Cochlear Limited (OTCPK:CHEOF) Q2 2023 Earnings Conference Call August 14, 2023 8:00 PM ET
Company Participants
Dig Howitt – Chief Executive Officer, President
Stuart Sayers – Chief Financial Officer
Conference Call Participants
David Low – J.P. Morgan
Mathieu Chevrier – Citi
Steve Wheen – Jarden
Andrew Goodsell – MST Marquee
Saul Hadassin – Barrenjoey
Chris Cooper – Goldman Sachs
Sean Laman – Morgan Stanley
David Stanton – Jefferies
David Bailey – Macquarie
Susannah Ludwig – Bernstein
John Copley – UBS
Operator
Thank you for standing by, and welcome to the Cochlear Limited FY ’23 Results, Analyst and Media Briefing. All participants are in a listen-only-mode. There will be a presentation followed by a question-and-answer session. [Operator Instructions].
I would now like to hand the conference over to Mr. Dig Howitt, Chief Executive Officer and President. Please go ahead.
Dig Howitt
Thank you. Thanks all for joining us today. Great to have you with us to talk through our FY’23 results and outlook. So let’s get started.
As always, we start with our mission that guides all that we do at Cochlear, both in our strategy and our day-to-day work. And sitting under our mission is our strategy and thinking particularly of what’s the impact that Cochlear has on society, on our customers, on our people, on the environment and financially and we talk about our strategy in that context.
I’m not going to go through all of the detail on this slide. You can read through it. But the one point I did want to make is that, in helping over 44,000 people here in the last year, the net societal benefit of that is over $7 billion, which just shows how cost effective our products are, that we can conservatively create that sort of value with what we do. And that comes from healthy outcomes, educational cost savings and through productivity gains.
I’ll now step into the result in a bit more detail and I will run through the revenue and each of the revenue lines, and then Stu will talk through the P&L and the cash flow and the balance sheet in a bit more detail.
Clearly, it was a really strong revenue result. We saw double-digit growth in each of our revenue lines, Cochlear Implant Services and Acoustics, and we saw double-digit growth in each of the regions. We often talk about having a portfolio of geographies and products. It’s rare that we see all of those growing at this rate at the same time. There were hardly any countries last year where we didn’t see good growth. And I’ll talk through each of those revenue lines in a minute, but certainly Nucleus 8 is a highlight.
In terms of net profit, Stu will talk more to that, $305 million. And we took the opportunity with the increase in sales to choose to increase our investment in R&D and in long-run growth. Something we’ll also talk about is we have an incentive system that runs right through the business, which is highly leveraged to above plan revenue growth. I’m sorry, employees get rewarded for the strong revenue growth in the year it happens, and then we obviously lock that revenue in for the baseline for future growth.
And we remain in a strong position from a balance sheet perspective, and Stu will talk to the dividend and I’ll talk to the outlook at the end of the presentation. But now let’s jump into each of the revenue lines in more detail.
Starting with Cochlear Implant, so clearly very strong growth in Cochlear Implants, 17% in constant currency, and we saw good growth across developed markets and emerging markets. And we called out there about 15% in developed markets, about 20% in emerging, and we caught out the second half growth rate there in developed of 18%. And that’s because if you just look at the raw numbers, you’ll see a 30% revenue lift in Cochlear Implants in the second half.
That’s driven by currency, but by the deferred revenue moving from first half to second half, and so the underlying growth rate, which you can see across all implants and then in developed markets it’s very strong, but well under that 30%.
So what drove that growth? So there were four factors. Market growth was there and clearly important. Improved clinical capacity, and that’s both the audiology, capacity for screening and the hospital surgical capacity. And as we’ve talked about, it’s the audiology capacity that is more of a constraint for us now.
We gained market share on the back of the strength in our product portfolio and particularly in Nucleus 8. And there were COVID catch-up surgeries, which we didn’t expect at the rate that we saw them.
Now, we don’t know exactly what each of those four elements contributed to growth. One of the ways we looked at this, we looked at the growth in children in the developed markets. Normally we would expect children in the developed markets to grow about 1%, which is pretty much in line with the birth rate. We actually had surgery growth of 5% of children in developed markets, and there’s two things that are driving that that we don’t think will repeat next year.
One is market share gains. We have gained share, but we don’t expect that to continue into 2024, just given the level that our share is at. And the second one, which we saw in children, but it flows through adults as well, is catch-up surgeries. And we can see that in the numbers and we hear that anecdotally from clinics that they are seeing some older babies come through that we’re assuming got missed through the last couple of years of screening. And again, that surprised us to see that come through. We don’t expect that to repeat. So as we look into next year, we think our growth will be just driven by market growth.
I think one of the very pleasing things on growth is that we are seeing an improvement in the adult surgery rates and in referral rates, but in key markets. So that gives us – it’s encouraging in terms of the investments we’re making in standard of care, which as we said, are long run investments. It’s encouraging to see the growth there. We obviously want to see that growth continue for more than just a year to give us even more confidence.
And emerging markets, strong growth there. We said we expected governments to come back with restart tender activity. We’ve seen that. So emerging markets are now well above pre-COVID levels and we expect continued growth there. We had also strong performance in China.
On to services. So a very strong second half, which we said would happen on the back of Nucleus 8, up 14% in constant currency. And we saw growth there across the world. One of the pleasing parts of service is, we are seeing increasing growth rates and increasing penetration of upgrades into emerging markets.
