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Baxter International Inc (BAX -0.25%)
Q3Â 2018 Earnings Conference Call
Oct. 31, 2018, 8:30 a.m. ET
Contents:
- Prepared Remarks
- Questions and Answers
- Call Participants
Prepared Remarks:
Operator
Good morning, ladies and gentlemen, and welcome to Baxter International's Third quarter 2018 Earnings Conference Call. Your lines will remain in a listen-only mode until the question-and-answer segment of today's call. (Operator Instructions) As a reminder, this call is being recorded by Baxter and is copyrighted material. It cannot be recorded or rebroadcast without Baxter's permission. If you have any objections, please disconnect at this time.
I would now like to turn the call over to Clare Trachtman, Vice President, Investor Relations at Baxter International. Ms. Trachtman, you may begin.
Clare Trachtman -- Vice President, Investor Relations
Thanks, Candice. Good morning, and welcome to our third quarter 2018 earnings conference call. Joining me today are Joe Almeida, Baxter's Chairman and Chief Executive Officer; Jay Saccaro, Baxter's Chief Financial Officer; and Brik Eyre, President, Americas.
On the call this morning, we will be discussing Baxter's third quarter 2018 financial results, along with our updated financial outlook for 2018. A supplemental presentation to complement this morning's discussion can be accessed on our website. This presentation, along with the related non-GAAP reconciliations can be accessed on Baxter's external website in the Investors section under Events and News.
With that, let me start our prepared remarks by reminding everyone that this presentation, including comments regarding our financial outlook, new product development, business development and regulatory matters contain forward-looking statements that involve risks and uncertainties and of course, our actual results could differ materially from current expectations. Please refer to today's press release and our SEC filings for more details concerning factors that could cause actual results to differ materially.
In addition, on today's call, non-GAAP financial measures will be used to help investors understand Baxter's ongoing business performance. A reconciliation of the non-GAAP financial measures being discussed today to the comparable GAAP financial measures is included in our earnings release issued this morning and available on our website.
On the call this morning, we will be discussing operational sales growth, with adjust for the impact of foreign exchange, generic competition for cyclophosphamide in the U.S. and approximately one month of sales from the acquisition of Claris in July 2017, along with our acquisition of two surgical products from Mallinckrodt in the first quarter of 2018.
Now, I'd like to turn the call over to Joe. Joe?
Jose Almeida -- Chairman, President and Chief Executive Officer
Thank you, and good morning. I will begin with some comments and perspective on our third quarter results. Jay will then walk through the financials and guidance in greater detail, and we will close with your questions. Brik Eyre, whom may you know from our May investor conference will join us for the Q&A to provide additional insights on our U.S. performance.
Baxter reported a solid third quarter, with sales up 2% on a reported basis, 3% on a constant-currency basis, and 3% operationally. On the bottom line, adjusted earnings per share were $0.80, increasing 25% year-over-year. Our strong earnings growth demonstrates the continued power of our operational improvement initiatives and we see more potential for these efforts moving forward. Drivers of growth in the quarter included the company's Renal Care, Pharmaceuticals, Advanced Surgery and Acute Therapies businesses. Increased demand for Baxter's contract manufacturing services also contributed to performance in the quarter. This strength helped offset declines in our Medication Delivery and Nutrition businesses.
Growth in Renal Care was primarily driven by increased patient volumes for our peritoneal dialysis products globally. In the U.S., this contributed double-digit PD therapy growth. In Asia Pacific, we continue to see strong patient growth in China. And for the first time in years, we're experiencing positive patient growth in Japan, following the launch of Kaguya earlier this year. In Pharmaceuticals, growth was driven by strength in the U.S., where we've experienced increased demand for our premixed injectables and extended our portfolio with addition of Claris products.
Claris, which we'll now refer to as Baxter Ahmedabad continues to deliver double-digit pro forma growth in line with our expectations. Increased sales in -- of anesthesia and critical care products also contributed to the results in the quarter. Advanced Surgery achieved double-digit growth, including a contribution of $14 million from sales of RECOTHROM and PREVELEAK. Acute Therapies also reported double-digit sales growth based on global strength across the portfolio. On Monday, this team initiated a worldwide launch of the leading-edge PrisMax system, beginning with 19 European countries. PrisMax is our next generation technology for CRRT or Continuous Renal Replacement Therapy in organ support therapies. It offers ICU practitioners a broad range of advantages, designed to make therapy simpler, safer, more accurate, and more efficient.
This is transformative innovation that builds on decades of Baxter's market leadership in the acute care space. The strong results posted by this business was partially offset by performance in our U.S. Medication Delivery and Nutrition businesses, which were frankly disappointing. I can assure you that steps are already been taken to address these issues. It starts with divisive action to put the right leadership in place accountable for renewing the strategic momentum and forecast, reliability that we and you expect. Overall, we remain on sound footing across a vast portfolio of products with market leadership positions. To be certain, we are in a period of course correction in a few key areas which we often occurs -- which -- rather, which often occurs from time-to-time in a dynamic market like ours.
Let me drill down a few key areas, starting with supply disruption due to Hurricane Maria. It has now become clear the market dynamics have fundamentally shifted in a few of our market segments in the aftermath of Hurricane Maria, at least in the near to mid-term. While we have resumed production at pre-hurricane levels, the gap in bringing supply back to market ultimately caused a longer lasting ripple effect for several products. And customer demand has not fully resumed to prior levels, specifically with respect to small volumes -- rather with respect to small volume parenterals, which include our Mini-Bag and Mini-Bag Plus lines, we have seen impacts from protocol changes, such as moving to IV push for administration of drugs, as well as some moves to competitive products and supply constrained quotes.
