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Zimmer Biomet Holdings (ZBH 0.48%)
Q4 2019 Earnings Call
Feb 04, 2020, 8:30 a.m. ET


  • Prepared Remarks
  • Questions and Answers
  • Call Participants

Prepared Remarks:


Good morning, ladies and gentlemen, and welcome to the Zimmer Biomet fourth-quarter 2019 earnings conference call. [Operator instructions] As a reminder, this conference is being recorded today, February 4, 2020. [Operator instructions]. I would now like to turn the conference over to Cole Lannum, senior vice president, investor relations and IRO.

Please go ahead, sir.

Cole Lannum -- Senior Vice President, Investor Relations, and IRO

Thank you, operator, and good morning, everyone. Welcome to Zimmer Biomet's fourth-quarter 2019 earnings conference call. In the room with me today, we have Bryan Hanson, our president and CEO; our CFO, Suky Upadhyay; and our new senior vice president of investor relations and chief communications officer, Keri Mattox. Now before we get started, there are a few things I want to go over with you.

I'd like to remind you first that our comments during this call will include forward-looking statements. Actual results may differ materially from those indicated by the forward-looking statements due to a variety of risks and uncertainties. Please note, we assume no obligation to update these forward-looking statements even if actual results or future expectations change materially. Please refer to our SEC filings for a detailed discussion of these risks and uncertainties in addition to the inherent limitations of such forward-looking statements.

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In addition, the discussions on this call will include certain non-GAAP financial measures. Reconciliation of these measures to the most directly comparable GAAP financial measures is included within the earnings release found on our website at zimmerbiomet.com. With that, I'll now turn over the call to Bryan. Bryan?

Bryan Hanson -- President and Chief Executive Officer

Thanks, Cole. I appreciate it. And before I jump into it, I just wanted to say the congratulations, first of all, to Keri. Obviously, Keri Mattox, it's her first call with us in Zimmer Biomet in her new role.

I'd say it's early on, but we're pretty excited about what we think she's going to bring to the table. So I'm looking forward to that. I also want to make sure that I take just a minute here and say thanks, Cole. It's been harder to leave but already two years that we've been working together in this capacity.

And I would say that we've come a long way, and a lot of that has to do with your guidance along the way. So I certainly appreciate it. I know you're not going anywhere. We're going to have access to you, but this will be the last time you're on one of these calls.

So I wanted to make sure that I call you out for what you've been able to do for us over the last two years and look forward to next year together. All right. So getting into the quarter, we're encouraged by our performance in the fourth quarter. We posted solid revenue growth, slightly above our weighted average market growth rate expectations and grew earnings per share faster than revenue.

This was driven by improved performance versus prior year across all geographic regions as well as most of our businesses. We also made further progress in executing on our short-term priorities: supply, quality remediation, new product introductions and ZB's mission and culture. We also continued to invest for growth. This progress has laid the foundation for further innovation and commercial execution that will drive our accelerated growth over the long term.

These are all important steps forward. And while we are happy with our progress, we're certainly not satisfied. Rest assured that we are still striving to continuously improve our business, our performance and the value we deliver to patients, as well as customers and investors. Along those lines, let me talk about the team's momentum around the key short-term priorities.

Regarding supply, we have consistently met customer demand and improved service levels, further enhancing the confidence of our global sales teams and putting them back on offense. With this supply stabilization, we are focusing more on opportunities to decrease the complexity and increase the efficiency of our supply chain. I'm happy with our progress thus far. On quality, I can confirm that the FDA recently concluded a reinspection of our Warsaw North facility.

This inspection is anticipated based on the progress reports we've been providing the FDA on site readiness. We want to thank the agency for a productive and collaborative visit. By way of background, the FDA last inspected this facility in April of 2018, and we've been executing a comprehensive remediation plan over the past couple of years. We believe the latest FDA inspection validates the significant improvement and progress that has been made at the Warsaw North facility.

Not surprisingly, the FDA issued observations at the conclusion of the inspection, and we are confident in our ability to address them to FDA satisfaction. Our anticipated path forward with the FDA is fully contemplated in the 2020 guidance that we provided earlier this morning. We look forward to continuing to partner with the FDA as we strive to make Warsaw North a best-in-class medical device manufacturing facility. Let me take a moment to thank our quality and operations teams for their tireless work and dedication to patient safety.

What they have accomplished over the past two years, and what I know they will deliver for ZB moving forward, is impressive. With improvements made in supply and quality, we also continue to sharpen our focus on innovation. Our enhanced R&D efforts drove significant new innovation in 2019 and give us increased confidence in our new technology pipeline as we move into 2020 and beyond. And these programs increasingly include enabling technology and solutions around our implants, such as robotics, mini robotics, informatics and operating room efficiency.

While the implant is core to what we do, our goal is to provide a complete ecosystem that is both patient- and customer-centric. At the upcoming AAOS meeting in March, we'll showcase additional innovations inside this ecosystem that connect our implants, data and robotics, all designed to optimize decision-making and improve patient outcomes. Moving to mission and culture, we continue to communicate and drive the mission of the ZB organization. I can say today with confidence that everyone in the organization considers themselves as part of one team.

Our strategy is very clear and cascades down to all team members in the organization. It's important that everyone knows where we are going and how we are going to get there. Now turning to our fourth-quarter results. All three of our regions performed well versus prior year, with strong performance from Asia Pacific and improving performance in the Americas.

Relative to our businesses, we are pleased with the performance of the knee franchise with solid results across all three regions. Our core knee business accelerated, driven by Persona, including the recently launched Revision system. ROSA Knee also accelerated and drove a little more than 50% of the overall global knee growth. ROSA placements were strong, accelerating from Q3, and our customer pipeline continued to grow, supported by a very positive feedback so far.

We project continued growth with ROSA in 2020 as we increase our commercial efforts, including sales force expansion and enhanced surgeon training support. In summary, we are very pleased with the ROSA Knee launch and the overall robotics uptake. While S.E.T. continues to be an important focus area for us, it is not yet delivering at our goal of durable mid-single-digit growth.

We will continue to prioritize innovation and accelerate the expansion and investment in our specialized sales channel in order to drive scale in the high-growth S.E.T. markets. Our dental team delivered its third consecutive positive growth quarter. The team's focus on strategic priorities, execution and culture, along with the targeted investments in key areas, continues to drive the business forward.