Upgrades over time has been much more focused on developed markets. It continues to remain largely a developed market source of revenue, but we are seeing increases in emerging markets. And I think that’s coming from, we’ve been in emerging markets for longer now. There’s largely children who get implants as those children get older and as wealth grows, more of them either themselves or through governments are looking to upgrade technology. So we’re encouraged by the longer run outlook and expect services to keep growing in 2024, given the full year opportunity with Nucleus 8.
And then onto Acoustics. It is strong growth again, 20% in reported currency, 15% in constant currency. Really two factors here. The Osia 2 System continues to go well. We’ve always said with Osia, this is a long run program. It’s effectively a new therapy. We need to get regulatory approval. We need to get appropriate reimbursement in countries before we will launch.
In the countries where we do have that, achieve those two things, we are seeing a strong uptick and strong growth in Osia surgeries. We’ve now sold over 12,000 systems since that launch and continue to be very excited by the long run opportunity.
Baha 6 was a strong contributor to growth in the last few years and a lot of that comes from people with the Baha implant upgrading from an earlier generation to Baha 6. We expect that the upgrades for Baha 6 will slow in 2024 and therefore while Osia will grow strongly, we expect slower growth in Acoustics overall in 2024, but remain very positive on the long run opportunity here in Acoustics.
Okay, let me just then run quickly through our strategy. There’s a lot of information on these slides. I think it’s actually very important to articulate our strategy clearly and our strategy is unchanged over the last few years and we continue to execute carefully and clearly on it and invest as we can afford to, to drive this strategy.
So I’m going to jump through a few slides. I do want to just pause on this one, the healthier and more productive society, because this is about standard of care. It’s about getting particularly the developed markets adults and seniors, and we’ve made good progress in the last year, not only helping over 44,000 people here and that’s across all of the world and all of our products, but the development of the Living Guidelines, which was 50 Cochlear Implant professionals from around the world collaborating based on evidence, building out practice guidelines, which are now available and able to be tailored to countries to get more consistent referral, more consistent clinical practice and post-surgery care. That’s an important part of building standard of care.
The ACHIEVE study, which is Frank Lin at Johns Hopkins, has been running for three years, reported just in July. For a long time, there’s been very clear evidence of a strong correlation between cognitive decline and hearing loss and between dementia and hearing loss. This study was looking for, is there a causable link? Does treating hearing loss change the rate of cognitive decline in people with that hearing loss?
What the study saw, that in the overall cohort, there wasn’t a change in three years, but for people with higher risk of cognitive decline, the study showed that the rate of decline slowed 48% across the three years for those people who had hearing loss and had it treated versus that didn’t have it treated.
And that’s a very significant result in terms of building the evidence base that shows that hearing loss is a serious and significant medical condition. It can be treated, it should be treated and treating it has the potential to improve overall health. So we expect more evidence to continue to come out over the next few years from this study and others, but all of this helps build that evidence background towards standard of care.
And finally, reimbursement. It’s very important that reimbursement expands with the effectiveness of the product and to support broader adoption. A good example of that is the CMS expansion of indications in the U.S. from a 40% word score to a 60% word score. Clearly that expands, that matches then in the U.S. insurance reimbursement, CMS matching insurance and expands the opportunity as did single-sided deafness a few years ago, and we’re seeing that come through now in our sales.
And Osia funding and in countries, more countries adopting newborn hearing screening and comprehensive programs for newborns. Okay, I’ll jump more quickly through the rest. So lifetime hearing solutions, we have a very strong product pipeline based on our investment in R&D. As we said with Nucleus 8, great reception, over 48,000 people upgrading their processor in the last year, up 19% on previous years.
As a technology business, we are a knowledge-based business now. People are critical to our continued success. We have strong engagement throughout the world. We continue to make progress on shaping our culture and our organizational processes to really underpin and support growth.
We are planning on continuing to grow and to be a bigger company and we need to make sure that we build out the infrastructure, the capability and the processes to support a much larger number of customers and underpin our growth. Our culture is central to doing that as it is to executing our strategy and driving growth. And we continue to make good progress on building out a diverse and inclusive workplace.
Our environmental impact, we’re a very small carbon emitter, but it is important that we take action and we are. So we have converted our manufacturing sites to renewable energy. Now 96% of energy used in our manufacturing sites is renewable and the constraint there is actually availability as to why it’s not 100%. We’ve had, as a result of that, a significant reduction in our Scope 1 and 2 emissions from our FY19 baseline down 68%.
And we’ve also committed to reducing air travel, both in terms of the number of flights per employee, and then buying offsets to reduce the overall flight related emissions, and you can see the impact there. And we continue to work with regulators to reduce the amount of paper that we need to distribute with our products. And as we make progress there, it not only as an environmental impact, but a pretty significant cost impact as well.
And then finally on to state value, we talked about the sales. Stu’s going to talk about the P&L and the balance sheet. We have started manufacturing a sound processor at our factory in China. So that’s an important milestone. We expect the implant approval to come through within the next 18 months. We’re making very good progress on our business process and IT platform upgrade with 150 million spending over four to five years. And we’re a little bit below halfway through that program. Connected care products remain important and the cyber security certification helps us with implementation in hospitals.