While we expect to regain most of this business, we do anticipate it will take some time, particularly for the portion of the business that has moved to alternative practices for drug administration. We are continuing to reinforce the benefit of Mini-Bag Plus, emphasizing safety and reduced potential for medication errors. We are also reinforcing the availability of supply with our customers. For select U.S. Nutrition products, we've seen some market contraction as a result of hurricane-related supply constraints, whether through providers delaying the start of parenteral Nutrition and/or reducing dosage. We also experienced some shifts to outsourced Nutrition compounding centers and competitive products. It is unlikely we will regain all our lost sales here, particularly where we've seen market contraction at least in the near-to-mid term. We're in process of rebasing this business and expect to resume US market growth of low single digits in the coming quarters. And while not directly related to the hurricane's impact on our production levels to historic tight supply in the market for IV solutions has also impacted the performance for the Medication Delivery business this year. Sales of large volume IV solutions spiked in the first five months of the year, driven by increased purchases, given the protracted industrywide supply challenges coupled with an intense flu season.
Customers rush to acquire any available IV solutions products. This resulted in growing inventory levels across our customer base, our forecast was built off this elevated run rate and didn't contemplate the level of inventory destocking, we currently experienced as supply constraints have eased. In addition to timing of adding incremental beds in non-acute customer has fallen short of our expectations. It's important to note that end-user demand for our LVPs is up approximately 2% year-to-date. We believe this is slightly ahead of the market, which we see as growing approximately 1%. So ultimately, while our overall share has remained stable, the impact from the inventory destocking as well as the timing of bringing on new customers has -- customers has clearly been lower than anticipated. As a result of these market dynamics, we are resetting expectation for these businesses in 2018. Going forward, our expectation is that the Medication Delivery and Nutrition business will grow in line with our long-term outlook.
Taken together, these learnings will help support greater predictability and forecast alignment. We have a unique fourth quarter of life-sustaining products and we've implemented some necessary changes that we believe will make our prospect, both stronger now and over the long run. In summary, our diversified portfolio, accelerating innovation, strong balance sheet and relentless focus on operational efficiency give us the confidence and flexibility to deliver on our long-term financial objectives.
With that, I will turn it over to Jay.
James Saccaro -- Executive Vice President and Chief Financial Officer
Thanks, Joe, and good morning, everyone. As Joe mentioned, although we've experienced challenging market dynamics in select businesses, our third quarter results reflect the benefit of our diversified portfolio as well as our ongoing commitment to accelerating bottom line growth. I'll start by discussing our third quarter results before providing our updated financial outlook for 2018. Beginning with the third quarter, global sales of $2.8 billion increased 2% on a reported basis, 3% on constant currency and 3% on an operational basis. On the bottom line, adjusted earnings increased 25% to $0.80 per diluted share. This exceeded our previous guidance of $0.72 to $0.74 per share, driven by solid operational performance and ongoing benefit from our business transformation initiatives and a lower tax rate.
Now, I'll walk you through performance by our regions and global business units. Note, for this quarter, constant currency sales growth is equal to operational sales growth for all businesses with the exception of our Pharmaceuticals and Advanced Surgery business. With these businesses, we will provide operational growth. Starting first with sales growth for our three regions, sales in the Americas advanced 4% on a constant currency basis and 3% operationally. Sales in Europe, Middle East and Africa grew 4% both constant currency and operationally. And finally, sales in our Asia Pacific region were flat on both in constant currency and operational basis. As a reminder, in the third quarter of 2017, we recorded $25 million of sales in our international compounding business due to an early contract settlement with one of our Australian hospital pharmacy customers which impacted growth in the Asia Pacific region by approximately 4%.
Moving on to performance by global business units, global sales for Renal Care were $910 million, advancing 3% on a constant currency basis. Performance was driven by mid-single-digit growth for PD therapies globally as well as low single-digit growth globally for our in-center HD business. Sales in Medication Delivery were $652 million, down 3% on a constant currency basis driven by the business dynamics that Joe walked through earlier. Pharmaceutical sales were $519 million, increasing 5% constant currency and 5% operationally. Sales growth in the quarter benefited from strength in our anesthesia business and increased demand for Baxter's injectable premixed drugs. Sales of U.S. cyclo were $40 million in the quarter and global Claris sales were $38 million.
Moving to Nutrition, total sales were $218 million, down 2% on a constant currency basis. Solid growth in international markets was offset by lower sales in the US, which Joe commented on earlier. Sales in Advanced Surgery were $200 million, increasing 15% constant currency and 7% operationally. As Joe mentioned, sales of RECOTHROM and PREVELEAK contributed approximately $14 million in the quarter. Sales in our Acute Therapies business were $122 million, representing growth of 10% on a constant currency basis, continuing the trajectory of delivering double-digit growth driven by increased global demand for Baxter's continuous renal replacement therapies.
Finally, sales in our other category, which primarily includes our contract manufacturing services were $146 million, an increase of 17% on a constant currency basis. Performance in the quarter was primarily driven by increased demand for our contract manufacturing services, specifically our, cytotoxic contract manufacturing services as well as incremental production volumes for seasonal vaccines.
Moving to the rest of the P&L, our adjusted gross margin of 46.3% increased 100 basis points over the prior year, benefiting from favorable product mix and manufacturing efficiencies. Adjusted SG&A totaled $622 million, decreasing 1% on a reported basis and flat on a constant currency basis. We continue to see a positive contribution from our relentless focus on effective expense management and business transformation initiatives, which helped to offset the loss of approximately $10 million in transition services income from Shire, and incremental expenses related to our recent acquisitions.
Adjusted R&D spending in the quarter of $153 million, increased 3% on a reported basis and 4% on a constant currency basis versus the prior year period as we continue to invest in high impact programs to accelerate innovation at the company. Adjusted operating margin in the quarter was 18.3%, an increase of 170 basis points versus the prior year. Growth was driven by strong operational expansion as well as continued effective expense management.
Net interest expense was $11 million in the third quarter, reflecting higher levels of interest income due to rising interest rates and other income totaled $32 million in the quarter, primarily reflecting a benefit from the recent changes we made to our US pension plan, along with foreign exchange gains on balance sheet positions. The adjusted tax rate was 17.1% for the quarter, which includes a benefit of $9 million from stock compensation. This came in favorable to our expectations driven primarily by certain discrete items recorded in the quarter. And as previously mentioned, adjusted earnings of $0.80 per diluted share exceeded our guidance of $0.72 to $0.74 per share. During the quarter, we repurchased $247 million or 3.3 million shares of Baxter's stock. These repurchases were partially offset by option-related dilution in the quarter.