We still have much to prove in this business, but I'm happy with the current momentum and the performance of the dental team. Relative to our Spine & CMF business, although we did see improvement from Q3, we continued to perform below market in the quarter. The primary focus areas for this business will be working through the final steps of our channel consolidation and leveraging our new product pipeline, including recent and upcoming product launches. We are making steady progress driving innovation and shaping the future of this organization.

We've built a strong foundation and are now better positioned to accelerate our innovation and execution strategy. I'm encouraged as we reshape Zimmer Biomet for sustained success. With that, I'll turn the call over to Suky to get further into the financials.

Suky Upadhyay -- Chief Financial Officer

Thank you, Bryan. We delivered solid financial performance in the fourth quarter with accelerated revenue growth and leveraged earnings while increasing investments for long-term growth. Also, through robust cash generation, we continue to make progress in delevering the balance sheet for strategic flexibility. I'll provide some highlights on our fourth quarter financial results, and unless otherwise noted, the numbers I will be discussing on a constant currency basis.

Net sales totaled $2.1 billion, a reported increase of 2.6% over the prior year with an increase of 3.2% excluding the impact of foreign currency changes. During the quarter, all three of our geographies performed well. Our Asia Pacific team delivered 8.6% sales growth driven by continued strength across both developed and emerging markets. The Americas increased 2.4% with strength in knees and hips driven by new product introductions, supply stability and improved commercial execution.

Our Europe, Middle East and Africa team delivered 1.4% revenue growth led by strength in developed markets. Turning to our businesses. In Q4, our global knee business grew 4.9% with improved execution in new product launches. Our hips business grew roughly in line with market growth at 3.2% and was aided by the recent launch of Avenir, where we are seeing good early market acceptance.

S.E.T. grew 3.1%, slightly below our expectations, but we remain focused on growing that business at mid-single digits over time. Dental posted another solid quarter at 5% growth, driven by increased commercial and channel investments throughout 2019. Spine & CMF posted 0.2% revenue growth.

While the growth was positive and sequentially better, we still have more work to do to stabilize the business. Turning to the P&L. We reported GAAP diluted earnings per share for the quarter of $1.54. Adjusted diluted earnings per share were $2.30, a 5.5% increase over the prior year.

Better adjusted operating margins and lower interest expense drove this leverage earnings profile. Adjusted gross margin was 73.1%, a sequential improvement, an increase over prior year due to higher volumes and favorable timing of costs within the quarter. Adjusted operating expenses increased sequentially due to sales commission and investments across commercial and R&D priorities in our knee and S.E.T. businesses.

Overall, adjusted operating margin was 29% in the quarter. Moving beyond operating margin. Interest expense of $52 million was down both sequentially and versus prior year due to debt paydown. Lastly, we had solid free cash flow generation of $295 million in the quarter and paid down an additional $161 million of debt, further deleveraging the balance sheet.

It was a solid quarter. Looking ahead, our growing confidence in the business is evident in the 2020 guidance that we provided in our press release. Starting with revenue. While quarterly results may fluctuate due to seasonality and timing, we expect our full-year constant currency growth to be between 2.5% to 3.5%.

The first quarter will benefit from about one additional billing day with no material impact expected in the remaining quarters. We expect our adjusted operating margin for the full year to be between 27% and 28%. Our adjusted effective tax rate should be between 16% and 17%, and we expect adjusted diluted earnings per share to be between $8.15 and $8.45. Against the backdrop of these 2020 expectations, I'd like to spend a few minutes on incremental steps we're taking to enhance shareholder value and to move our financial profile closer to top quartile.

We have begun to implement a comprehensive multiyear restructuring plan with the objective of reducing costs and driving a mix shift of investments to higher priority growth opportunities. We estimate that these activities will generate gross annual adjusted pre-tax operating expense savings of approximately $200 million to $300 million by the end of 2023. This program gives us additional confidence that we can invest for growth and accelerate adjusted operating margins. I know the next question will be what does accelerate margins mean.

Well, we expect to deliver operating margins of at least 30% by the end of 2023. To support this restructuring, we estimate approximately $350 million to $400 million in onetime costs over the same period. Consistent with this, during the fourth quarter, we recorded a charge of $31 million. As part of these restructuring activities, we have also reorganized several businesses to drive enhanced strategic alignment across our key growth areas.

As a result of this reorganization, you can expect that we will modify elements of our external reporting in the first quarter of 2020, and we'll share that information with you before our next earnings call. With that, I'll turn the call over to Bryan.

Bryan Hanson -- President and Chief Executive Officer

Thanks, Suky. And in summary, we are proud of the progress that we are seeing in 2019. We've clearly stabilized many parts of the business. We've made key investments in priority areas.

We drove better top line growth and delivered solid, sustainable financial performance. While there's clearly more work to do, we enter 2020 with increased confidence in our business and remain optimistic about our future. Now I'll turn the call over to Cole and Keri to manage the Q&A portion of the call.

Cole Lannum -- Senior Vice President, Investor Relations, and IRO

Thanks, Bryan. [Operator instructions] With that, operator, may we please have the first question?

Questions & Answers:


[Operator instructions] We'll take our first question from Raj Denhoy with Jefferies.

Raj Denhoy -- Jefferies -- Analyst

Good morning. I wonder maybe I could start with the knee growth in the quarter. It really stood out. So Bryan, maybe a couple of questions there.

One, can you maybe offer whether you think you have stabilized that business on an underlying basis? You offered it half the growth with some ROSA. But on an underlying basis, do you feel your share position is now secure? And then on ROSA, is there anything more you can offer in terms of where you're seeing placements, what the demand has been? Just really anything you can offer in terms of how that system is faring.

Bryan Hanson -- President and Chief Executive Officer

Yes, absolutely. I would tell you that we're pretty excited actually about the quarter. It is unmistakable with that across the business, but particularly knees was strong for us. And what I like about it, in addition to us, we saw strength in other parts of the market.

So I know it's just one quarter. We don't want to get too excited about that. But the fact that we were able to surge in the market as others did, I think that is a good sign. And yes, ROSA was clearly a big part of that contribution and knee growth.

As we said, it's a little bit more than half of the overall growth. But even when you look at the base business, I would say that we're seeing that business move as one would expect. It's not where we need it to be. I need the overall market in knee, our business in the market in knee to be able to outperform the overall market.