We talked a lot and reported a lot on the Oticon Medical acquisition that we’re now focused on the Cochlear Implant business. Happy to take questions on that, but there’s really no new news from our previous updates, but happy to go into that further in Q&A.
With that, I’m going to hand over to Stu to talk about the P&L.
Stuart Sayers
Fantastic. Thanks, Dig. Good morning, everybody. You’ve heard a lot already about the strength of the top line sales result. I’m not going to add anything more to that. I think that the next line gross margin, we came in at 75.
[Technical Difficulty]
Okay, sorry about that. I think we are now back on. So as I was saying, gross margin we are expecting about 0.5% headwinds in ’24 as Chengdu moves into production. We are actually making sound processes there now. We’ll be expecting to get certification to make implants there within about 18 months, which is that headwind increasing for a year or two and then moving to a net positive tailwind as Chengdu goes to full capacity.
Moving to sales marketing and general. Big increase there, 19% year-on-year. Biggest driver of that was investments I growth. So that’s particularly putting more people out, selling in the regions. It’s also the sales commissions that went with that with a very strong year as Dig’s alluded to and it was deliberate investments in growth. So that things like standard of care, and actually there is thing like market excess and getting more funding, expanding their funding criteria and direct to consumer, DTC activity, where we are spending more direct with candidates to try and pull them into clinics to get addressed.
R&D similarly alongside they are selling and marketing. We saw with the strength of the momentum and the business in the second half. We saw the opportunity to accelerate programs within R&D. That saw us land just a fraction above our long term target of 12% of revenue we have and 13% of revenue in R&D and very happy with the rate of innovation and that team.
Admin expense is up 20. That’s driven by a couple of things. First off, again, that’s where we see some of the bonus and incentive payments coming though off the back of a strong year. It’s always where we see the Oticon transaction costs flowing though, and we also took the opportunity to reduce a small amount of restructuring when the business is well and that’s really completing the integration of our Acoustics business and our services business into the main group.
So that’s saw us land at the absolute top of guidance, and with some very deliberate investment choices give the strength of the revenue result.
If we jump to the next page on the balance sheet. And since on net profit we delivered 17% ex-cloud, we’ll keep targeting 18% long term. On the balance sheet, the big movement here is in that working capital line, the $80 million. That’s a combination of very strong growth and receivables. That is absolutely driven by the strength of the sales and particularly in half two and Q4. Very happy with what we see in terms of debt levels and recoveries, so that really is indicative of the underline sales strength.
Inventories, slight up, about 40 million. Slightly more in components and rural materials at this point versus this time year ago. And again, that’s us opportunistically taking the chance to do lifetime buys for componentry and raw materials when those opportunities come up. And it’s to make sure that we stay insulated from what is an increasingly tricky supply chain, but the guys are going a fantastic job managing that.
Payables is up on a year ago, but that’s very much a timing thing. It swings plus or minus $20 million based on weekly payments.
On to cash flow. So the underlying EBIT result was strong again, indicative of the strong results and you can see we earned more interest sitting on that large cash balance that we have. The big change, the biggest change to call out here is that income tax paid line.
Now, this is hopefully the last of some big swings and differences between cash tax versus tax due, where we had a small refund in ‘23, we had a much, much bigger refund in ‘22. And that meant that our cash tax expense in ‘23 was $50 million higher and that’s what’s driven the operating cash flow to be slightly lower.
We expect those big swings to have really flushed through the business now and we expect that to be more consistent from ‘24 and ongoing. And in terms of the effective tax rate, we’ve got a couple of permanent benefits in terms of the increase on R&D that’s allowed to be claimed against. We had some one-off benefits in terms of annual adjustments. So we’re sitting at about 24% effective tax rate in ‘23. We think ‘25 is about right going forward.
CapEx up to – just under $96 million there. That includes the beginning of a pretty significant overhaul of the Lane Cove facility. Big – alluded to say, the solar panels going on the roof there. We’ve also – Phase 1 of that is the solar panels and all of the communal areas, the lunchroom, the reception area, trying to make it a nicer environment for the staff. The next phase of that will be about actually expanding the production capacity as well. In terms of looking forward, somewhere between where we landed in ‘22 and ‘23 on CapEx is about right, somewhere in that sort of $70 million to $90 million range.
And then lastly here, the other net investments, the $29.8 million, that’s us putting additional money into Precisis, Nyxoah and Epiminder. It’s hard to be very precise about that looking forward, but that sort of $30 million range feels about right to us. It’s a good balance of enough to be putting stakes into interesting growth opportunities and IP, but also not so great at risk becoming a distraction.
Onto then the next slide. So the dividend, the full year dividend is going to be $1.75. That’s up 21% on this time year ago, and again, that reflects the strength we see underlying in the business. That gives us a full year payout ratio of 71%, just 1% ahead of our long-term target. And it’ll be 70% francs. We expect it to be 100% francs in ‘24 and beyond, and that’s again, those historic losses just washing through the business and trailing off.
Last but not least, the share buyback; we announced that at the half. We said we aim to reduce our cash balance gradually over time over a number of years. For the first 12 months, we were targeting $75 million buyback. We’re about four months into that. We spent $30 million. We’re on glide path to achieve that $75 million and we’ll be updating you again at the half on what the spend for the next 12 months will be. But we absolutely expect that program to be ongoing over a number of years and obviously maintaining that 70% dividend payout ratio at the same time.