Before turning to 2018 outlook, I will briefly comment on our cash flow performance in the first three quarters of 2018. We generated free cash flow of $873 million, with improvements in net income offset by higher inventory levels as we work to rebuild supply for select products to ensure adequate product availability.
Let me conclude my comments this morning by providing our guidance for the fourth quarter and full year 2018. Given the market dynamics we discussed for our US Medication Delivery and Nutrition business, we've lowered our sales forecast for the year. Globally, we now expect 2018 full year sales to increase approximately 5% on a reported basis. We now expect growth of approximately 4% on a constant currency basis and approximately 3% on an operational basis.
Moving to full year guidance by business, on a constant currency and operational basis, except where otherwise noted, in Renal Care, we continue to expect growth of 3% to 4%. In Medication Delivery, we now expect sales to decline, low-single digits. We now expect our Pharmaceuticals business to increase high single-digit at constant currency. This assumes 2018 U.S. cyclo sales of $160 million, above previous guidance of $130 million. We continue to expect full year Claris sales of approximately $145 million. Adjusting for cyclo in the first seven months of Claris, we now expect operational sales to increase approximately 7%.
Moving to Nutrition, we now expect sales to decline low-single digits. For our Advanced Surgery business, we now expect sales to increase approximately 10% on a constant-currency basis. This includes a contribution of approximately $45 million related to the acquisition of RECOTHROM and PREVELEAK. Excluding the impact of these sales operational growth is expected to be approximately 4%. For the Acute Therapies business, we now anticipate growth of 10% to 11%. Finally, in our other business, we now expect growth of high single-digits, given increased demand for our contract manufacturing services.
Moving down to P&L, we now anticipate adjusted operating margin expansion of approximately 100 basis points. We expect net interest expense of approximately $45 million and other income of approximately $105 million for 2018. For the year, we continue to expect an adjusted tax rate of approximately 17%. For full-year 2018, we anticipate a diluted average share count between 545 million to 550 million shares. Based on these factors, we expect 2018 adjusted earnings, excluding special items of $2.98 to $3 per diluted share.
Finally, for the year, we now expect to generate operating cash flow of approximately $2.2 billion, with capital expenditures of approximately $700 million and free cash flow of approximately $1.5 billion, down slightly from our previous guidance due to higher inventory levels. Specific to the fourth quarter of 2018, we expect sales growth of approximately 1% on a reported basis and between 3% and 4% on both a constant-currency and operational basis, and we expect adjusted earnings excluding special items of $0.71 to $0.73 per share.
That concludes my comments. We can now open the call for Q&A. As a reminder, also on the call today is Brik Eyre, President, Americas to join us during the Q&A. Candice?
Questions and Answers:
Operator
Thank you. We will now begin the question-and-answer session. (Operator Instructions) I would like to remind participants that this call is being recorded and a digital replay will be available on the Baxter International website for 60 days, at www.baxter.com. And our first question comes from Bob Hopkins of Bank of America Merrill Lynch. Your line is now open.
Robert Hopkins -- BofA Merrill Lynch -- Analyst
Thank you and good morning.
Jose Almeida -- Chairman, President and Chief Executive Officer
Good morning, Bob.
Robert Hopkins -- BofA Merrill Lynch -- Analyst
So, thanks for taking the question. I guess, my concern looking at the last two quarters is that at least some of the issues that you're facing seem a bit structural given that you're experiencing share loss and it moved to some alternative, cheaper technologies. So I guess my question is this. Can you quantify for us or describe the degree to which you think you're losing share here, and then help us understand how these issues could impact growth into 2019?
Jose Almeida -- Chairman, President and Chief Executive Officer
Okay. Bob, I'm going to pick up half of the answer here and I'm going to pass to Brik to get a little bit more color on the question on the shift. First of all, there were shifts in the market, because us not having Mini-Bags and Mini-Bags Plus and amino acids, we actually were the ones teaching our customers how to use alternative methods. Some of them will come back and we expect in 2019 to pick-up a portion of that without a problem. The other ones will take a little longer for us to convert because those are medical practices, you have a significant amount of hospitals in the country, and we have large market share.
I would say that we don't see the issues that we experienced in '18 by rebase in '18 to offset tremendously growth rates going forward. Just as a matter of fact, I would say that the full-year of 2018, results are the base for the LRP, that we presented in May, which runs from '18 to '23. So using the projected performance of 2018, we -- that we just shared with you, we are now revising our long-term guidance for Total Baxter, either in the top or bottom line. So there are structural issues that take a little longer to resolve, but we have not lost any customers at this moment and we may have lost up some temporary share in accounts where some fluids are being substituted, which we expect from the mid to long-term to recapture.
I'd like to see if Brik would like to add anything to it?
Brik Eyre -- Senior Vice President and President, Americas
Thanks, Joe. Bob, let me talk about a couple of segments of the business. So first, our small volume parenterals. So these are 50-milliliter, 100-milliliter, 150-milliliter bags that are used to administer infuse medication to patients. In that segment, when there were no products to be -- that our customers could find, about 25% of the doses that are historically been used or been administered through infusion, using our Mini-Bags and Mini-Bag Plus product, had to find other ways to administer those drugs. A portion of that went to a new practice, which is IV push.
Now to be clear, IV Push happens in every hospital, everyday across the country, typically in oral (ph) drugs et cetera. But in this particular case, when there was no product, specifically cephalosporins, penicillins, those anti-infectives were moved to an IV Push. This practices the nurse literally takes a syringe and dilutes the drug into 5 ml, 10 ml worth of a diluent, and then injected into a port, that is at the set (ph) at the hand, where there is access to the vein. And they will do that over a period of time.
