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Have diversified medical technology companies blown their competitive advantage?

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After decades of high growth and high valuations, large diversified medical technology companies (MedTechs) are faced with low growth and challenged to create long-term value
This is partly due to exogenous macroeconomic conditions and partly due to companies themselves eschewing broader strategic considerations and focussing on short-term performance
MedTechs’ past period of stellar performance benefited from company concentrations in large rapidly growing wealthy markets and benign fee-for-service business models that rewarded volume
During this time, large diversified MedTechs engaged in weak competition at a level of health plans, payers, and hospitals - an institutional level - and ignored competition at a patient level
Creating long-term future value for all stakeholders will require companies to compete at a patient level and accelerate the adoption of value-based care programmes that remunerate patient outcomes
To compete effectively at such a level requires vast amounts of patient data and sophisticated data handling and security capabilities, which many companies do not have
MedTechs that respond efficaciously to the rapidly evolving healthcare ecosystem and develop data and competences to compete at a patient level will have opportunities to create future long-term value
Companies that continue with the status quo are likely to struggle to create long-term value and shall become acquisition targets

Have diversified medical technology companies blown their competitive advantage?

In the current fiscally constrained healthcare environment, creating long term value for medical technology companies (MedTechs) is challenging and many industry leaders have accepted ~5% annual revenue growth rate as the “new normal”. It has not always been like this. Between ~1990 and the late 2010s, medium and large diversified MedTechs were high growth, high value enterprises, which benefited from weak competition, large and rapidly growing underserved wealthy markets, barriers to entry, advancing medical technologies and benign fee-for-service business models that rewarded volume.

MedTechs’ recent decline in enterprise growth rates is partly due to worsening macroeconomic conditions, but a big part is due to companies themselves. Many became trapped in an outdated, narrow approach to creating value where a significant proportion of scarce corporate resources are focused on optimizing short-term financial performance. Albeit essential, this often meant that unmet market needs, and broader long-term strategic influences tended to be overlooked. We explore how this happened and what can be done about it.

In this Commentary

This Commentary describes how after ~3 decades of stellar growth many medium to large diversified medical technology companies (MedTechs) have become trapped in short-term performance-oriented cultures and struggle to create long-term value for all stakeholders. During their stellar years these companies operated at the level of payers, health plans and hospitals - an institutional level - where competition was, at best, weak, and patients’ therapeutic pathways largely ignored. Today, many diversified MedTechs struggle to create long-term value in the face of low growth rates, fiscal and regulatory constraints, vast and escalating healthcare costs, and increasing competition from giant tech companies and innovative start-ups. Further headwinds come from payers shifting away from benign fee-for-service payment models that reward volume to value-based care, which remunerates patient outcomes. To create long-term value MedTechs will need to radically change their strategies and business models. This will entail replacing legacy technology systems that hinder efficiency and innovation, tightening their security risks and improving their business process flows. If corporations do this efficaciously, they will be positioned to compete at a patient level where value is created and destroyed. However, competing at this level requires vast amounts of patient data and sophisticated data handling capabilities. Many companies neither have such data nor the capabilities to analyse and manage them. It seems reasonable to suggest therefore that, in the near- to medium-term, MedTechs that eschew retooling and competing at a patient level will struggle to create long-term value and likely become acquisition targets.

Structural challenges

As populations in wealthy economies age and shrink, due to increasing longevity and declining fertility, so healthcare headwinds increase and challenge MedTechs. Consider the US, which is an exemplar of most wealthy nations. Today, >56m Americans are ≥65, which accounts for ~17% of the nation's population. By 2030, when the last of the baby boomer generation ages into older adulthood, it is projected there will be >73m older adults, which means >1 in 5 Americans will be of retirement age. As the American population ages a growing number of people present with age-related chronic conditions, which are costly to treat. Today, in the US, ~86% of people ≥65 is living with a chronic disease. This increases the risk of insuring the average US citizen, and the higher the risk, the higher the cost of annual health insurance premiums. According to the Centers for Medicare & Medicaid Services, in 2020, the US national health expenditure (NHE) grew ~10% to ~US$4trn, which equates to ~US$12,530 per person, and ~20% of the nation’s Gross Domestic Product (GDP). By 2030, US NHE is expected to reach ~US$7trn.