And with that, and apologies for the IT glitch, I’ll hand you back to Dig for the outlook.
Dig Howitt
Thanks Stu. Yes, apologies from me too for losing connectivity in the middle there. Onto the outlook. So let’s see, a net profit guidance range of $355 million to $375 million. And that anticipates revenue growth and improved net profit margin, so getting our net profit margin back towards the 18%.
As I said earlier, actually working out all of the factors that impacted growth this year is difficult to do and in a highly analytical way. But as we look forward, we do expect to see high single digit growth rates in Cochlear Implants, driven by this improving trend in adult referrals in developed markets and obviously continued growth in emerging markets.
We don’t expect that the share gains we achieved this year and the COVID related backlog of surgeries that came through, we don’t expect them to repeat in 2024.
A full year of upgrades with Nucleus 8. We expect to drive the services number with strong growth, and as I said earlier, with Acoustics, continue to see strong and the long run growth for Osia, but lower growth rates from Baha 6 as we just moved to later in the upgrade cycle, slowing the rate of Acoustics growth from the level we’ve seen in the last few years.
We continue to – our strategy I said is unchanged. It is a long run strategy, and we will continue to invest both in our product portfolio and to strength – continuing to strengthen our portfolio on improved hearing outcomes for our customers. And investing in standard of care for adults and seniors in the developed market and building out the evidence, the referral path, the awareness, and the funding.
And as we talked about in the past, we really believe in building a clear and consistent referral path. We are building an asset, and it makes sense for us to invest in that asset as fast as we can justify and can manage from a capacity perspective, because that underpins our long-run growth.
You can see there cloud computing. We’ve also put currency rates in and compared those to ‘23, because we can see that our net profit is growing faster than revenue. That comes part from currency, and it also comes part from expanding the net profit margin.
And we expect to maintain 70% payout ratio, and we have not included anything from Oticon Medical. We do still anticipate closing in December, but conscious that we are in the hands of the regulators on the process there and the timing. So we haven’t factored any costs of the acquisition and integration into our FY24 outlook.
Okay, so I’m going to stop there and hand over to questions.
Question-and-Answer Session
Operator
Thank you. [Operator Instructions]. The first question today comes from David Low from J.P. Morgan. Please go ahead.
David Low
Thank you very much for taking my questions. Could we just start with the audiologist capacity expansion that you talked about? That’s certainly a topic that we hear from particularly U.S. centers that is a bit of a challenge. I was just wondering if you could talk to what you’ve seen and what you expect going forward and how much that might be a constraint into future growth, please.
Dig Howitt
Yes David, thank you, and a really good question. It is particularly in the U.S. one of the constraints on growth and we were pleased to see obviously the volumes that came through this year.
Now we are working – the key to expanding audiology capacity is to reduce the amount of audiological time spent post-surgery, where there is an opportunity both with evidence to reduce the number of appointments and to use tools like connected care to significantly reduce the face-to-face clinical time, and therefore use that audiology time upfront on screening and diagnosis.
We are working with a number of the leading clinics in the U.S. to trial new models and build the evidence that supports those models, and obviously integrating our technology into the delivery of those models.
So we’re confident over time that we can continue to expand that capacity but certainly in the shorter run and at the bigger clinics, delays in getting an audiological assessment for a new candidate is one of the constraints on growth, but certainly we’re pleased to see that the volume come through this year, because it’s an indicator that clinics are making progress in dealing with that bottleneck.
David Low
So delays at the bigger clinics are effectively the norm for the moment?
Dig Howitt
Certainly in some of them. It varies. Some of those clinics are moving faster than others in reducing the post-surgery appointments and therefore freeing up capacity, but it’s just by weight of numbers. It’s more likely to be in a bigger clinic than a smaller clinic and what we’re seeing is that the smaller clinics are not surprisingly growing faster than the bigger clinics, because they don’t have that load of patients, but also typically the smaller clinics have come into Cochlear implant more recently and they are adopting less intensive practices in their post-surgery care, which enables them to grow faster too.
David Low
Great. Thank you. And just one other for me. I was looking at slide 10 where it talks about having helped 48,000 prior generation Cochlear implants up 19%. Can I back calculate from that that it’s 7,000 odd that were added with the upgrades that were done this year? And the same question, can you talk about the penetration rates that you’re seeing there please?
Dig Howitt
So 48,000 is the number of upgrades done in the year and that’s 19% higher than the prior year. In terms of penetration, as we’ve talked about last few years, we now think about this as an annual number of the number of people who are eligible and what proportion of those people are actually getting an upgrade.
Now we haven’t put those numbers out there, because we’re still trying to get our own comfort with them and as we see growth in emerging markets, we think through how does that change the calculation. So before we put something out, we want to actually make sure it’s meaningful. But I think that’s the – the sort short way around that is we are seeing some improvements in penetration, which is very encouraging.
Operator
Thank you. The next question comes from Steve Wheen from Jarden. Please go ahead.
Sorry, the next question comes from Mathieu Chevrier from Citi. Please go ahead.
Mathieu Chevrier
Hi, good morning. Can you hear me okay?
A – Dig Howitt
Yes, we can. Thank you.
Mathieu Chevrier
Excellent. I just wanted to dig a bit deeper in the growth in developed markets that you’ve been seeing, in developing markets. Could you give us a sense of what you think is the normal type of market growth rate in developed and emerging markets?