There are some safety concerns, et cetera that we are talking with our customers, but some customers have moved to IV push. And in so doing, they have to change their protocol, they change their protocol and they change their system et cetera. So while we do believe we will get this back, it's taking a little bit more time than we had anticipated. Other customers went to competitive products. We actually feel very confident that we will get those products back and we are working with our customers now to ensure that they understand that we have capacity, supply et cetera.
Now the other component of this is Nutrition, that was impacted from a -- the hurricane perspective. The Nutrition business actually did contract and market contracted, whereas Joe mentioned in his -- in the opening comments, when customers didn't have product, they delayed start times et cetera. So we believe the overall Nutrition market has contracted about 7%. We have also lost some share, because we didn't have product and we are working again with the customers to get that share back. So while we don't think it's a long-term piece, certainly over the next few quarters, we anticipate seeing a ramp up of bringing those products back to us. But anything that required a change in protocol will take a little bit more time.
Robert Hopkins -- BofA Merrill Lynch -- Analyst
So, thanks for the clarity there. I just have a very brief follow-up. Joe, is now the right time to be more aggressive with the balance sheet relating to buyback given your confidence that these things will be temporary?
Jose Almeida -- Chairman, President and Chief Executive Officer
I would say that with the capacity that we have and we're going to look at the sentiment of the investors, it's always a good time at this moment to look at some buybacks. But also we continue to use a significant amount of efforts inside Baxter in the M&A space. So we want to make sure that we have capacity to do all the above, continue to increase our dividends annually, and buy back shares and have plenty of capacity to go after M&A targets, which has a renewed and very focused effort at Baxter.
Robert Hopkins -- BofA Merrill Lynch -- Analyst
Thank you.
Operator
Thank you. And our next question comes from Vijay Kumar of Evercore. Your line is now open.
Vijay Kumar -- Evercore ISI Institutional Equities -- Analyst
Hey guys, thanks for taking my question. And may be, just going back to Bob's question on some of the disruptions you guys have had, and this is a little unusual for you guys, where the Street's gotten used to have stellar execution. So I just want to understand the dynamics, right? So you had -- I think Joe you mentioned, LVP, so if I'm understanding what happened on the LVP side is, customers pre-boughtas in they built up inventories. One, how long does it take for them to work through those inventories? Should we still be expecting the impact in first half of '19, and then back to I guess Brik, sort of a big thanks for that explanation on the push syringe impact. But I would think like, I mean, 50 ml to 100 ml bags, someone pushing in using an IV push, that's a lot of inconvenience from a time -- use of a time perspective in the hospital for the nurse. I'm just trying to think whether all of that comes back or the assumptions around why some of that may not come back?
Jose Almeida -- Chairman, President and Chief Executive Officer
Vijay, good morning. So I'm going to have Brik answer 95% of your question. Just want to go back to the LVP. We now have a very good understanding of what happened in terms of the stocking and destocking. As I said, we haven't lost a customer, but what we learned from this whole thing was that there was a pattern of purchases, there were for many years in place due to the product allocation that customers would buy whatever was available for them to buy, because what's usually a little less than they would wish to purchase. We have created a significant flexibility in the supply chain, and for the first time, we are in the market with no allocation, which creates flexibility for us, not to sell in U.S., but sell the product in other parts of Latin America, like we just did the other day in Mexico, extremely well executed, our flexibility in supply chain.
So we are going into a new era of LVPs, where not only our plant in North Cove has done extremely well remediating and improving the output of the plant. So at the same time, we're resolving long lasting quality issues, things of the past have been resolved effectively. That plant is also now surpassing capacity plans because it's doing so well. We have capacity in Mexico, Ireland, so we now have the ability to really put the product to work. And this will be fundamentally important for us to resign customers up where we signed in the past. So we talk about execution, we had an execution issue in the short-term by having the team that did not understand what was happening with the difference between inventory, end distributor and demand at the end of the day. It didn't change the dynamics. We did not see the signal and we should have seen that and communicated more effectively. So to that end, we are relentless in execution. That's why we made significant changes in the U.S. team and have replaced people, in process of replacing people who did not understand how we operate.
I want to pass onto Brik to speak specifically about the Push and how this business can come back in terms of market share as well.
Brik Eyre -- Senior Vice President and President, Americas
So, Vijay. Thank you. I want to just make sure I'm clear. In the packages for administration of a ceph or a pen for example, there is a couple of ways that they can do that. They can -- put it into a Mini-Bag and then fuse it over 30 minutes, 45 minutes of an infusion, or that would be like 100 ml, or you can inject it trough IV Push with 5 ml to 10 ml of diluent. And so it's not -- they're not doing an IV Push of 100 ml, it is 5 ml to 10 ml and they will do that over three minute to five minute period of time, we'll see in the package insert, how long they should wait? The practical reality is studies have shown that a lot of the times, they don't wait that long to push it, and so there could be an over prescription overdosing and there could be a medication error. And that's one of the things we're talking to our customers about. So IV Push, the issue really is they're comfortable with IV Push for certain drugs. But those drugs that can be infused cephs, pens, et cetera, really the best way to administer that drug is through Mini-Bags and that's what we're talking to our customers about.
Now, I might take just a moment on LVPs to add just a little bit of color. This has been a business that's been highly successful for us for a number of years and it's driven tremendous, tremendous growth. And the vast majority of that comes from new customer sign-ups. As you know over the last five to six years, we've actually signed up to three to five-year contracts, above 100,000 beds. So tremendous market shifts over the last five, six years in our business from an LVP perspective. And that has been -- that coupled with an industry challenge in supply, our customers virtually purchased almost everything we could produce. In fact, these products have been on allocation. So we allocated a number of units that each customer could buy based on historical performance, because we had to do that to make sure that we got the product to every customer.
As we discussed and as Joe just discussed, we brought more product from Latin America, we were able to increase the allocation to customers above their historical usage and ultimately to remove that. As we did that, the demand for our products was tremendous in the first half of the year, particularly in the first quarter, as customers were concerned and distributors as well were concerned about the hurricane disruption of the market in general, as well as products that have just been on allocation for a long time, exasperated with a larger flu impact that we had in last quarters or last -- earlier this year.