In 2020, Medicare spending rose by 3.5% to ~US$830bn or ~20% of total NHE. In the same year, Medicaid spending grew by 9% to ~US$671bn, or ~16% of total NHE. The largest shares of America’s total health spending are provided by the federal government (~36%) and households (~26%). The private business share accounts for ~17%, local state governments account for ~14%, and other private revenues account for ~6.5%. According to the 2022 annual Kaiser Family Foundation (KFF) healthcare survey the average insurance premium for family healthcare coverage in the US increased 20% over the previous 5 years and 43% over the past decade. The average premiums for employer-sponsored health insurance are US$7,911 for single coverage and US$22,463 for family coverage.

Such changes are forcing the medical technology industry to adjust what products and services it develops and how value is created.

Stellar growth and short-term performance

During ~3 decades before ~2015, the medical device industry benefitted from unmet clinical needs, significant barriers to entry, technological advances, benign fee-for-service payment systems that reimbursed volume and industry concentrations. During this time MedTechs enjoyed stellar growth, and high valuations. Investors prioritized revenues over profit and cash flow, which encouraged enterprises to engage in portfolio moves: M&A, divestitures, and spin-offs. This had the advantage of helping companies to exit low-growth businesses and enter higher-growth segments, without engaging in years of uncertain and expensive R&D. It had the disadvantage of encouraging short-term performance rather than long-term value creation. During this period many senior leadership teams became weighed down with the demands of quarterly reporting and grew accustomed to using a variety of short-term accounting measures and ratios as their principal means to drive business and reward executives.

As a result, ‘successful’ medical technology companies had high growth rates but a deficit in ideas to unlock transformative new treatments for underserved patients and plans to seize opportunities presented by technological advances. The industry’s indifference to develop and leverage digitalization is indicative of corporations overlooking broader strategic influences and unmet market needs. Consequently, by ~2015, many large diversified MedTechs had fragmented technology systems that hindered efficiency and innovation and were overburdened by legacy products overexposed in slow growth markets. This made them ill-equipped to either respond quickly to innovative trends or compete with disrupters. According to a McKinsey & Company report published in June 2022, “84% of CEOs believe that innovation is critical to growth, but only 6% are satisfied with their company’s innovation performance”. To survive and stand a chance to create long-term value MedTech functions from R&D to sales will need to change.

Slow response to market changes

As MedTechs’ performance slowed and executives accepted ~5% growth as the “new normal”, markets continued to evolve: consumer-centred healthcare increased, clinical procedures moved out of hospitals into daycare centres and homes, regulation tightened, international markets expanded, medical technology continued to advance at pace, and tech giants and new entrants disrupted healthcare markets with innovative solutions and digital platforms that served patients rather than surgeons and hospitals. Because of MedTech companies’ lack of preparedness to respond positively to such changes, many doubled down on their traditional business models. This meant their M&A ecosystems were kept intact and active, and R&D continued with incremental additions to legacy products that mostly served the needs of surgeons and hospitals rather than patients.

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According to the Center for Studying Health System Change, the prominent trend of M&A in America’s healthcare industry increased consolidation and decreased competition, which is critical for lowering costs and improving productivity and innovation. With weak competition providers and insurers were able to drive up their prices unopposed. Findings of a study published in the American Journal of Managed Care found that hospitals in concentrated markets could charge considerably higher prices for the same procedures offered by hospitals in competitive markets. Although price increases often exceeded 20% when mergers occurred, studies suggest such increases neither improved healthcare quality nor patient outcomes.

With MedTechs focussed on consolidations and increasing the prices of their legacy offerings as a way of maintaining and increasing their revenue growth rates, many failed to keep current with the accelerating pace of technologies that were transforming healthcare. For example, over the three decades of stellar growth in the medical device industry, digitalization improved customer experience, connected devices, integrated, and leveraged external data sources and patients’ electronic health records, and connected with other stakeholders. This changed the way patients were diagnosed and treated, changed the way healthcare professionals communicated and collaborated, and changed how biomedical research was conducted. Notwithstanding, MedTechs were reluctant to digitize and continued to employ outdated labour-intensive business processes to market their product offerings. Today, providers, payers and patients are increasingly demanding digital solutions that are easier to use and more cost effective. This presents a challenge for traditional medical technology companies slow to adapt their business models to meet the needs of changing market conditions.