We're not there yet, but the fact is we're definitely seeing traction in base knee as well. It's actually one of our best growth quarters in base knee that we've seen since the merge. What I would tell you is that ROSA demand is very strong. Probably we do have the largest funnel right now for replacements than we've ever had.

We've done over 2,000 procedures already. And again, we're just a couple of quarters into this launch. So that would tell you that we're really seeing acceleration of focus in this area. I had an opportunity to be out in the field and see a few cases, one particularly on the West Coast, where I had a surgeon continue to look across the operating room and say, "I couldn't do this before without ROSA." He was making 0.5 millimeter adjustments in tissue balancing and getting real-time feedback in the procedure.

And he was practically giddy about the response he was getting from the robotic system. And so again, I think people are seeing this. As a result of that, more people are desiring to get trained on the system, and we're going to continue to see that momentum go forward. It was great to see our competition have a really strong quarter as well.

That tells you that the uptick in robotics is real, and that benefits all of us. So again, I'm pretty happy with where we are right now with base business, as well as momentum with ROSA. Still have a lot to do. I think it's going to take us some time to get above-market growth in knee.

Remember, we have a very large base. That's going to take time to influence it because it's a significant number. We still have some of that negative inertia associated with the competitor's placements of robotics. It's going to take a while for us to disrupt that inertia, but I think we will over time.

And we still have the major products that are out there that are launching. They're doing well, but they're early. So again, I feel really bullish in the area, but it's just going to take us some time to be able to get that business growing above market.

Raj Denhoy -- Jefferies -- Analyst

Great. Thank you.

Bryan Hanson -- President and Chief Executive Officer

Thanks Raj. Next question please.


Our next question comes from Vijay Kumar with Evercore ISI.

Vijay Kumar -- Evercore ISI -- Analyst

Hey guys. Thanks for taking my question. If I could, maybe a two-part question. One, ROSA expectations for 2020.

I know you said a sequential step-up in placements for '19. Is that still the margin assumption for 2020? And on the margin side, Suky, implicitly, we're looking at 60, 70 basis points of annual margin expansion. When does that kick in, right? Is that kick starting in 2020? Or is it more for 2021 nuance? And congrats.

Bryan Hanson -- President and Chief Executive Officer

OK. Yes. I'll start off with the ROSA and then cast our view certainly obviously on the margin piece. Yes, as I said before, ROSA funnel is as strong as it's ever been.

We're adding commercial infrastructure to be able to support that, and we're adding significant training capabilities so that we can get people trained with a safe and effective use of the product. So I absolutely expect 2020 to be better than what we saw in 2019. It's kind of logical just given the fact that we will have it for the full year. We did not have it for the full year of 2019, but that momentum is real.

I would expect it to continue and certainly be a driver for us in 2020.

Suky Upadhyay -- Chief Financial Officer

Yes. Regarding margins and the overall restructuring program that we announced just a few minutes ago, you're right. We talked about 30% operating margins by 2023, at least 30% operating margin. So your math is right.

If you sort of took a linear glide path, that's about 60 to 70 basis points per year. However, I would say that it may not be linear, right, depending on the overall revenue profile, our investment profile. Over that three- to four-year horizon, that margin expansion could be a bit lumpy, and it could fluctuate. So I wouldn't look at it as sort of in a linear fashion.

Regarding 2020, operating margins, completely consistent with how we have characterized this all the way through 2019, including our third-quarter call, where we said we see the opportunity for modest operating margin expansion in 2020. And if you look at our guidance, that's represented in the top half of that guidance. But we also said, given the number of attractive opportunities we have across the business, that we may use some of that margin upside to instead invest against the business for top line growth because we do see top line growth as the best, most durable pathway to long-term margin expansion, earnings growth and shareholder value. And so that's reflected more in the bottom half of that overall margin profile guidance.

I would say we're in early days as part of that restructuring program. However, we do expect to see some benefit into 2020, and that's been fully incorporated into the margin guidance that we've provided today.

Vijay Kumar -- Evercore ISI -- Analyst

Thanks guys.

Suky Upadhyay -- Chief Financial Officer

Thanks Vijay. Next question please.


Our next question comes from Matt Miksic with Credit Suisse.

Matt Miksic -- Credit Suisse -- Analyst

Thanks so much for taking the question. Just one follow-up on Raj's question on knees, and then I have one follow-up as well if that's OK. On the knee growth, Bryan, you mentioned it's going to take a while to get above-market growth in knees. If you could talk maybe a little bit about where you are in the U.S.

in terms of holding share and what the timing looks like in the U.S. given the trajectory robot sales and some of the other projects. You mentioned timing to get back to or get above-market growth.

Bryan Hanson -- President and Chief Executive Officer

Yes. So I won't give specific timing on that, but just know we have our sights on getting above-market growth, and we also believe that we have the fuel to do it. And I'll just go through a couple of those things that I think will give us that confidence. But when I think about the U.S., we're still below market.

We're still seeing share, but the rate that we're losing market share is much lower. So we're clearly closing that gap, and our confidence level is high. I mean the U.S. momentum is real.

I was just at a kickoff meeting for the Americas. Obviously, a big part of that is the U.S. commercial organization. And I can tell you in all my years of doing kickoff meetings around the world, I have never been to an event where the energy was as high as it was in that meeting.

So people are ready to go. They're fired up, and that momentum is real, and that's meaningful. Beyond products and innovation, supply and everything else, the way people feel, their confidence absolutely drives traction in the field, and I can say right now it's there. So that's probably the first thing that would tell me that we have a pathway to get above market.

The real brass tacks is associated with products, though. As I mentioned before, ROSA's strength is real. As I am out in the world and I'm seeing ROSA placements, I am seeing people that we did not even expect, surgeons that are competitive surgeons now getting trained rapidly to understand how to use our robotic system. And as a result of that, over time, we're going to expect to see that pull through because they have to use our implants when they begin to use the ROSA system.

Now that will take time because they have to first drop the implants that they're using, really get trained and understand how to use the robotic system that we have. And then we're going to get that uptick, but that will take time because we're early in the launch but it will happen. When I look at cementless, we are still seeing traction in Persona cementless. I am not going to get into specifics here, but there's no question this gives us an opportunity for mix.