So there was tremendous, tremendous demand for our product and of our U.S. team took that run rate on product that has always been able to -- whatever we manufacture and people purchased over the last five years because of allocation, and used that for our forecast in the back half of the year. And they did so not realizing that distributors and customers purchase significantly over the end-user demand in the first half, most notably in the first quarter as I mentioned. Now the good news is that those distributors have worked through that inventory, caused a significant impact in the third quarter. But we believe that we are close to being back in equilibrium, we've been in contact with our distributors, our wholesalers, we know our end-user demand, we get praisings from our distributors, so we are -- we've really improved our analytical capabilities and certainly, we will be at equilibrium over the next couple of months.
Vijay Kumar -- Evercore ISI Institutional Equities -- Analyst
That's extremely helpful, Brik. And maybe Jay, just on the margin front, that was the stellar standout raise in terms of the positives, irrespective of what the top line was, I mean you guys have executed on the margins. But as we -- it looks like may be Q4, may be there are some below the line items impacting them, I'm having a little bit of a hard time getting to the low end of that EPS guide range. And when we look at '19, just qualitatively, should we be assuming some of these revenue headwinds persist, but on the margin front, the guide that you guys laid out at the Analyst Day, nothing changes on the margin front? Thank you.
James Saccaro -- Executive Vice President and Chief Financial Officer
Sure. Vijay, let me talk a little bit about Q4 and our expectations there, because to your point, while in the second half of the year, we were pleased to be able to confirm the overall guidance at the high-end of the range. You pointed out very accurately that the Q4 implied guidance is down relative to what we previously shared. There's a few factors in play here, the largest of which is this issue that we've highlighted and discussed extensively about Medication Delivery and Nutrition. Overall, as we think about the impact in the fourth quarter relative to our prior expectations, that's about $0.06 of impact.
Now, offsetting that is savings initiatives that we have in place, roughly $0.01, and cyclophosphamide impacts approximately $0.03. And then there are a couple of financial adjustments, more financial items I should say, related to foreign exchange and tax. We have taken -- we reduced our expectations with respect to FAS 123R, so you do see a bit of a tax uptick. But in combination, foreign exchange and other financial items impact us roughly $0.04 in the quarter. So in combination, all of those items take us roughly down $0.05 midpoint to midpoint in the fourth quarter.
As it relates to 2019, we'll stop short at giving guidance for that today, we do believe that there is real opportunity to recover, and I think Brik has discussed that extensively, as has Joe. But as far as specific guidance for 2019, we'll stop short of that. We have reiterated confidence in the long-range plan that we shared, which shares through 2023, with also 2020 numbers.
Vijay Kumar -- Evercore ISI Institutional Equities -- Analyst
Thanks, James.
Operator
Thank you. And our next question comes from Robbie Marcus of JPMorgan. Your line is now open.
Robert Marcus -- JP Morgan Chase & Co -- Analyst
Great. Thanks for taking the question. I wanted to ask that some of the businesses that did well in the quarter, particularly Acute Therapies and Pharmaceuticals, these are ones where we've seen trends progressing positively each quarter. Can you help us understand Pharmaceuticals, what's driving that, how sustainable it is? And then in Acute Therapies, there were some new product launches recently. Can you help us understand the impact from those going forward?
Jose Almeida -- Chairman, President and Chief Executive Officer
Can you repeat the second part of your question, I understood the Pharmaceuticals, I missed --
James Saccaro -- Executive Vice President and Chief Financial Officer
Acute Therapies --
Jose Almeida -- Chairman, President and Chief Executive Officer
Acute Therapies. Okay. Robbie, we had an extraordinary performance in the Pharmaceuticals business, some of that is our capability of producing products that others can't and being there all the time. Cyclophosphamide is one of them, despite the fact there is the new competitor that was authorized by the FDA to produce. We haven't seen that product coming out of this manufacturer yet, it's a very difficult product to make. We're not saying that we're the only ones who can, because there is another competitor in the market, Sandoz has their product out there. But at the end of the day, we can make oncolytics and cytotoxic, extremely well, one of the best in the market.
We have BREVIBLOC that we do well and also TDS which we source and be able to have the product for our customers. We don't see these products repeating the same performance all the time, because as the nature of the business being when we can produce, then people can't, people sometimes come back to the market. The BREVIBLOC is one that now has couple of other manufacturers on the market, but we are always hedging our capabilities. So the performance of the Pharmaceuticals have been driven primarily by our ability to execute versus others who can't. I will give you a little bit of a mid to long-term view of Pharmaceuticals, which is our ability to continue to look into acquire molecules, which we've been doing. Second is our commitment to deliver on the LRP that Brik had presented at the Investor Day. We are still on track for all of that.
Moving to the Acute Therapies and I just want to say that we just launched PrisMax, a great product, launched in Europe, it's going to launch in the U.S. following. We are very excited, we're number one in this therapy around the globe. You can see by the performance of this business and the performance of a competitor that has released earnings the other day, specifically yesterday, that we continue to be very successful in gaining share and also creating adoption for this technology, this just proves this is a structurally sound business and we're very happy with the execution. I just also want to take the opportunity to mention, things are going well to underscore our launch of PD business and -- relaunch of our PD business in Japan was a great success, and a 10% growth overall in China on all of our businesses combined. So we have some really good stuff happening.
The unfortunate part is that we missed some of the market signals in the U.S. that created a headwind for us in Q3, you (ph) will create in Q4, and we'll recover probably through '19 into '20. So, we have some really good businesses within the company, there are really good cash generators and also we have a good and sound pipeline coming out of the company in '19 and '20.
Robert Marcus -- JP Morgan Chase & Co -- Analyst
Okay, great. And I know there has been a couple of questions on Medication Delivery. But just to look at it from a different angle. I haven't heard anything on -- in terms of how infusion systems have done in the quarter year-to-date. May be how that's playing out with the system that you're launching? Then also, can you comment on large volume pricing, you've said that volumes were up 2% year-to-date. How does the pricing situation look for first half and then versus third quarter? Thanks.