Dig Howitt
So what we’re forecasting for 2024 is that we see high single digits in our cochlear implant unit growth. We think that that is pretty much the market growth number and that we don’t expect the sort of, as I said, the abnormal increase in share – well, not abnormal, but we don’t expect an increase in share, we don’t expect COVID catch up.
And in that typically we’d see a little bit higher growth in emerging markets than developed overall and that’s remembering that in developed, around about 30% of the surgeries are in children and we expect sort of 1% growth there and obviously then a higher double digit rate of growth in the adults and seniors.
Mathieu Chevrier
Yes. And just on that topic of growth in adults and seniors, do you see yourself increasing that sales and marketing expenses perhaps a bit more than you thought just a little while ago, given the response that you seem to be seeing from the market point?
A – Dig Howitt
Look, we continue to watch that carefully and you saw that, as we said, we did lift our [Audio Gap] come in, and that sort of set us on the basis that we’re building this referral path, which we think of as an asset. Therefore it makes sense to sort of build that asset faster if we can afford to. The things that therefore constrain the rate of growth, we do want to make sure that we deliver appropriate and growing profitability. And secondly, it’s just our organizational capacity. We want to make sure that we don’t take on more than we can execute effectively.
Mathieu Chevrier
Understood. Thank you.
A – Dig Howitt
Thanks, Matt.
Operator
Thank you. The next question comes from Steve Wheen from Jarden. Please go ahead.
Steve Wheen
Yes. Good morning, Dig. Can you hear me?
A – Dig Howitt
Yes Steve, can do, yes, yes.
Steve Wheen
Okay, cool. Yes, I just want to pick up on that, the process upgrades. Obviously a very strong launch into the second half, which seasonally is not that – well historically, that’s not normally where you’d be as strong. So I’m just wondering what the potential looks like for next half as everyone starts to burn through their deductibles. I mean, is it your expectation that that surge is again from here into that half?
A – Dig Howitt
I think we certainly expect to see strong growth in upgrades this year. Largely, that’s just the full year potential. Your point on deductibles is particularly relevant obviously for the U.S. and with people on an annual calendar year deductible, we often do see more upgrades in the U.S., sort of in Q4 than we do in the earlier quarters as people have used their deductible and therefore don’t have to pay out of pocket for an upgrade.
So I think that has some impact, but with the growth in emerging market numbers of upgrades, that impact of sort of seasonality in the U.S. is more muted on the total. So full year of Nucleus 8, and expect good numbers and we don’t have Nucleus 8 – like we don’t have Nucleus 8 approved in Japan just yet for example. So there’s still some approvals to – we’re largely there, but we still have a few approvals to come through, which we think will help support that good growth.
Steve Wheen
Yes, great. And secondly for me, I just noticed a bit of change in your commentary, particularly around the expansion of the eligibility criteria. Previously you seemed to think that that was probably a little bit more long dated, but certainly from channel checks that we’re seeing, it sounds like you’re starting to see a lot more come into the funnel, maybe through the audiology clinics in the first instance. Is that what we’re hearing with your commentary now, that that is starting to open up that adult channel a lot more?
A – Dig Howitt
We’re certainly seeing a good rate, an increased rate of adult referrals. As you would have heard on channel checks or checks with clinics, single-sided deafness is a part of that and that change in funding is a couple of years ago. So I think the more recent change on the CMS funding will take a little bit – will still take some time to come through.
But what we’re seeing is that – and that’s why we want to see these referrals run for longer. So as I said, we’re encouraged, but we want to see it run for longer. This has always been a multifaceted problem to solve in increasing referrals. It’s not just indications, it’s not just hearing aid clinic awareness, it’s not just funding. It’s all of these pieces working together.
It is hard to sort of disaggregate them, work out what’s contributing what, but we’re certainly pleased with what we’re seeing, but do want to see this increase in referrals sustained over time. But it does give us more confidence, increasing confidence to the path we’re on with our strategy and investments we’re making are having an impact.
Steve Wheen
Great. Thanks, Steve.
Dig Howitt
Thanks, Steve.
Operator
Thank you. The next question comes from Andrew Goodsell from MST Marquee. Please go ahead.
Andrew Goodsell
Good morning. Thanks very much for taking my question. Just asking you to be a bit more granular on the growth that you saw and where you got some of that market share. Just I guess specifically asking around Oticon and the gains you might have taken in both CI and Baha. But also we did note a couple of markets were a bit slower in their recovery. Like Germany and just whether they’ve now kicked in or whether that’ll be more of a ‘24 event?
Andrew Goodsell
Yes Andrew, good questions. So certainly on market share, it’s been – the growth there we’ve seen pretty much across the board and certainly in developed countries. It’s always a little bit patchier in emerging countries for a whole range of reasons. We have seen the biggest growth over the last couple of years has been in France. And certainly that’s on the back of the Oticon medical recall and our commitment to support their customers. That certainly helped our share in France. But we have seen share growth across a whole range of countries. Small amounts, but obviously they all add up and it’s all important.
From a growth, we saw, as I said good growth across just about all of the developed markets last year. Some of them were coming from lower bases or higher bases depending on how well they’d gone the previous year and how low they went in COVID. But pretty much all of them have recovered very well and are well above pre-COVID levels. And I think part of the context for that is back to our strategy is, in every market the clinical opportunity is huge. Our penetration is low and we have the opportunity with the right strategy and good execution to increase that over time.