The impact of Covid-19

The medical technology industry, along with many others, was adversely impacted by the Covid-19 crisis. In 2020, most medium to large MedTechs saw their revenues drop significantly. During lockdowns many experienced reductions in sales mobility, changed purchase demand profiles, supply chain disruptions, and increased risk aversion towards unnecessary spending. Such headwinds prompted some companies to re-evaluate their business models and set new directions for future success. This included digitally enhancing existing products, unlocking customers in new geographies, and monetizing data from existing devices to create new patient-centred solutions. Notwithstanding, today many MedTechs with reduced growth rates struggle to create long-term value for all their stakeholders.

There is no single answer to how value might be achieved as strategies will vary depending on specific industry segments and specific product offerings. However, some general suggestions include: (i) continue portfolio moves to divest low growth legacy products and reduce risk pathways to innovative offerings and growth. Target acquisitions with healthy growth prospects, well-stocked innovation pipelines and product offerings positioned to benefit from leveraging larger company infrastructures, (ii) establish a pro-active venture function aimed at early-stage companies with disruptive offerings, (iii) invest in R&D to create new products and services that enhance patients’ therapeutic journeys, (iv) look beyond core devices and increase digital offerings and capabilities as software and digital solutions have become an essential part of patient journeys and clinical practice, (iv) shift away from volume-based care and accelerate value-based care to improve patient outcomes and reduce costs.

Value-based care

Healthcare experts have suggested that the fee-for-service healthcare payment model is wasteful, outmoded and partly responsible for US healthcare spending being significantly higher than other Western nations, but with patient outcomes no better and often worse. During the past two decades health plans, payers, employers, and patients have been requesting that healthcare systems deliver on value. The market responded to this with a shift towards value-based care, which instead of rewarding volume, pays providers based on patient-centric health outcomes. According to America’s Health Care Payment Learning & Action Network’s (LAN) annual survey; >60% of US healthcare payments in 2020 included some form of value component, which is up from ~53% in 2017 and ~11% in 2012. Similarly, 49% of primary care practices responding to the American Academy of Family Physicians (AAFP) 2022 Value-Based Care Survey said they are participating in some form of value-based payment, and 18% are developing the capabilities to do so.

Much of the energy for value-based care comes from America’s Affordable Care Act (ACA), (“Obamacare”), which is the most significant regulatory overhaul and expansion of healthcare coverage since the enactment of Medicare and Medicaid in 1965. The 2010 Act was originally developed to help reduce the rate of hospitalizations and readmissions by focussing on quality outcomes rather than quantity of patient visits. Value-based healthcare concepts have grown, and the ACA has created new incentives and penalties designed to encourage providers to deliver higher quality care at lower costs. These include the Hospital Value-Based Purchasing Program, which ties Medicare reimbursement to hospital performance on a set of quality measures, and the Medicare Shared Savings Program, which rewards provider groups for achieving cost savings while meeting agreed quality targets. The Centers for Medicare & Medicaid Services (CMS) supports value-based care as part of its “larger quality strategy to reform how health care is delivered and paid for”.

Omar Ishrak and value-based care

Omar Ishrak, CEO and chairperson of Medtronic plc between 2011 and 2020, championed value-based care by incentivizing and leading discussions about how MedTechs should align value and price and how suppliers should get paid according to patient outcomes. He believed “[clinical] value has to be tied to economic value, otherwise people will not be able to afford the care we provide”. Before joining Medtronic, Omar Ishrak was the head of GE HealthCare and was well-versed in global politico-economic challenges associated with markets with a deep understanding of the human toll that comes from inadequate healthcare systems. “We live in a world where we get paid for our technology with a promise to improve outcomes, not a guarantee, a promise”, said Ishrak. While at Medtronic he extended value-based healthcare by insisting that efficacy is aligned with patient expectations and MedTechs get paid for medical outcomes rather than medical devices. He was convinced that value-based care incentivises MedTechs to develop and deploy products, services, and solutions, which improve patient outcomes per dollar spent, and measure value in terms of long-term patient outcomes rather than short-term transactions.

In 2016 Medtronic established a value-based care partnership with UnitedHealthcare, an American multinational managed healthcare and insurance company, which gave its customers living with diabetes access to Medtronic’s insulin pump and support services. After the first year, the partnership reported ~27% decline in the rate of preventable hospital admissions compared to patients using traditional daily insulin injections. Between 2015 and 2018, UnitedHealthcare's payments to physicians and hospitals tied to value-based care programmes were reported to be ~US$65bn and projected to grow to ~US$75bn within two years.