Jose Almeida -- Chairman, President and Chief Executive Officer
Robbie, just want to amend my answer on Pharmaceuticals that are premixes, which are replacements, for me -- we would sell Premixes every day of the week in favor -- in detriment of Mini-Bag Plus, OK? Because premix carry higher margins and they're up 18% and they're reflected in Pharmaceuticals, they're not reflected in SVPs, just want to highlight that because I missed that in my answer to you. So to the folks on the call, premixes has done extremely well, this is a GALAXY product. And those were ones that we told the customers to substitute for, when we did not have Mini-Bag Plus available after the hurricane. So this is the positive side that we did not talk about.
Let me pass onto Brik to answer the rest of your question.
Brik Eyre -- Senior Vice President and President, Americas
So Robbie, relative to pricing, relative with LVPs, Nutrition et cetera, the reality is, these are products that are on longer-term contracts that have modest price increases built into those contracts. So pricing remains in line with our expectation across all of those product lines. Relative to infusion pumps, we continue to believe that we will pick up approximately 1% of market share this year in the United States with our SIGMA SPECTRUM pump. We have found that as more customers desire to have auto programming, one of the key features of our new pump that we recently launched, our Spectrum IQ which we sometimes refer to as Version 9, and other integrated features that the selling cycle has lengthened a little bit. And so I see it's now involved in a much higher level, at a hospital level or at a hospital in each of our hospitals, and so we did reduce our pump number a little bit in the back half, as products slip out into next year. But overall, we anticipate picking up the one percentage point as we had suggested earlier on, with the new launch of SIGMA SPECTRUM.
Robert Marcus -- JP Morgan Chase & Co -- Analyst
Thank you.
Operator
Thank you. And our next question comes from David Lewis of Morgan Stanley. Your line is now open.
David Lewis -- Morgan Stanley -- Analyst
Good morning.
Jose Almeida -- Chairman, President and Chief Executive Officer
Good morning.
David Lewis -- Morgan Stanley -- Analyst
May be Jay, just start with -- Good morning, guys. To start, Jay with you a question on free cash, so just free cash flow growth reversed a bit second quarter, third quarter. So I imagine there's been some supply chain reinvestment. Can you just sort of walk us through second quarter to third quarter and as you think about, so next year, do you think free cash flow gets back to that historical double-digit growth rate?
James Saccaro -- Executive Vice President and Chief Financial Officer
Yes, look, thinking about overall performance from our free cash flow, year-over-year, I think we're still talking about north of 20% growth, so very solid growth from 2017 to 2018. You'll recall, earlier in the year, we raised free cash flow guidance. We have subsequently lowered it and really what that has to do with is a couple of other factors that we discussed during this call. One is, to the extent that you fall short on a sales forecast. I mean, it's very difficult to adjust your supply chain planning such that there is not an inventory build that takes place.
The second thing is, we're very pleased with the performance coming out of our North Cove manufacturing facility, but that has been overproducing in terms of getting fully back up to speed ahead of our expectations, which is another factor contributing a bit to the inventory build. And then as we said earlier, when we look at year-over-year performance, we did make some strategic decisions to make select product inventory builds. So really, those are the three factors that we see. We do not see this as a structural issue, and frankly, once we kind of tighten up our forecast going into next year and this will be an opportunity for us to claw this back. So this year was -- if we think about the progression of free cash flow, we've gone from $300 million in 2015 to $1.5 billion in 2018, inherently and when you see that kind of extraordinary growth, there will be some volatility and some puts and takes. We wanted to make sure we share the -- obviously the most updated thinking in terms of where we see this landing. But like I said, I don't believe this is a structural issue that we're faced with, and we will plan accordingly as we look to next year.
David Lewis -- Morgan Stanley -- Analyst
Okay. Thanks, Jay, and just may be two quick follow-ups. So first is for Joe, for Brik. We haven't heard a lot about the SVP manufacturing dynamics in Puerto Rico. How did they trend here in the third quarter and what's the pathway to approval? Then Jay, sorry, just for the fourth quarter assumptions, we have two different dynamics, inventory and some of these customer chasing dynamics. Inventory is you can look at tracing data and get relatively comfortable. Just basically trying to ask as it relates to customer recapture rates, how risk adjusted are these fourth quarter numbers? And I'll jump back in queue. Thanks, so much guys.
James Saccaro -- Executive Vice President and Chief Financial Officer
So let me first talk a little bit about SVPs, David. Our production level is back to where we want -- needed to be et cetera. We were able to put Mini Bags back into channel kind of mid-July. So mid-summer and we're starting to see an impact of having that back into channel, which is a good thing as customers can buy from their primary distributors. Mini-Bag Plus just went back into the channel in September. We are healthy on most codes in Mini-Bag Plus, we've got one or two codes that we're still getting healthy on, but the vast majority of our business, we're very healthy now from an inventory perspective and we are working again diligent with our customers, relative to ensure that they have confidence in our ability to supply.
And then David, from our fourth quarter financial forecast, we've spent a lot of time with a bonds up build up, trying to be appropriately conservative as we look across the portfolio and that includes LVPs, that includes SVP recapture and so on. And so I think we've got the right number as we look to Q4 in the guidance that we shared.
Brik Eyre -- Senior Vice President and President, Americas
The only thing I think I might add, David, is we have launched a new product, which is sourced out of Castlebar, which is a single pack Mini-Bag Plus product which we're really excited about. From an operational efficiency perspective in a hospital, it's been very, very well received. And so this continues to diversify our risk as we have other sites manufacturing, this Mini-Bag Plus product that is such a great product for us.
David Lewis -- Morgan Stanley -- Analyst
Thanks so much guys.
Jose Almeida -- Chairman, President and Chief Executive Officer
Thank you.
Operator
Thank you. And our next question comes from Larry Biegelsen of Wells Fargo. Your line is now open.