A little bit of conversion opportunity, too, particularly tied with robotics, but a big part of it is mix benefit, and then Persona Revision. I got to tell you, there's a few different ways we can drive revenue growth here, but the traction we're getting and the momentum that we're getting is bigger than we expected. As a matter of fact, we're actually building triple the amount of sets that we expected based on the demand that we're seeing. So there's no question in my mind people love the revision system and it's being well accepted in the marketplace.

Really three different ways that we can grow business inside of Revision. First one is I've already got Persona users out there that are not using my revision system because we're just launching it. There's no reason if they like the Persona product that they wouldn't convert to the Persona Revision system. So that's the first order of business.

Go to our current accounts where they're using Persona, and get the revision business. The second one is I've got an opportunity to get out and get those surgeons that wanted to move to Persona but wouldn't go there until we got the revision system. And the third one is just competitive conversions. We have a great revision system.

Revisions are always a little more challenging for surgeons. So when you can make a revision easier as a result of a system like Persona, there's an attraction to that system. That opens the door to competitive conversions. So those are the pieces that I know we have in place to get us to at or above-market growth.

But the key thing is it's going to take time. We're early on in the rollout of these things, but I can guarantee it's going to happen. It's just a question of when, and I just can't give you a specific time right now.

Matt Miksic -- Credit Suisse -- Analyst

I appreciate that.

Bryan Hanson -- President and Chief Executive Officer

I am sorry. Can we just have one question per person? Sorry. Next question please.


So our next question comes from David Lewis with Morgan Stanley.

David Lewis -- Morgan Stanley -- Analyst

OK. I'll keep it to one question there, Cole. Bryan, you just talked about the 2020 outlook. I think you've been adamant around 2.5%, 2% to 3% growth.

This is 50 bps better on the margin, and the comps are going to be tougher in 2019. So you're clearly guiding to improving momentum in the business at 2.5% to 3.5% for 2020. Can you sort of walk us through where that confidence is coming from, either by segment or sort of across the business broadly? I think that's the kind of the key focus here on the call.

Thanks so much.

Bryan Hanson -- President and Chief Executive Officer

Yes. So David, it would have been funny if you were to come on and say you had a three-part question, but you're also [inaudible]. So I would tell you yes, it's a number of things. First and foremost, it's just the momentum we're seeing.

I mean if you look at the last couple of quarters, there's no question that there's a difference in the business right now, that the momentum is real and we have proven that now for two quarters. And that's a big confidence booster for all of us. If you think about it, the performance is good, but there hasn't been that many quarters as a company that we've had that type of performance. So half two in a row does give you some of that confidence.

So certainly, that strength across all regions, that performance that we've had already and the future-looking impact of new products gives us the confidence to be able to take their revenue, I am not going to follow up guidance but our view of what 2020 is going to look like up. So that was really the major impact. I mean I look at it to say we're still not delivering what I expect us to deliver in S.E.T. but the investment is there.

New product innovation is there. So that is going to happen. I have confidence It is going to happen. We are not where we want to be yet.

But just given the amount of investment and focus in this area, I know it's coming. I already talked about knee. Hip just continues to hang in there. The Avenir Complete is going well.

We have a robotic application that will be coming soon. That may be the catalyst for us to be able to boost the hip performance as well. We have been hanging in with market, but I'd like to see that above market. And I believe that the robotic application would give us that momentum.

So again, a lot of things moving in the right direction. I always want to balance that with some of the things that could be challenges for us. The fact is we do have great momentum in our products. The demand is high but they are early.

So that momentum has got to continue. Suky just talked about a multiyear restructuring program which is a must-have because it is going to allow us to invest for growth while also driving margin expansion, but there is always a risk obstruction when you put a program like that into place. So I am trying to look at the ebbs and flows, the puts and takes for our business and give you guys what we really believe is going to happen in 2020. And there's enough momentum, there's enough positive to offset all those things that could be disruptive, and that's why we took the number up.


We will take our next question from Bob Hopkins with Bank of America.

Bob Hopkins -- Bank of America Merrill Lynch -- Analyst

Great. So I guess my one question. I'd love to, Bryan, if you do not mind, follow up a little bit more on your comments on S.E.T. and just maybe a little more specifics on kind of what is coming and when, and when we might see better growth.

And obviously, a lot of people are trying to wonder if some of the merger activity going on around you might lead to some opportunities. So maybe just a little more color on S.E.T.

Bryan Hanson -- President and Chief Executive Officer

Yes. Yes. So when I just take a step back, when I think about this business over time, obviously we're not suggesting in 2020 being at the overall business, ZB, being at a midsingle-digit grower because that's where we need to go. When you think about our strategic pillar, of being a top quartile performer in total shareholder return, it requires us to increase our growth rate.

We have to get to that midsingle-digit growth rate. And one of the major contributors to that is going to be a sustained kind of durable growth rate in that market growth range for S.E.T. As a matter of fact, really need to see it on the top end of that range, that midsingle-digit range, and we need to see the outperformance of knee. So those are the two major categories that we're going to be heavily focused on to ensure that we get ZB at midsingle-digit growth, right, again, over time, but that's what's got to happen.

When I think about us being able to do that, it was pretty clear to me we have the formula in place. Number one, we've got to be able to increase the innovation pipeline. And we've been doing that, not just the pipeline but the cadence of those new products. Things like the Alliance Glenoid that we are launching that gives a more personalized way to do a total shoulder is going to be exciting to surgeons.

We're early on in this, but I can tell you right now the response in surgeons is very strong. The Signature ONE Planner, we lagged in this area. When you look at presurgical planning, we no longer lag in this area. And we have a lot more coming when it comes to informatics and/or robotics in this space as well.

So I feel confident that the innovation cycle is real. It's coming, and it will have an impact. And the other one that we've been talking about for a long time now and we're really doubling down in is continued investment in a dedicated channel. This takes time, obviously.

The hope would be that with some of the disruption out in the marketplace, that facilitates quicker expansion of our sales organization. We're certainly going to try to make sure that we take advantage of that, but the fact is we've got to be able to get that channel in place. We're investing in it now. And then the operating mechanisms around that channel to make sure that we are driving accountability and focus brings all these things together.

So I know the formula is there. The variables are all lined up. We discussed all the equation. And it's just a matter of time.