I think COVID has put a lot of noise in the system. We hope we’re getting through that and can get back to more consistent and predictable revenue outcomes.
Andrew Goodsell
Okay, that’s great. And just a quick one for Stu. Just on the NRIs in both ‘23 and ‘24, I think you flagged or just trying to get a bit more granular on restructure costs and then Oticon costs in ‘23 and then if you can talk to Oticon in ’24. I know you’ve excluded that from guidance, but just a bit more color on that.
A – Stuart Sayers
Yes sure, thanks a lot Andrew and good to hear you. A couple of one-offs in ‘23, so we had about 5 million more uplift in Oticon transaction expenses relative to ‘22 and sort of similar level of non-Oticon related restructuring charges, and as I said, that was the tail end of us integrating our own acoustics business fully and the services business fully into the group.
Going forward on Oticon, as Dig said, we’re expecting that to complete in quarter two by the end of the calendar year. We’re still in discussion with Demont and trying to find a happy landing that meets the needs of the CMA and then through the European regulators and the ACCC as well. I think that the numbers we’ve put out there in terms of the potential impacts in the first 12 months of acquisition haven’t really changed. We’re still in that 30 to 60 range and we’ll update as soon as we know more.
Andrew Goodsell
Okay, got it. Thank you.
Operator
Thank you. The next question comes from Saul Hadassin from Barrenjoey. Please go ahead.
Saul Hadassin
Good morning, Dig. Good morning, Stu. Can you hear me?
A – Dig Howitt
Yes Saul. Good to hear.
Saul Hadassin
Thank you. Dig, just following up on that discussion around processor upgrades, I know historically the company has spoken to maybe a target penetration rate globally of around 50% and potentially being able to move that higher. Just wondering if you’re willing to give us a sense of where you think with this N8 cycle, you think that penetration might ultimately get to?
A – Dig Howitt
Yes, a couple of ways to look at it. So one is that we used to look at it that way. Talking about penetration over the cycle got more complicated when we launched off-the-air processors, because some people go that way, some people go with a BTE and that’s where we start to look at on an annual basis, which as I said, we just haven’t put the numbers out yet, because we’re just trying to – we want to make sure they are meaningful.
But as we are looking at this in different ways internally and we do see that we’ve seen small lifts in penetration, that’s what we’d hope to see, because we’re investing in the Cochlear family or in building out connectivity with customers so that they are more aware of the opportunity to upgrade.
We continue to – Nucleus 8 is absolutely a standout product delivered on the three dimensions of improvement in a sound processor. It’s smaller, it’s better connected and has better signal processing, which gives better hearing outcomes. We have key goals in each of those three dimensions and customers appreciate that and they are taking it up.
Saul Hadassin
Thanks for that color. And then I’m just interested in your comments around no expectations for additional market share gains into 2024 for Cochlear implants. And on the basis that you’re presumably outspending your competitors significantly in both R&D and SG&A, just wondering why you think that seeding of share will slow down into 2024?
A – Dig Howitt
Yes, it’s – I mean we’ve got – Good question. We’ve got very strong competitors. They fight hard for share, which is good to see. People want a competitive market and want to make sure that there are other players alongside us. So we think there’s probably a limit on how much share we can gain and it’s also about how do we invest.
We want to weight our investment to market growth, because that’s the driver of our overall revenue rather than weighting it towards market share and trying to eke out another percentage share. We’d rather put that amount of money into growth and hopefully get more than 1% out of it.
Saul Hadassin
Thanks, Dig. That’s all I had.
A – Dig Howitt
No worries. Thanks, Saul.
Operator
Thank you. The next question comes from Chris Cooper from Goldman Sachs. Please go ahead.
Chris Cooper
Good morning. Thanks for taking the questions. I just wanted to follow-up on a previous answer. I’ve kind of shared the view that you’re sounding a lot more positive on the adult referral rates in developed markets. Dig, you mentioned you need to see a bit more evidence of that before calling it a trend.
Can I ask what you would need to see? Whether that’s sort of time or a bit more sort of referral coming through? And maybe just to push you a little bit on quantifying this. I mean as you stated yourself, it’s unusual for each segment to be growing double digits here. How much of the growth you’ve seen in implants would you say is a function of the referral rates as opposed to sort of COVID backlog and market share gains that you’ve also called out?
Dig Howitt
Yes, so on the first one of what will give us more confidence it really is time, because I think there’s been – it has been with COVID quite a bit of noise in demand or variability in demand over the last few years off a low in 2020. Through that time we’ve continued to invest in standard of care, in building the funnel pipeline of adults and seniors.
We see over the last year and a bit longer than that, we’ve seen good increases in that funnel and the quality of candidates coming through. We still want to see that trend continue for longer. So it’s more about time than it is about increasing the rate.
And as I said, in our outlook, we’ve said high single digits on Cochlear implants driven by market growth. And as I said earlier, if you think about that from what’s that mean for adults and seniors in developed markets, it’s probably like you know it’s in the in the double digits given that we expect children about 1%, so that’s what we’re seen.
As I said, very hard to back out last year how much was here in referrals, but the best – our best analysis or estimates of that we see that high single digit overall, which probably means low double digit for adults and seniors.