Lawrence Biegelsen -- Wells Fargo Securities, LLC -- Analyst
Good morning, thanks for taking my question. One on the P&L, one on capital deployment. So, Jay, in the past, you've been very helpful in pointing out kind of headwinds in the subsequent year, and you guys have been very good at being able to overcome those headwinds on the P&L. So for 2019, you have currency, cyclo, BREVIBLOC, may be on other income, and tax potentially as headwinds. And in the aggregate, by our math, could reduce 2019 EPS by about $0.40. So can you walk us through some of the P&L headwinds next year and help us understand if you can still grow EPS at a double-digit reported rate in 2019, and I had one follow-up?
James Saccaro -- Executive Vice President and Chief Financial Officer
Yes, sure, Larry. Stay tuned, come join us on I think January 31 or February 1 for guidance for 2019. At this stage, I think it's premature. What we've said is -- we've shared financial guidepost for 2020 and 2023. There are numerous puts and takes, which we've confirmed and feel -- we feel confident and there are numerous puts and takes as we look at any given year. I mean, our objective is to do as well as we possibly can do in any given year. And so certainly things like new product launches, I think that we'll highlight as we come to our earnings call at the beginning of next year, but like I say, it's too premature to give 2019 guidance at this point.
Lawrence Biegelsen -- Wells Fargo Securities, LLC -- Analyst
Understood. And Joe, regarding M&A at a healthcare conference, Jay, not to get you in trouble, but you said Baxter is agnostic to deal size which surprised me a little bit. So, Joe, I thought you had a strong preference for smaller deals because it was hard to get a good ROIC from larger deals. So my question is, has anything changed? Thanks for taking the questions, guys.
James Saccaro -- Executive Vice President and Chief Financial Officer
Thank you. I'm trying to figure out if Jay and I are on the same page, and we are actually. Jay called me right before, he said that, said, can I say that? And I authorized him to say then without being present. We are looking at any opportunities that we have either adjacent to the core or completely outside of the core in terms of another leg to the stool. And why do we take the constraint of size, because that creates an issue in selecting targets, not necessarily that we will execute on that, but not -- but being agnostic of size, where Jay meant to say was that we have -- we are looking at every opportunity that is -- that will get us what we need to do, which is to refresh the portfolio of Baxter, to create momentum on the gross margin line, argument growth on the top line and be accretive to the bottom line. We're doing this and by taking the size from the restriction, now, we can see better what's available to us.
But let me also put a commentary that was implied in Jay's response to your question during your confidence that is, we will push the boundaries off our debt ratio to the limit of investment grade, but not go below that. So, that creates a size limitation of what we can do. Okay? Secondly, I have to say to you that what Baxter has done in terms of its business transformation and what we're able to bring to the company, when I first started, exactly three years ago, yesterday, we had 9% of operating income and now we have about 18% of operating income. That transformation of a company is difficult to achieve. But once you know and learn how to do it, it is paramount upon the acquisition.
So if you think about, when we talk about sizes and how we do it, is not about integration per se, but is our ability also to go in with that mentality, with that trademark and get the savings out of the target independently, if the synergies are all in terms of connecting systems and doing this stuff than more traditional people think about. I'm coming from a different angle that said, that is doable, but the first thing we'll do, we'll put a business transformation office identical to what we have in Baxter at that company. And we're going to remove the cost in this path that companies usually have in the medical technology and generics pharmaceutical business.
So it's long answer to you, to say that we are looking in multiple size deals, we're looking for also adjacencies and outside of our space within the healthcare. But also we have the ability to really be a cost-driven organization that can extract value from a target, even if it's not core or highly synergistic to us.
Lawrence Biegelsen -- Wells Fargo Securities, LLC -- Analyst
Thank you for taking the questions.
Operator
Thank you. And our next question comes from Larry Keusch of Raymond James. Your line is now open.
Lawrence Keusch -- Raymond James & Associates, Inc. -- Analyst
Yeah, hi, good morning. Just wanted to -- we've already spent a lot of time on LVPs and SVPs, but wanted to come back to Nutrition and just get some thoughts, as it relates to sort of the protocols changing in terms of delayed starts for Nutritional products. How do you influence that to kind of go back to where it was, because I guess my concern is that could become a bit more permanent?
Brik Eyre -- Senior Vice President and President, Americas
So Larry, let me take that If I can. Certainly it's more problematic when protocols change, but ASPEN, the American Society for Parenteral and Enteral Nutrition rolled some guidelines to help people when they are in conservation mode. There are guidelines for feeding and while these patients are typically really, really sick, they don't have a gut function that is why they are on parenteral nutrition. So it's very difficult to be able to track specifically what the clinical outcome is to, there are so many different inputs.
But if you take a step back, we do know there's good data that would suggest that outcomes are better when a patient is nourished appropriately and effectively. So we are working with all of the societies now, that there is an appropriate supply to see if we can help customers go back to feeding protocols that have been established by ASPEN here in the U.S. by ASPEN which is in Europe to help make sure that patients are fed appropriately. We'll continue to work with those societies, continue to work with our customers, but as you mentioned, when a protocol changes in the hospital, it just takes a little bit more time to get it back. We are working very closely with our customers and they do recognize the importance of feeding, and we just have to make sure that they're are confident in our supply chain and the supply to the market in total.
And to your point or just from a framing perspective, about 7% of the market is contracted, and we will be working over the next several quarters to bring that back.
Lawrence Keusch -- Raymond James & Associates, Inc. -- Analyst
Okay, perfect. And then two other perhaps quick ones. I think Joe, you may have mentioned in your prepared comments about some management changes following some of the forecasting missteps, if you will, relative to the business. So again, I want to make sure I heard that and kind of what the plans are there. And then for Jay, just on the gross margin expansion year-over-year, which was clearly impressive. Just trying to understand the components that drove that expansion if there are any one timers there. Thank you.