So I have high level of confidence it is going to happen. It's just not happening yet, and it's not happening durably yet.


We will take our next question from Richard Newitter with SVB Leerink.

Richard Newitter -- SVB Leerink -- Analyst

Thank you. Just a follow-up on the restructuring. Could you maybe just elaborate a bit on the types of projects or initiatives and the timing within that three-year trajectory? I guess really if you could also parse it out between things like sales, incentives, structure changes or any kind of incentive structure changes throughout the organization, what's low-hanging fruit versus kind of maybe the harder stuff to go after and when in the time frame, the three-year time frame, you're going to go after each?

Bryan Hanson -- President and Chief Executive Officer

Yes. Why don't I just kind of provide just a real general overview of what we were trying to accomplish in the restructuring? And again, early days so we don't know that we've done these things yet, but just the intent of the restructuring. And then Suky, maybe you can get into some more detail of the underlying assumptions. First of all, the whole goal of this was to drive better alignment, better accountability and efficiency, right? So we really do believe the restructuring is a better way to manage the business with efficiency included.

And if I just think about it, we've taken all businesses now. We have them under one leader. And the whole intent behind that is to have faster and less biased resource deployment decisions, right? We still have centers of excellence around robotics and informatics and other areas that you want to have unbiased views of how you are going to deploy those resources across the businesses. That now exists by having all businesses going to one person.

We also want to have clear accountability. So if you are going to make these decisions on resource deployment, you better have accountability for getting it done and accountability for executing against it. And we are streamlining the organization. We're making it less complex.

And as a result of doing that, you can drive margin expansion, right? So those are the reasons why we have done this. Ultimately, it is going to allow us to invest aggressively for growth while expanding margins and managing the business more effectively. So that was the purpose behind it. And then Suky, if you want to give some additional detail.

Suky Upadhyay -- Chief Financial Officer

Yes, sure. So Richard, you're thinking about it the right way. There are a number of initiatives, and there are going to be cadence at different times just based on sort of complexity and time it takes to get some of these initiatives up and running. In the early days, I would say it very much is about blocking and tackling and some of the low-hanging fruit that you sort of referenced.

One, we took a complete cost taxonomy of the organization, and we looked at that cost taxonomy relative to that spending versus external benchmark, relative to internal benchmark, relative to our growth opportunities in our markets and our businesses. And that's leading to, quite frankly, a mix shift in a lot of our spending but also some very clear areas of opportunity to reduce spending in lower-value areas. Blocking and tackling things like T&E, procurement, just basic costs down, again, blocking and tackling. The second area that's more near term, Bryan talked about the reorganization of some of our business units.

That is leading to efficiency. It is leading to efficiency by delayering the organization. So we are putting our commercial leadership closer to our customer and closer to the patient, and that is also leading to some reductions in redundancies. So those are all we call no-regret moves because they lead to margin expansion but also make the organization more efficient and effective.

Longer term, we're also putting things into place. It's going to take some while for those to mature and bear fruit. But it's around consolidating a pretty fragmented footprint when you think about the two companies, Zimmer and Biomet, coming together and then follow-on acquisitions and some of the focus that the companies had to spend over the last few years in supply and quality remediation. We can now start to turn the corner from stabilization to efficiency and start to think about how we consolidate some of that footprint and make ourselves more efficient.

And then of course, there's going to be some opportunity in the longer term around centralization of back-office and G&A type functions. So those are just a few examples. There are several other initiatives. There are a number of initiatives as we've talked about going on in manufacturing supply chain which we think over time, after we have stabilized gross margins, can lead to some modest improvement in gross margin as well.

So hopefully, that gives you a little bit more color as to how we're thinking about it and how we're approaching it.

Richard Newitter -- SVB Leerink -- Analyst

Thanks for that. Next question please.


We'll take our next question from Matthew O'Brien with Piper Sandler.

Matthew O'Brien -- Piper Sandler -- Analyst

Thanks for that question, and Cole, good look in the future. Bryan, I was hoping to talk a little bit about ROSA. Over the last maybe four or five years here, you've lost about 400 or 500 basis points of knee share. So I'm curious on the ROSA side, and I know it's early, but you talked about this massive funnel.

Can you talk about what you are seeing in that funnel in terms of is it just more people that have been using Zimmer over the last several years and have been good customers? Or is it a majority of those people that are in the funnel right now? Or have you been surprised by the number of folks that you've worked with in the past that have come back into the funnel and could be customers here in the near term again? Or even just de novo people that you've never worked with in the past? If you could kind of weight where some of those clinicians would kind of fit within those three buckets, I think that would be helpful.

Bryan Hanson -- President and Chief Executive Officer

Absolutely. It's kind of a mixture. When we put the strategy in place, it was pretty clear that our first intent was to go after those accounts that are already using us. The folks that know and love our implants have always had an interest in moving into robotics but wouldn't do it if they couldn't use their own implant.

So there's no question that, that's a pretty big element of our success, just pursuing those that love the implant of Zimmer Biomet and now can use that implant in concert with robotics. But what we're finding is that it's never a perfect world in the way you roll out a plan, and there are situations that are competitive where we know accounts that we would not have pursued in the first place are actually active in looking at robotics. So naturally, as a result of having a robotic solution, we get involved in that process. And we have found that in those competitive situations, even where we didn't have the primary strength in the account, we're winning some of those decisions.

And so as a result, we are actually seeing conversions being a part of the placement that we see with ROSA. So it's kind of both. And then on top of that, what we're also finding, which I kind of referenced before, is once we do get a robotic system in place, even in an account that is one of our platinum accounts, one of our big users, there's always individual surgeons that are using competitive implants. And if they want to migrate to robotics, there's obviously a natural gravitational pull to do that, but they have to use our implants.

And so that was what I was referencing before. I was just in an account where five surgeons that were using competitive or are using competitive implants are now getting trained on robotics, want to begin using robotics, which is great because that will drive conversions, but it will also drive demand for another robotic system because that's going to get tapped out pretty quick. So again, it's a combination of those things. I also want to make sure that we recognize that there's multiple ways to drive revenue when we do place robotic system.

The obvious upfront capital purchase is clearly an opportunity for us. You get a mix benefit, kind of a share of wallet benefit because there is an increased price associated with the disposables you need to do a robotic procedure. And then you get that natural pull-through that I just referenced, where you get competitive conversions to be able to use robotic system. So again, it's all coming together.

