Stryker (SYK) Q1 2020 Earnings Call Transcript

Stryker (SYK -0.62%)
Q1 2020 Earnings Call
Apr 30, 2020, 4:30 p.m. ET

Contents:

• Prepared Remarks
• Questions and Answers
• Call Participants

Prepared Remarks:

Operator

Welcome to the first-quarter 2020 Stryker earnings call. My name is Christine, and I'll be your operator for today's call. [Operator instructions] This conference is being recorded for replay purposes. Before we begin, I would like to remind you that the discussions during this conference will include forward-looking statements.

Factors that could cause actual results to differ materially are discussed in the company's most recent filings with the SEC. Also, the discussions will include certain non-GAAP financial measures. Reconciliations to the most directly comparable GAAP financial measures can be found in today's press release that is an exhibit to Stryker's current report on Form 8-K filed today with the SEC. I would now like to turn the call over to Mr.

Kevin Lobo, chairman and chief executive officer. You may proceed, sir.

Kevin Lobo -- Chairman and Chief Executive Officer

Welcome to Stryker's first-quarter earnings call. Joining me today are Glenn Boehnlein, Stryker's CFO; and Katherine Owen, VP of strategy and investor relations. On today's call, I will provide opening comments, followed by Katherine with some perspectives on our mix of deferrable and capital businesses. Glenn will then provide additional details regarding our quarter results and liquidity position before we open the call to Q&A.

As you know, Katherine will be shifting out of her role on June 1, so this will be her last Stryker earnings call. While this is not quite the finish she had in mind at the end of February, I did want to take a moment to express my gratitude for her outstanding work the past 13 years. She has been a great help to me and the management team of Stryker. Also if you include her time covering Stryker as a sell-side analyst, this will be her 97th Stryker earnings call.

She has seen a lot, but nothing quite like what we are going through right now. On today's call, we will review our first-quarter results and provide additional details regarding the impact of COVID-19 on our businesses in March and into the second quarter. I would also highlight many initiatives under way to ensure we maintain a strong cash position through stringent controls to manage through this unprecedented environment. For Q1, we achieved organic sales growth of 2.4%, reflecting strong momentum through the first two months of the quarter and into March, followed by a marked slowdown tied principally to a deferral in elective procedures.

We took a number of steps in March to aggressively limit travel to ensure the safety of our employees and customers, while ensuring our essential personnel were available to support healthcare workers around the world. These efforts, along with other cost controls, helped to mitigate some of the impact on earnings, from the slowdown in sales resulting in adjusted per share earnings of $1.84, a decline of 2% versus the prior year. The sales drop became more pronounced toward the end of March, and in the last week of the month, our company sales declined 30% versus the prior year. The biggest declines were in hips, knees, spine and endoscopy, offset by our other businesses.

By geography, Japan, Canada, and smaller countries in Europe and emerging markets performed well, while China was clearly the weakest. In Q2, we expect a recovery in China, but most other geographies will get worse, given the spread of the virus. For the month of April, our company sales will decline by 35% to 40% versus 2019. Looking at the remainder of the quarter, we are encouraged by the planned gradual resumption of elective surgeries in the U.S.

and abroad. Portfolio products are being impacted by COVID-19 in numerous ways. Clearly, we are seeing a deferral in elective procedures, particularly within our orthopedics and spine businesses. We fully expect, given the chronic and progressive nature of the conditions impacting these patients, that the vast majority of them will be treated in the coming months, recognizing that the exact timing of a broad resumption of elective procedures is too fluid to predict.

And as hospital needs to treat COVID-19 patients escalated sharply in March and into April, we saw a significant increase in the demand of products across our roughly $2 billion medical portfolio, which Katherine will discuss in more detail. In response, our manufacturing teams have been aggressively ramping capacity of much needed products while also ensuring we scale back other plants where demand has been negatively impacted. Overall, given our mix of businesses and the cost control initiatives under way, coupled with our strong balance sheet, we believe we are well positioned to manage through this slowdown. Given the fluid nature of the current situation, we are not providing Q2 or full-year guidance.

However, we expect to maintain the cost control efforts for most of 2020. We are also setting ourselves up to respond quickly as customer demands return. We are providing financial assistance to hold our sales forces in place and continue to invest in our pipeline of new products. We are proceeding with integration efforts regarding Wright Medical.