In February 2018, Medtronic signed a 5-year value-based care partnership with Lehigh Valley Health Network, (LVHN) based in Allentown, Pennsylvania. The two organizations established processes to treat more than 70 medical conditions using Medtronic devices to improve patient outcomes and cut costs. The endeavour reached ~0.5m patients in Northeast Pennsylvania and cut the cost of care by ~US$100m. Another benefit of the partnership was Medtronic obtained access to thousands of patient insights to their products, which the company used to establish baselines to monitor and improve outcomes. Another example of Medtronic linking a product directly to outcomes is its Tyrx Absorbable Antibacterial Envelope, a mesh used to hold pacemakers and implantable cardioverter defibrillators (ICD) in a stable environment and release antimicrobial agents over a period when the chance of infection related to surgery is high. These are just a few examples of devices that Ishrak linked to value-based payment schemes, there are many others. Cumulatively they “had a real differentiating value for Medtronic”, said Ishrak.

Although manufacturers of medical devices were slow to follow Ishrak’s example, the economic slowdown has led to a heightened cost-consciousness among healthcare providers and accelerated a shift towards value-based care and a growing influence of healthcare group purchasing organizations (GPOs). This, in turn, has incentivized MedTechs to increase their M&A activity to expand their portfolios and allow them to provide high-volume, discounted product bundles. Furthermore, value-based care has moved purchasing decisions away from physicians toward hospital administrators, who are more focused on costs than devices and their features. This has resulted in a downward pricing pressure across the MedTech landscape and rendered market entry more challenging for small companies, which provides large diversified MedTechs with further potential acquisition targets.

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Low Back Pain and the global spine industry

Spinal surgery and value-based care

A segment of the medical technology industry that looks ripe to benefit from value-based care is spinal surgery for low back pain (LBP), which is a common age-related health condition associated with degenerative spinal disorders. According to the World Health Organisation (WHO), LBP is one of the top ten global disease burdens and ~80% of all individuals will experience the condition at some point in their lifetime.

In the US, ~3 in 10 adults - ~72m - currently suffer from chronic LBP. Each year, ~0.3m people present with LBP but only ~0.7-4.5% of these will have specific identifiable causes for their condition. This is because LBP is challenging to diagnose as there is no established protocol to evaluate the condition and it may be a symptom of many different causes. Notwithstanding, American third-party payers have tended to reimburse spine surgery for LBP more than non-invasive therapies, but this is changing. America has the highest rate of spine surgeries in the world, and each year, clinicians perform ~1.6m spinal fusions in an attempt to cure LBP. Between 2004 and 2015, the volume of spinal fusions increased by 62% and aggregate hospital costs increased ~177%, exceeding US$10bn in 2015, and averaging >US$50,000 per admission. A 1994 international comparative study found that, “the rate of back surgery in the US was at least 40% higher than in any other country and was more than five times that in England. Back surgery rates increased almost linearly with the per capita supply of orthopaedic and neurosurgeons in the US”.

A significant percentage of patients with LBP continue to experience pain after surgery, which is referred to as ‘failed back syndrome’ (FBS) and is characterized by an inability to return to normal activities. A study reported in the American Journal of Medicine suggests that recurrent spine surgeries do not necessarily mean success. Notwithstanding, when a primary surgery fails to cure LBP, a significant percentage of patients have further surgeries. However, with each recurrent surgery the probability of a successful outcome drops: ~50% success rate after the first repeat surgery, ~30% after the second, ~15% after the third and ~5% after the fourth.

Research published in theBritish Journal of Pain, suggests that the overall failure rate of lumbar spine surgeries is between ~10 and 46%. A study reported in a 1992 edition ofSpine, followed 53 patients for an average of 20 months after a spinal fusion surgery and found that only 50% reported improved outcomes. Another study, published in the journal Trials, suggests that ~40% of lumbar fusion patients experience ongoing back pain and limited function two years after surgery; and research findings published in the Asian Spine Journalfound ~5 and 36% of people who undergo a discectomy for a lumbar herniated disc saw their leg and back pain return two years after surgery.