I mean the fact is it is early. We're rapidly training and getting these things out there and building the commercial infrastructure to be able to support demand, but it feels good so far.


Our next question comes from Larry Biegelsen with Wells Fargo.

Larry Biegelsen -- Wells Fargo Securities -- Analyst

Just on the ROSA pipeline, just a question on that. Bryan, I heard you talk about hip coming soon. So could you give us an update on the hip, uni and revision knee or those 2020 approvals and if ROSA ONE Spine is still an early 2020 launch?

Bryan Hanson -- President and Chief Executive Officer

Yes. So I would just take a quick step back and just let you know that there's been a pretty significant shift of focus in the organization. We've done a very good job of rethinking how we deploy resources inside of research and development and commercial infrastructure, by the way. But we've really taken a hard look at the R&D pipeline, started to get more biased toward robotics and informatics and spent significantly more money.

Almost a mix shift that has occurred in those areas. It doesn't mean that we're not going to continue to do implants. But the fact is a good portion of that money is shifting toward ROSA, toward mini robotics, toward informatics, toward efficiency in doing the procedure. So that was a pretty significant innovation shift for the organization because we think it could bring real value to the patient and the customer.

So that was a big shift that occurred. As a result of that, we now have more in the pipeline in applications for ROSA and other areas. And so the next things that you are going to see from ROSA, we've been very transparent about this, a partial knee application, as well as a hip application. Those will likely come in 2020, but I don't want to give specifics.

You'll learn more about these at the AAOS meeting, but those are the next in line. Revision is something that we're clearly working on. We have an opportunity to be able to do this because we don't need a CT scan to be able to use the robotic system. It opens the door for our revision procedure, but that's a challenging application to provide.

It would be a big window because it is one of the most challenging procedures to do. So if you could have robotic assistance inside of that, it would be attractive. But I don't want to give a view on time line for that. So again, we're shifting dramatically our innovation pipeline to those very important elements of the ecosystem that are around the implant.

We don't lose focus on the implant, but we enhanced our capability to bring the implants to the market in a way that helps patients and customers more.


Our next question comes from Matt Taylor with UBS.

Matt Taylor -- UBS -- Analyst

So I just wanted to clarify one thing on this operating margin guidance. When you talk about the 30% in 2023, is that the full year number? And the reason I asked is because if we use the midpoint of this year, that does imply higher than that 50 to 70 bps beyond this year over that time frame. And I guess I was wondering if that is right. And what has to happen on the top line for you to achieve that?

Bryan Hanson -- President and Chief Executive Officer

I'd say it is interesting because we're talking about 30%, and 30% of our questioners have been [inaudible] but I'm sorry. Suky?

Suky Upadhyay -- Chief Financial Officer

Yes. So you're thinking about it correctly, Matt. It is 30% in-year in 2023. Again, as I said earlier in the call, we would not expect the cadence to be linear.

It could happen sooner. It could be more in the back end of that period, depending on top-line growth and our level of investment back into the business, and I'll come back into that. You're right. Relative to 2020, the midpoint would not suggest any significant margin expansion on an operating margin level.

And that is consistent with how we've talked about the year, where we could see some modest improvement in overall operating margin. However, again, coming back to if we see the right opportunities to invest for long-term growth -- near-term growth for that matter, we will make that decision. And the overall guidance range reflects that optionality, if you will, around margin expansion or investment. I will say, though, I've got confidence.

And we are early days, but the team is executing extremely well against these programs that we've launched. And I would say that we're going to see margin expansion as early as 2021. But again, I don't know that you can take a linear footprint from today to 2023 and March 2021 in that way, but we do expect to see some margin expansion into 2021.

Cole Lannum -- Senior Vice President, Investor Relations, and IRO

Matt, it probably is worth it to expand on that just to remind everyone again, we don't guide to midpoints. We guide to ranges, and that's exactly what Suky is talking about there. And I think that's an important thing to keep in mind as we think very carefully about what ranges to give.


Our next question comes from Rick Wise with Stifel.

Rick Wise

Some people won't miss Cole, Bryan. Maybe turning to some of the financial perspectives, maybe I missed sort of the operating cash flow guidance. But obviously, the balance sheet made significant improvement over the last 12 months. A year ago, it was almost four times levered.

Now you're roughly two times levered. Are you where you want or need to be? Just where are you aiming toward from here? And does this progress on the balance sheet and driving cash flow open the door in some way? Should we imagine the doors a little more open to increased growth-enhancing M&A in the year ahead?

Suky Upadhyay -- Chief Financial Officer

Yes. Thanks for the question, Rick. So first of all, on 2019, we ended the year at about $1.1 billion of free cash flow. As we move into 2020, we expect that number to be somewhere between $1.1 billion to $1.3 billion, again, 2020.

And that's inclusive of these restructuring charges that I talked about a bit relative to the restructuring programs that we're initiating. Again, we're saying operating costs or investments for that program will be somewhere between $350 million to $400 million over the time horizon to 2023. We think a little more than half of that will be in 2020. So again, our guidance for free cash flow in 2020, $1.1 billion to $1.3 billion.

And again, that is inclusive of these restructuring charges that we'll have to take. You're right. We've made good progress on the balance sheet in delevering. We got ourselves to a point where we are just under three on a net-debt-basis ending 2019.

And relative to our overall capital allocation priorities, we expect to continue to make progress on delevering the balance sheet into 2020. And again, that strong, durable, sticky cash flow generation is a big component of that. The second thing I'd say, though, is beyond the priority to continue to delever the balance sheet, we are in a better position now operationally, financially, I think strategically as well, where if we see attractive M&A targets that meet our strategic filters, our financial filters, but also maintain a strong capital structure and profile and investment grade, we may decide to invest capital into M&A in 2020 and beyond. So again, organically, we expect to continue to delever the balance sheet.

But again, we may also decide to deploy some capital toward M&A that meets all of our structures that I talked about.


Our next question comes from Robbie Marcus with JP Morgan.

Robbie Marcus -- J.P. Morgan -- Analyst

Just for me, Bryan, I was hoping you could give a little more color on the updates with the FDA inspection. What exactly did the new items entail? How should we think about the seriousness of them? And then is this something that can get resolved in 2020? Or do you expect a resolution more in 2021 time frame?

