half of our
respondents work as sole practitioners (38), while most other participants work with
multiple other dentists at a single practice owned by dentists (27). Of note, 3 respondents
work for a DSO or dental management organization affiliated group practice. On average,
our respondents see 123 patients on a weekly basis.
4Q Snapshot: Relevant company survey highlights
■ Dentsply Sirona (XRAY, Outperform): Overall, the survey results are mixed for
Dentsply Sirona, where we are forecasting 4Q18 revenues to fall 3.1%, driven by a
2.7% rise in consumables and -11.4% growth in Equipment to reflect ongoing
distributor-level inventory shifts. We remain optimistic on XRAY’s salesforce execution
push, where 33% of respondents currently purchase consumables directly from the
company, with 12% expecting to purchase more directly from the manufacturer over
the next twelve months. We also view XRAY’s recently revised strategy, where it has
foregone its longstanding approach to promote a more comprehensive chairside
CAD/CAM systems (scanner + mill), shifting focus toward its standalone digital
impression offering (with also a dedicated lab strategy), offers incremental opportunity
to capture share, particularly as only 9% of our cohort of dentists currently use its
CEREC offering. Importantly, while most of our respondents view XRAY’s equipment
pricing as unchanged, net-net our cohort views pricing is slightly more aggressive,
potentially coinciding with de-stocking/inventory shifts at the distributor level. Focus on
its earnings call will be on end-market fundamentals, equipment trends, and salesforce
initiatives.
■ Danaher (DHR, Outperform)—Earnings Date 1/29: Danaher’s dental business
continued to experience the impact of a lackluster consumables and equipment
landscape in 3Q, though we are encouraged by strengthening sellout trends, where we
expect +0.8% dental growth in 4Q, supported by management's recent
preannouncement that noted an improving Dental experience. Moreover, we view
DHR’s business will continue to experience healthier growth in a strengthening
demand environment, as indicated by our survey results (+2.2% NTM practice revenue
growth) and as it invests in key business lines. As a reminder, DHR has recently
announced its intention to execute a tax-free spinoff of its Dental business (est. $2.9
billion in 2018 revenue, 14% of total), with the transaction expected to close in 2H19.
DentalCo’s current President aims to replicate the DHR playbook (DBS), which should
help it to drive +LSD organic growth (+MSD specialty, 50% of DentalCo revs) and ~50
bps ongoing margin expansion LT.
■ Distributors – Patterson Companies (PDCO, Outperform), Henry Schein (HSIC,
Neutral): On balance, while expectations for distributors remain relatively low, we are
cautiously optimistic on prospects for the respective dental businesses of Patterson
Companies and Henry Schein based on the positive NTM outlook on dental traffic and
volume trends amongst our cohort. We also highlight positive commentary as it relates
to Patterson, where respondents who utilize it as a primary distributor are more
satisfied with the salesforce knowledge, on average, than competitors. Moreover,
Amazon’s penetration remains low, only currently accounting for 2% and 3% of dental-
specific consumables products and equipment, respectively. As a caveat, direct
purchasing from manufacturers will also be a dynamic that we will monitor going
forward in our survey work.
28 January 2019
Dental Update 4
■ Align Technology (ALGN, Outperform)—Earnings Date 1/29: While news of several
new entrants into the clear aligner space has increasingly pressured shares along with
recent pricing degradation that is expected to persist into 2019, we deemphasize the
competitive threat, with the view that the highly underpenetrated clear aligner market is
large enough for several players. Moreover, Align’s continuous innovation proves just
how far behind competitors are on the innovation and learning curve, with several
respondents highlighting the benefits of its recently launched mandibular advancement
offering. Currently, ALGN represents ~90% of the clear aligner market, where our
cohort of dentists expects demand to grow +3.1% over the next twelve months, with
volume growth also supported by a growing base of trained dental professionals. Also
of note, several respondents highlighted iTero price discounting, which will likely
support unit volume sales and scanner penetration. All in, we forecast -3.1% EPS
growth fueled by +22.5% topline growth, supported by +20.9% clear aligner growth and
+33.0% iTero growth, offset by 176 bps margin contraction in 4Q. Investor focus will be
on 2019 commentary and guidance, with folks looking for evidence of continuing robust
volume growth to offset aforementioned ASP pressure.