Such failure rates have prompted health insurers in the US to reassess their fee-for-service payment policies.According to a New York Times article, reimbursements for spine surgeries are becoming tighter, and “financial disincentives accomplished something that scientific evidence alone didn’t”. The article draws on research published in the journal Spine, which found that, “spinal fusion rates continued to soar in the US until 2012 and shortly afterwards Blue Cross of North Carolina said it would no longer pay for such surgeries”. It seems reasonable to assume that benign fee-for-service reimbursement policies are partly responsible for the increase in spine surgeries that fail to cure LBP. Following the Blue Cross decision other insurers followed, and US payers started to move away from fee-for-service models towards reimbursing “value”. This transfers the costs of over-treatment, revision surgeries and adverse clinical outcomes from payers to providers and is expected to utilize resources more efficiently. Such shifts are beginning to happen in all the major medical technology markets. For example, in Europe fiscal pressure on healthcare systems has meant rationing and/or delaying elective spine surgeries, and in Japan more spine surgery costs are being shifted to employers and patients.

Given the changing ecosystem in the spine market, a potential opportunity for MedTechs might be to apply machine learning AI techniques to patient data in an endeavour to determine what products and procedures are most likely to produce optimal solutions for individuals contemplating spine surgery for LBP. Assuming enough relevant data are collected, and successful algorithms developed, this process might help to reduce the high failure rates of spine surgeries for LBP, improve patient outcomes and lower healthcare costs.

Weak competition at the wrong level

Value-based care has the potential to: (i) improve patient outcomes by incentivising providers to focus on the quality of care, (ii) create a more efficient healthcare system by eliminating wasteful spending, (iii) improve patient satisfaction by making the healthcare system more patient-centered, (iv) make it easier for enterprises to commercialize new products and services by providing a pathway to reimbursement, and (v) provide a platform for companies to partner with other healthcare stakeholders to improve care delivery and patient outcomes.

However, MedTechs are not well positioned to transition expeditiously to value-based care. This is because, for decades they have benefited from a benign fee-for-service business model and participated in weak competition at an institutional level: the level of health plans, providers, and hospital groups. Competition at this level is weak and neither creates value nor benefits patients. This is because the principal actors behave as if playing 'pass the parcel', i.e. shifting costs onto one another, restricting services, stifling innovation, and hoarding information.

In the medical technology industry value can only be created or destroyed by competition at a patient level, but this has been absent throughout the history of the industry. Because of this deficit company costs are high and rising, services are restricted, clinical procedures overused, standards of care often fail to adhere to clinical guidelines, diagnosis errors are common, quality and cost differences persist across providers and geographies, best practices are slow to spread, and innovation is resisted. In most other industries such outcomes are inconceivable.

The future for MedTechs must be at a patient level where costs and quality persist and where competition can drive improvements in efficiency and effectiveness, reduce clinical errors and incentivize innovation. Notwithstanding, competition at this level requires devising patient outcome measures for specific devices and procedures that are acceptable to all industry stakeholders. Data are essential to develop such measures and may be provided by surveys, electronic health records, personal devices and clinical studies or a combination of all four. However, the analysis and utility of such data require sophisticated data handling and security capabilities, which many MedTechs do not have. Companies that successfully re-tool and become eloquent at competing at a patient level will be well positioned to create long-term value for all stakeholders. Companies that fail in these endeavours will likely become targets for acquisitions.

Takeaways

MedTech companies have become trapped by their former commercial success and legacy structures and operating models that were neither set up to respond quickly to innovative trends nor to compete with disrupters. For ~3 decades high growth rates and valuations persisted in the medical technology industry despite companies ‘competing’ weakly at the wrong level and their cultures being defined by short-term financial performance. Such entrenched business models and the time and resources they consumed did not leave room for broader in-depth strategic considerations that could influence long term value creation. Today, MedTechs are at a crossroad: they can either change their strategies and business models and compete at a patient level or they can continue their weak competition at an institutional level. The former positions companies well to create long-term value for all stakeholders while the latter does not.

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Low Back Pain and the global spine industry

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This is a series of seven Commentaries on Low Back Pain and the global spine industry. They are not meant to provide “answers”, but to stimulate strategic thought and discussion.
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Have diversified medical technology companies blown their competitive advantage?

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Low Back Pain and the global spine industry

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Low back pain, spine surgery and market shifts

If spine surgery fails to relieve low back pain why is it increasing?

Minimally invasive spine surgery and computer assisted navigation systems

Robotic surgical spine systems, China, and machine learning

Will a rear mirror mindset slow the adoption of technologies poised to influence the spine market?

Digitalization: the reinvention of spine companies’ supply chains and controlling the inventory-to-revenue ratio

The spine market and smarter diversity and inclusion policies

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