Chris Cooper
Okay, thank you. And second one, you’ve obviously sort of taken the decision here based on the strength of the top line to put a bit more into growth initiatives. Are you able to split that out for us in some way? Can you give us a sense of how much that additional cost growth we saw in the second half was, sort of I guess discretionary as opposed to the normal run rate?
Dig Howitt
I mean we’ve got a lot of discretionary spending. So of the of the extra as Stu said, there was choices to invest a bit more in R&D, choice to invest a bit more in growth, and also the – as we’ve said, our incentive program is highly leveraged to above plan revenue growth and so there’s a good chunk of the extra, which is going to employees as a reward for delivering the sales growth. That’s a great one-off for them and now we’ve got a higher base as we look towards ‘24 to grow from.
Chris Cooper
Okay and just a quick one on the cognitive decline data published in the Lancet a couple of months ago. So I know we’ve got to be careful making cross trial comparisons here, but in the cohort which were at higher risk of decline, you did seem to show quite a meaningful benefit or – not you, but the study showed a meaningful benefit in rate of decline, somewhere above where the pharmaceutical guys are currently purporting their product to be. So I just wanted to ask, I mean is there something that can be done here that you perhaps could be leading to perhaps increase that referral rate further?
Dig Howitt
I think this, the building out of evidence of the importance of hearing loss to healthy aging is a very important part of that overall referral. Now that’s been – the sort of fundamental issue with hearing loss forever is it’s not seen – hasn’t been seen as a medical condition.
People accept that as a natural part of aging and what this shows and others starts to show is that not only is hearing loss obviously treatable, but actually treating it improves overall health. And I think that’s what gets people to get up and take action on their health is a sort of a fear that something else could be wrong.
I mean look people go and get blood tested for cholesterol now routinely, not because they enjoy blood tests, but because they want to know what the outcome is because of the consequence. And I think what we’d like to see over time is that people once they get past a certain age they get their hearing checked regularly, because it’s people often don’t know they’re losing their hearing.
But now and not just this ACHIEVE study, but other studies are increasingly showing that treating hearing loss has important medical health – sorry, health benefits beyond just being able to hear better. So I think it’s a very important study. We think more data will come and this links directly to our strategy of making hearing loss a medical condition and being really clear on the paths for treatment and the effectiveness of our products in providing that treatment.
Chris Cooper
Okay. Thanks for taking the questions.
A – Dig Howitt
Thanks Chris.
Operator
Thank you. The next question comes from Sean Laman from Morgan Stanley. Please go ahead.
Sean Laman
Thank you. Good morning Dig. Good morning Stu. I hope you both well. Dig on the audiologist bottleneck issue, are you able to give us a description of your experience with remote check so far?
Dig Howitt
Yes Sean, good question. So remote check, we continue to roll it out. It’s been slower progress than I think we anticipated up front and what we’ve learned out of that is it actually takes quite a bit of work, because there’s patient data involved to get through the hospital privacy and cyber security screens. That’s why we got the ISO 27000 cyber security rating because it helps us.
Where it has been implemented, it definitely cuts down on the need for face-to-face appointments beyond the first year and that’s part of the work we’re doing. Part of the work we’re doing is not only going to get into hospitals, but then you actually got to change clinical practice. So if a clinic is set up to set appointments and put the one-year follow-up in, unless we actually change with the clinic, change the process to put a remote check-in instead of a one-year appointment, it doesn’t have an impact.
So it’s the change management piece that we’re now working through, but it’s an important step. But the other important step which is significant is there are still clinics that will do 10 or 12 appointments in the first year after surgery, whereas other clinics now are down to three appointments in the first year for adults. And demonstrating with evidence, there’s no impact on outcomes.
So being able to take seven or nine appointments out of the first year is actually an even bigger impact than remote check, which takes an appointment out one a year, but obviously on a bigger base. So it’s both of those things got to work together over time. But it will take – changing clinical practice takes time and that’s certainly one of the things that I suppose we knew, but it’s only once you get into it and now working on it that you’ll learn that it really does take time and effort, but the rewards are worth it.
Sean Laman
Thanks Dig. And on the Cochlear Provider Network, what’s the progress across the U.S. in terms of numbers over the period? Is a program that’s still ongoing? How helpful has it been driving penetration into those older demographics?
Dig Howitt
Yes, it’s only one of our CPN and hearing aid referrals. It is one of our drivers of growth under the adult and seniors growth strategy under standard of care. We are seeing an increasing number of referrals.
With the CPN, what we’ve done the last couple of years is slow down the rate of addition of new CPNs and really work with the ones we’ve got on the education and on expanding the number of referrals, because we’ve seen that they’re referring only a very small proportion of the potential.
We think we’re better off not expanding it, but actually working with them to show them the benefits, how they make money, who’s a candidate and with the expanded CMS. That’s where the expanded CMS criteria in the U.S. is very helpful, because it gives us more of a base for people without insurance to be able to talk to – for the audiologist to talk to them about the potential for an implant. And in Australia, we’re doing a lot of work with hearing aid clinics and seeing definitely an increase in the rates of referrals from that too.
Sean Laman
Great, thanks Dig. And squeeze one more in if I can. Just remind us if you haven’t disclosed already, the portfolio of products due to come out of Chengdu, how different to other manufacturing sites?