State of the Industry
Despite what should be favorable demographic and macro dynamics, dental consumable
trends have not experienced a meaningful, sustained pick-up in demand since the 2008
recessionary timeframe, likely driven by rising out-of-pocket healthcare spend,
representing a growing percentage of total discretionary income for consumers, share
shifts to specialty, among other potential factors.
While dental consumables trends were mixed across the majority of the major dental
companies in 3Q, industry commentary continues to point to a healthier experience near
term, with seemingly stabilizing sell-out trends. That said, we remain cautious in
suggesting a broader stabilization or pick-up in demand in 4Q, particularly given several
company specific issues.
Figure 1: Recent quarterly Dental demand trends as reported by industry constituents
Source: Company data, Credit Suisse
Patient volume & practice revenues
According to our survey, 47% of respondents experienced 0% to +5%+ growth in patient
visits in 4Q18, with total traffic increasing 0.5% on a weighted average basis (vs. + 0.2% in
3Q). Nearly a third of respondents (31%) reported ~flat patient volume growth over the
past three months. Notably, only 23% of respondents reported declines in patient visits
during 4Q (vs. 31% in 3Q).
1Q16 2Q16 3Q16 4Q16 1Q17 2Q17 3Q17 4Q17 1Q18 2Q18 3Q18
Consumables +LSD +LSD +LSD -- Negative Negative -MSD -L-MSD -LDD + Slightly
-MSD
Equipment -LSD +MSD +MSD -- Positive +LSD +LSD -MSD -HSD + Slightly
-MSD
Consumables 3.3% 0.9% -2.5% -2.8% -4.3% -3.6% -4.4% -7.4% -6.7% -5.2% -2.2%
Equipment -6.9% 5.4% 4.2% -1.0% -16.9% -15.1% -17.7% -10.6% -20.2% 5.4% -0.9%
Consumables 4.6% 1.8% 1.8% 1.9% 2.5% 0.8% 1.3% 1.9% 2.7% 4.7% 4.3%
Equipment 13.5% 2.7% 13.3% 2.7% -5.5% 14.8% -0.7% 18.1% 4.4% 6.2% 5.9%
Consumables 1.6% 4.5% 2.7% 2.5% 8.0% 1.4% 3.4% -2.6% 2.4% 3.0% 3.5%
Equipment 4.3% 3.1% 4.2% -3.9% 3.1% 3.6% 2.6% 7.7% 3.1% 4.7% -4.2%
Consumables 4.5% 3.8% -0.3% 3.5% 2.4% 2.0% 4.3% 3.9% -1.3% 3.3% -3.0%
Technologies 6.8% 0.8% 0.2% 0.0% -12.7% -10.0% -1.1% 5.9% -1.6% -1.1% -9.3%
3M
Oral Care 5.0% 3.0% 0.0% -1.0% 5.0% 0.0% 3.0% 3.0% 0.0% 3.0% 2.0%
Dentsply Sirona
Danaher
Patterson
HSIC N.A.
HSIC Int'l
28 January 2019
Dental Update 5
Figure 2: Dental practice visits (Y/Y growth) – Respondent distribution (+0.5% weighted average vs. +0.2%
in 3Q)
Source: Credit Suisse, n=75
Practice revenues increased 0.5% on a weighted average basis in 4Q18, a stable, though
admittedly lackluster trend (in line with 3Q). Practice revenues were driven by new patient
traffic (+0.9%), pricing (+1.0%), bridges and implants (+0.8%), and preventative (+0.6%).
As a caveat, this is our second dental survey, and we expect more meaningful takeaways
to our dental coverage with greater historical context in future surveys.
Figure 3: Dental practice revenues (Y/Y) – Respondent distribution (+0.5% weighted avg., in line with 3Q)
Source: Credit Suisse, n=75
8%
13%
10%
27%
19%
13%
9%
5%
4%
13%
31%
32%
5%
9%
0%
5%
10%
15%
20%
25%
30%
35%
40%
< -5% or more -3% to -4% -1% to -2% Flat +1% to +2% +3% to +4% > +5% or more
3Q18 4Q18
47% of respondents have experienced +1% to
5%+ in patient visits during 4Q18
8%
12%
9%
25%
21%
9%
17%
8%
7%
9%
29%
25%
12%
9%
0%
5%
10%
15%
20%
25%
30%
35%
< -5% or more -3% to -4% -1% to -2% Flat +1% to +2% +3% to +4% > +5% or more
3Q18 4Q18
47% of respondents have experienced +1% to
5%+ practice revenues during 4Q18
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