Jose Almeida -- Chairman, President and Chief Executive Officer
We always look at execution, at Baxter in a way that is pretty straightforward. Some stuff, we expect from people to accomplish at a certain level, understanding their markets, the first one. So when people don't understand their markets or they have been complacent in doing their jobs, it is our responsibility as leaders to identify that either correct with the personnel that we have or just replace. So that's what we did and we do that all the time in our businesses. We have significant changes, for instance, we made significant changes in the international business of Baxter, it was really under managed to be honest with you. And we brought some really good people in and we started seeing the performance going up. Brik had issues with the performance in the hospital business in the U.S. and we just did the same thing. So it's pretty straightforward, no different than it would have been in any other prior jobs, but we take performance very seriously. We take performance as the number one criteria, only second to FX and compliance.
James Saccaro -- Executive Vice President and Chief Financial Officer
As it relates to gross margin, which was a bright spot in the quarter, the lion's share of the improvements relate to cost initiatives and business transformation. As Joe mentioned, where the margin journey that we're on is something that initially was focused primarily on SG&A as that it was the fastest area to take out. But now under the leadership of Scott Pleau, we've been able to make changes to our operations network to facilities to optimizing within facilities. So probably 75% of our margin improvement year-over-year relates to some of these cost initiatives. And perhaps 25% or so relates to mix and operational growth that took place in the quarter. So, on balance, as we look from 2018 to 2023, you can expect to see more progress driving cost out with a lot of that coming from the gross margin line in the coming years.
Lawrence Keusch -- Raymond James & Associates, Inc. -- Analyst
Okay, terrific. Thank you.
Operator
Thank you. And our final question comes from the line of Joanne Wuensch of BMO Capital Markets. Your line is now open.
Joanne Wuensch -- BMO Capital Markets Equity Research -- Analyst
Good morning and thank you for taking the question. There are a number of new products that you're launching right now in the second half that should benefit you in 2019; from Spectrum IQ, Evo IQ, PRISMAFLEX, PrisMax. Can you give us a brief update on how those products are rolling out the door and how we should think about them ramping into next year to possibly offset some of the continued Nutritionals and Medication Delivery recovery?
Jose Almeida -- Chairman, President and Chief Executive Officer
Yes. Joanne, clearly we are looking into '19 to be a year that we're going to have growth. The question that we're going to tell you how much the growth is going to be is going to be a conversation in January. Those products will contribute and we're counting on them to help because as you see, some of this change that Brik just mentioned in Nutrition is several quarters in the making to recoup that kind of a sales volume. So those new products will be key.
We're counting on PrisMax. I think dexmed is one that we're very excited. Once we launch that, it's actually doing very well. We have four new molecules launching next year as well. So we -- one thing we have proven is the ability to really ramp up quickly to big sales on those molecules. If I'm not mistaken, dexmed will -- peak sales will go into '19, will get it to '19 pretty quickly. So we need those products. We're counting on Kaguya next year to be a driver in Japan because of the profitability, not as much of sales growth as much as the profitability. That product has showed that, the patients in Japan are highly profitable in terms of our reimbursement. So we are counting on those products without a doubt.
And for me, and this is a message that I give to Brik, to Cristiano, who runs Europe, Middle East and Africa, and Andy Frye, it's all about executing on those new products. They have the message. They know what needs to be done and we're counting on them. Thank you.
Joanne Wuensch -- BMO Capital Markets Equity Research -- Analyst
Thank you. And as my follow-up question, you mentioned that you're a little bit more revitalized on the M&A focus and you gave a great answer earlier to what you were looking for in terms of size. But is there anything in particular that has made you revitalized? Is it the business as we're seeing today? Or is it just opportunity or something else? Thanks.
Jose Almeida -- Chairman, President and Chief Executive Officer
If you think about the transformation, Joanne, I put that in three different phases and some of them are all in parallel. But the M&A was the one and the portfolio revamping and transformation of the portfolio is one that had to come after two things that we had to do. We need to put the house in order in terms of organization structure, finance, balance sheet and culture. Once we get those things done and we have our own organic programs, now we have a team that is working diligently on finding the opportunities for us to tag along. So if we don't have those things in place, we couldn't do the other, couldn't come up six months into this job and still we're going to buy this company and that company. We didn't have the balance sheet.
Now we do. Not only that, we have the strategy and we have competent leaders for the most part that we're making sure that we can execute on this. So as we make adjustments to our organization, I have to say that the people and the employees of Baxter have done a significant amount of heavy lifting due to so many headwinds that we had with this hurricane, anticipated and unanticipated, because some of this stuff caught us by surprise. Not because we didn't prepare, but because the long-lasting effect. But the people of Baxter have worked relentlessly and get this done. Now it's time for us to really get the M&A going as these things are starting to get behind us.
Joanne Wuensch -- BMO Capital Markets Equity Research -- Analyst
Thank you. And happy Halloween.
Jose Almeida -- Chairman, President and Chief Executive Officer
Happy Halloween as well.
Brik Eyre -- Senior Vice President and President, Americas
Happy Halloween.
Clare Trachtman -- Vice President, Investor Relations
Happy Halloween, Joanne.
Jose Almeida -- Chairman, President and Chief Executive Officer
Thank you.
Operator
And that concludes our question-and-answer session for today. Ladies and gentlemen, this concludes today's conference call with Baxter International. Thank you for participating. Everyone have a great day.
Duration: 64 minutes
Call participants:
Clare Trachtman -- Vice President, Investor Relations
Jose Almeida -- Chairman, President and Chief Executive Officer
James Saccaro -- Executive Vice President and Chief Financial Officer
Robert Hopkins -- BofA Merrill Lynch -- Analyst
Brik Eyre -- Senior Vice President and President, Americas
Vijay Kumar -- Evercore ISI Institutional Equities -- Analyst
Robert Marcus -- JP Morgan Chase & Co -- Analyst
David Lewis -- Morgan Stanley -- Analyst
Lawrence Biegelsen -- Wells Fargo Securities, LLC -- Analyst
Lawrence Keusch -- Raymond James & Associates, Inc. -- Analyst
Joanne Wuensch -- BMO Capital Markets Equity Research -- Analyst
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