Dig Howitt
So the product portfolio in Chengdu will be a subset of our total portfolio. So at this stage they won’t be different products, but they’ll be products that we are currently making in Sydney and may move to Chengdu or more likely add new capacity, most of it around the implants we’ll be adding. Implants we make in Sydney, we’ll also – some of them, we’ll also make them in Chengdu.
Sean Laman
Perfect. Thanks for answering my questions. Appreciate it.
Dig Howitt
No worries. Thanks, Sean.
Operator
Thank you. The next question comes from David Stanton from Jefferies. Please go ahead.
David Stanton
Good morning, team, and thanks very much for taking my question. Look, I’ve just got one. If it’s and it’s around Oticon, perhaps it’s sort of for Stu. If you do get disclosed in December 2023, will you take the expense of it, that 30 to 60 you’ve talked to above the line or will you treat it as an NRI? What’s the thinking at the moment, knowing that that might change in the future?
Stuart Sayers
Hey Dan, good to hear from you. Look, we’d take it below the line. It would absolutely be a cost that we would not be seeing as recurring. And as I said, it’s early days, right. We’re still in discussions with Demant and then obviously with CMA and the other regulators. But yes, we’d definitely be taking it outside the underlying result.
David Stanton
Understood. Thank you very much. That’s it.
Operator
Thank you. The next question comes from David Bailey from Macquarie. Please go ahead.
David Bailey
Yes, thanks, morning. I’ll also be quick. Just in terms of ASP, it looks like there was a bit of a step up in the second half of 2023. Is that all going to be mixed or is there some pricing to consider there? And then just for fiscal ‘24, 16% to 23% growth year-on-year. Just wondering what the benefit of currency looks like. So what that growth rate might look like in constant currency terms. Thanks.
Stuart Sayers
Thanks, David. So on the ASP, there was a significant currency piece in the ASP lift. Backing out currency, there was a small increase in developed markets. And when we launched Nucleus 8, we said we were trying to put some price increases through where we could. And we’ve got a modest increase out of that, which is nice to see.
In terms of the outlook, we haven’t been specific on how much of that’s currency, but we have put the direct comparison of the rates we’ve used for the outlook. And you can see the big difference is there in the euro, and it is part of the revenue growth that we and – part of the reported revenue growth will be driven by currency. And that given the outlook for margin does help push that profit up a little bit. But certainly the majority of the lift is sales growth and some margin expansion and a little bit of currency.
David Bailey
Thanks.
Operator
Thank you. The next question comes from Susannah Ludwig from Bernstein. Please go ahead.
Susannah Ludwig
Great. Thanks and good morning. I just have one question. Can you talk about how successful your DTC marketing has been so far? I guess just how expensive are you finding it is to sort of bring people in through this direct to consumer channel?
Dig Howitt
Yes Susannah, good question. So again, like the CPN referrals, DTC is one of the legs of our adults and senior referral strategy. It’s not just one thing, its multiple things we do. We’ve been at DTC for quite a while now and we have learnt a lot out of that. So we are seeing a better uptake or better success with our DTC as we just continue to refine the messages, how we respond to inquiries, what sort of information we provide at each stage of the people’s journey.
So it’s improving and the goal across all of the elements of our strategy is to take results to experiment with things, to learn as we experiment and then when we find something it works to continue to build on it and spread it across the globe.
Susannah Ludwig
Okay, great. Thank you.
Operator
Thank you. The next question comes from John Copley from UBS. Please go ahead.
John Copley
Thank you, John Copley on here for Laura Sutcliffe. You’ve spoken in the past couple of years about funding for Cochlear implants in emerging markets being withdrawn during the pandemic, but now returning. Could you quantify perhaps in percentage terms where funding for Cochlear implants in emerging markets is today relative to the pre-pandemic baseline and also perhaps where you see that funding headed directionally please? Thank you.
Dig Howitt
Yes, so – yes John, good question. We haven’t actually quantified that. The two markets we called out that had the most significant dips were Brazil and India. In both, the public funding dried up significantly in COVID and has been restored. And in both, and then those markets are above pre-COVID levels. And if you look at our emerging market growth rates, the funding across the board is certainly above where it was pre-COVID, but we haven’t quantified it exactly.
And I think just a reminder on those markets is we often don’t see just linear growth, and that it can go up and down a bit depending on economic conditions, and there can be steps up too, as another state, for example, in a country as a program.
John Copley
Thank you, and if I could just squeeze in one more, is it fair to say that mix was less favorable than usual, looking across FY’23, in terms of gross margin impact? So, on that basis could we expect Cochlear to be able to maintain 75% gross margin even with the Chengdu headwind next year as mix normalizes? Thank you.
Stuart Sayers
Thanks, John. Broadly, no. So we certainly saw a lot of sound processes, we saw an implant in ‘23, so we didn’t see a massive mix impact on that COGS line. And projecting forward, the bigger impact we do see in ‘24 is that headwind as Chengdu comes online. Obviously, there’s a bunch of other factors like FX and yield and other things, but that’s the one we’re calling out for now. Don’t anticipate mix being at an offset there.
John Copley
Okay, thank you. That’s all from me.
Operator
Thank you. At this time, we’re showing no further questions. I’ll hand the conference back to Mr. Howitt for any closing remarks.
Dig Howitt
Okay, just thanks all for joining, and I know the CSL call started, so there’s probably not too many people left, but for those who are still here, thank you. Talk to you again in the next results, if not before.
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