Bryan Hanson -- President and Chief Executive Officer

Yes. So first of all, I just want to say any time that we're talking about interaction with the FDA, quality, patient safety, any of those things, I just want to be very clear that we take quality of our products and patient safety as the most important thing we do as an organization. The mission of this company is to alleviate the pain of people in the world and make their quality of their life better. That absolutely means that our product needs to do what it's intended to do and keep them safe.

So that's the first thing that we look at, and we feel very confident we're in check there. The fact is it also shows, when we saw the FDA come in, that we've made real progress. I mean it's hard to describe because you have not been able to see the factory, but a lot of the same FDA investigators that were there actually were there from the very beginning. And even for me, when I walk in the factory, it just looks different.

It literally looks different. And the culture, the energy in the factory is different, and that was recognized by the FDA. The fact is we've got observations, though. We have eight observations in the factory.

I would tell you that all of the observations we feel are manageable. And we feel very confident that we can respond to the FDA in a way that's going to be satisfactory to them. The way I look at these things is we already have money earmarked to be able to continuously improve that factory. And the fact that the FDA has given us guidance in the way that they have on where we should focus, it's actually a good thing.

Because if we're going to spend money, I'd rather spend in an area that I know the FDA is concentrating on. So it's basically a road map for us to be able to do that. But I want to reiterate the fact that we feel very confident that we're going to be able to respond in a way the FDA is going to be satisfied, and we're going to be able to continue to move that factory forward. I think it is important to recognize, though, that this isn't going to be an issue that gets resolved in 2020.

It's just not. I mean the only way you move down a path to remove a warning letter is to have an audit where you have basically very little to no observations. And obviously, that didn't happen this go around. And from here, it is just up to the FDA.

And when they come back in, we're going to respond to the observations in a very timely manner, in a comprehensive way, keep that dialogue moving with the FDA. But ultimately, it is their decision when they come back in. And even when they come back in, if we get a stellar audit and we have very few to no observations, it still takes time to be able to remove a warning letter. So it is just a process that's involved.

At the end of the day, though, even with the warning letter in place, I just want to reiterate the fact that we can absolutely function effectively out of that factory. So I appreciate the question. We feel really good about the progress that we're making. Obviously, some work to do still, but we feel confident we can get there.


Our next question comes from Mike Matson with Needham & Company.

Mike Matson -- Needham and Company -- Analyst

I guess I just wanted to ask another ROSA question. So I did not really hear any commentary on the status of the spine and brain version of robot. So can you maybe talk about the launch plans there and whether or not you sold any in the fourth quarter?

Bryan Hanson -- President and Chief Executive Officer

Yes. Yes, I appreciate that. We have folks using the ROSA Spine system, but it is really just those that are developers. And so we are not in really a launch mode yet for that system.

But if I just take a step back and I think about the spine business overall, I think about it in a few different ways. We clearly have not been performing the way I would like, and we're not performing right now with predictability in that business. There are key areas that we need to concentrate on. The No.1 thing is we have to get the channel that we have decided on to be able to take advantage of the portfolio that we have.

The fact is we have the best cervical disc in the market. And we need to make sure that now we're taking advantage of the Mobi-C in the way that we should, now that we have stability in the channel. We have The Tether, which is an absolute pivotal change for those with scoliosis. It dramatically changes the care for that patient population, a very exciting technology, but the channel has got to take advantage of that.

And we have now gap fillers like the TrellOss titanium 3D-printed interbody. That was a major gap for us. We now have that 3D-printed interbody that we need to make sure that we are taking advantage of. And we have to launch ROSA, and that is got to happen in 2020.

It is not just ROSA, though. It is got to be ROSA in concert with our mini robotics platform and Walter because that provides a comprehensive solution for the surgeon when we talk about robotics, not just placing screws but also being that third or fourth arm for the surgeon and the procedure. All those things need to come together in a predictable way so that we can start to turn that business. So ROSA Spine is definitely a part of the equation, it's just not the whole equation and the intent is to launch that in 2020.


Our next question comes from Ryan Zimmerman with BTIG.

Ryan Zimmerman -- BTIG -- Analyst

Great. So just want to follow up, Bryan. I heard you loud and clear on the S.E.T. business.

And I just want to dig into the components of that between sports, extremities and trauma. Can you just talk about kind of where you're most focused of those three if we were to kind of parse that out a little bit more than kind of what we've seen thus far.

Bryan Hanson -- President and Chief Executive Officer

Yes. It's a great observation. I mean the fact is the S.E.T. businesses, although in aggregate, they do grow in that midsingle-digit growth area, they are not all created equal, obviously.

And the whole idea in our organization is to make sure we are disciplined and focused. So as a result of that discipline and focus, we need to make sure that we're picking the most attractive submarkets inside of S.E.T. And I can tell you it is kind of obvious when you look at it. Sports and extremities will be the areas that we focus most on.

And so you're going to see a lot of our attention not just in research and development but also from a commercial channel standpoint, training and education being focused in those areas. The fact is we already have a significant right to win, and we need to take advantage of that in upper extremities. I want to see us build more scale in lower extremities and absolutely become a market share leader there, and we have a lot of traction and opportunity for us in sports. So those are going to be the areas where you're going to see significant investment, significant focus.

Our operating mechanisms are being built around that, and that will be the area that we concentrate inside of S.E.T.

Ryan Zimmerman -- BTIG -- Analyst

Thanks for that.

Bryan Hanson -- President and Chief Executive Officer

Next question please, operator.


Next question comes from Josh Jennings with Cowen.

Josh Jennings -- Cowen and Company -- Analyst

Hey good morning. Thanks for taking the questions. I was hoping to just get an update on the sales force. I know there is different sales forces for different divisions.

But just from a high level, can you just share with us the attrition rates you're experiencing entering 2020 or exiting 2019 versus exiting 2018? And then I think you've talked historically about the compensation scheme being in place to drive the sales force coming on offense. Can you help us understand if there are any nuances to that compensation scheme and when that was put into effect? Thanks for taking the question.

Bryan Hanson -- President and Chief Executive Officer

I would tell you it is we have actually had zero regrettable turnover in the commercial organization. And I always look at it to say if you stuck with the organization through all the hell that occurred over the last number of years and you leave the organization now when the momentum comes, I probably don't want you in the organization anyway because you are not making rational decisions. But that's playing out. I said it kind of tongue in cheek in the past.

But the fact is we have had zero regrettable turnover in the commercial organization. It is a testament to the fact that people understand momentum is coming, that we have a market leadership position in large joints. We have potential to do the same thing in S.E.T. And we have new products that are coming that get the sales organization excited.

Again, I see that momentum. I feel it. I was in the Asia Pacific kickoff meeting. I felt significant energy there.

Same thing in Americas. I'll be in actually after this event, we will be heading to Spain for the European kickoff event. And I can tell you the energy is just there. So we're not seeing that turnover.

When you see momentum like this and you don't have a critical turnover, it gives you the opportunity to decide who stays in the organization and who doesn't. And that gives us an opportunity to upgrade talent as we go. That will be a major focus of this organization, always ensuring we have the best talent, developing the best talent and retaining the best talent.


Our next question comes from Pito Chickering with Deutsche Bank.

Pito Chickering -- Deutsche Bank -- Analyst

Cole, thanks for your help over the years. While still early in the ROSA launch, I'm curious what percent of ROSA Knee are being done cementless right now. I'm certain that you use that with knees and the robots. Are you starting to convert the non-ROSA Knee to cementless?

Bryan Hanson -- President and Chief Executive Officer

So yes. So the cementless opportunity is kind of bifurcated. We have an opportunity to be able to convert knees to cementless without ROSA. So we are certainly trying to do that and are doing that.

At the same time, when you look at the robotic application, you get such confidence in cuts that typically what you find is people are more willing to go to cementless as a result of having robotics in. So it is a combination of those two things. And you would naturally see in robotic cases a higher mix of cementless versus nonrobotic cases. But either way, we do not have a lot of robotic systems out there today.

And we're not slowing down in our pushing of the cementless option because we think it's a very good one. So it's both of those things, right? So we are going to go after conversions and get a mix benefit for those that are already using our implant with cementless. And we're absolutely going to take advantage of robotics to be able to drive cementless as well.


Our next question comes from Kristen Stewart with Barclays.

Kristen Stewart -- Barclays -- Analyst

Thanks for taking my questions. Cole, I guess you will be missed. I have a question just about the restructuring program in general. So if I look at the pre-tax savings that you're expecting to be generated, it looks like that contributes pretty much all of the operating margin expansion over the next several years.

And then the free cash flow I guess as well. I guess that's also eating into the cash flow, I guess, that you're expecting as well, the $1.1 billion to $1.3 billion that you're guiding to. How should we just think about the operating cash flow for the next couple of years, too? Because $1.1 billion to $1.3 billion seems kind of flattish relative to where you've been at for the last couple of years. So I'm just trying to understand what kind of the base business is doing absent this restructuring charge or charges and savings.

Suky Upadhyay -- Chief Financial Officer

Yes, sure. So you're right, Kristen. If you took the range that we discussed, $200 million to $300 million by 2023, and you dropped all that to margin, you could effectively get to 30%, right? Your math is right on. But I think it is important to understand that, that program is not just about margin expansion and through cost reduction and dropping that.

It really is more about creating a mix shift and providing us the ability and the confidence to invest against our highest priority opportunities to drive top line growth, right? So I would say the program is more about creating and leveraging that funding to drop top line versus just a sheer drop-down into operating profit. So we think it's actually going to be a combination of accelerating revenue growth from where we are today but also improving overall margins as we leverage our infrastructure and grow SG&A at a slow rate than top line. OK. So that's how we think about overall the margin profile between now and 2023, where we're seeing at least 30% operating margin.

Relative to free cash flow, again, we ended 2019 at just about $1.1 billion. We do expect to see an improvement into 2020. So our guidance, our guidance has that profile baked into the $1.1 billion to $1.3 billion. And again, that $1.1 billion to $1.3 billion is burdened by some of these restructuring costs that we said will be $350 million to $400 million over that three- to four-year period, again, more than half of that being in 2020.

So the underlying cash flow operationally within the business is, in fact, improving and improving at a really healthy clip into 2020. And again, as we think about what are our key metrics and financial priorities, revenue growth, margin expansion, free cash flow conversion, we do expect to see an increase and an improvement in overall free cash flow conversion into 2020. So hopefully, that gives you a little.

Kristen Stewart -- Barclays -- Analyst

Yes. Is that $1.1 billion to $1.3 billion, is that an adjusted cash flow? Or is that like a real cash flow number?

Suky Upadhyay -- Chief Financial Officer

No. That's straight cash flow. That's operating cash flow less property, plant and equipment and instruments.

Kristen Stewart -- Barclays -- Analyst

OK. I'll have another question online.

Cole Lannum -- Senior Vice President, Investor Relations, and IRO

Yes, let us do the last off-line because we're at the bottom of the hour. So we're going to wrap it right there. Thanks, everyone, for joining us today. Certainly appreciate it.

Keri and Barb and I will be around for the rest of the day to answer any questions you may have. There will be a replay of this call available on our website posted later on today. The best way to reach us is probably by email. So send us a note if you have any follow-up questions.

Have a great day and a great week, everyone. Goodbye.


[Operator signoff]

Duration: 64 minutes

Call participants:

Cole Lannum -- Senior Vice President, Investor Relations, and IRO

Bryan Hanson -- President and Chief Executive Officer

Suky Upadhyay -- Chief Financial Officer

Raj Denhoy -- Jefferies -- Analyst

Vijay Kumar -- Evercore ISI -- Analyst

Matt Miksic -- Credit Suisse -- Analyst

David Lewis -- Morgan Stanley -- Analyst

Bob Hopkins -- Bank of America Merrill Lynch -- Analyst

Richard Newitter -- SVB Leerink -- Analyst

Matthew O'Brien -- Piper Sandler -- Analyst

Larry Biegelsen -- Wells Fargo Securities -- Analyst

Matt Taylor -- UBS -- Analyst

Rick Wise

Robbie Marcus -- J.P. Morgan -- Analyst

Mike Matson -- Needham and Company -- Analyst

Ryan Zimmerman -- BTIG -- Analyst

Josh Jennings -- Cowen and Company -- Analyst

Pito Chickering -- Deutsche Bank -- Analyst

Kristen Stewart -- Barclays -- Analyst

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