And given the impact of the virus on competitive hiring, we are expecting a minimal level of sales force attrition. As was publicly announced, Wright held its shareholder meeting on Friday, April 24, and the deal was approved. This reduced the tender of threshold from 95% to 80%. The tender offer was extended until June 30, which is customary as we continue to work through the closing conditions.

We expect to close around the end of Q3 2020. Please note, beyond this update, we have no new information to share with you regarding Wright Medical and we will not be taking any questions on this pending acquisition during today's call. Before I turn the call over to Katherine, I would like to take a moment to thank all of our employees around the globe for their commitment to ensuring the safety of their colleagues, their families and our customers. Our sales forces across our businesses who are essential to supporting doctors and caregivers have demonstrated unwavering commitment during this pandemic.

Our manufacturing teams have worked tirelessly to optimize the plant network and to ramp capacity where needed. And we have created rapid innovations in response to the pandemic. We will continue to support our employees and our customers as they work to meet the needs of the many patients that will need treatment. While our many year growth momentum has been temporarily derailed, the Stryker spirit is alive and well and we remain poised to capitalize as the situation improves.

And now over to Katherine.

Katherine Owen -- Vice President of Strategy and Investor Relations

Thanks, Kevin. My update today will focus on providing greater granularity around our mix of businesses that are particularly impacted by the COVID-19 virus. Overall, we estimate that 40% to 50% of our total global revenue include procedures that are considered elective, or more accurately, can be, in many cases, deferred for a period of time. This includes primarily our orthopedic businesses, including hips and knees, extremities as well as spine and Neurotech's ENT.

There are also procedures within our endoscopy portfolio that can be deferred, including some of the scoping procedures and sports medicine. Additionally, with many states and countries having implemented or recently come out of state-at-home orders, we have seen a slowdown in trauma. This can be attributed to fewer people out driving, a slowdown in construction and general decline in overall activity that traditionally drives trauma procedures. Unlike truly elective procedures, the patients deferring surgeries addressed by our products will not improve with time, rather, their underlying conditions generally continue to deteriorate.

So while the exact timing of the resumption of elective procedures to more normalized level is difficult to predict at this point in time, we do anticipate the vast majority of patients treated by our products will return. We also assume the resumption of procedures will continue to vary by country, state and municipality as they increasingly move past the peak impact of the virus. In contrast to the impact we are seeing from deferred surgeries, other parts of our portfolio are experiencing significantly heightened demand, as Kevin noted. This is most noteworthy for our medical business, which had sales of roughly $2.3 billion in 2019 or approximately 15% of total Stryker revenue and is comprised primarily of capital equipment.

It's important to recognize that our capital equipment portfolio, which represented about 25% of our total sales in 2019, includes both large capital and small capital at about 9% and 16%, respectively. Our large capital equipment offering includes Mako, beds and structures within medical, Endoscopy's communication portfolio and Spine's enabling technology, which includes Mobius and navigation. Turning to smaller capital equipment, this bucket includes medical emergency costs and defibrillators, Endoscopy's cameras, Instrument's power tools and waste management, and neuro-powered instruments that are reported within Neurotechnology. Of note, small capital is typically used in the OR and, as such, tracks more closely to growth in procedures.

Against that backdrop, we are seeing strong demand across essentially the entirety of the medical offering, including beds and stretchers, physio, emergency cost and Sage. We are also seeing meaningful increase in demand for Instruments flight personal protection offerings, which is included in their base product portfolio within surgical technologies. Across the board, we have ramped capacity to meet the current demand and what we anticipate will be ongoing demand as hospitals look to better position their capacity and stockpiles going forward. In late March, we developed the Stryker emergency release bed, which helps emergency responders manage patients efficiently during this critical time.

We started manufacturing this low-cost bed at the end of March, which broadens our medical offering beyond ICU and MedSurg beds to better meet customer needs. Other efforts to assist with responding to COVID-19 include the production of face shields for healthcare professionals and a new patient protective covering product, which attaches to our ambulant structures. Overall, while the slowdown in elective procedures has and will continue to impact our top line, we are able to leverage our unique product portfolio and offset part of that impact through the demand for our medical and instrument offered. We expect this trend will continue into Q2 with an ongoing gradual increase in elective procedures.

With that, I will now turn the call over to Glenn.

Glenn Boehnlein -- Chief Financial Officer

Thanks, Katherine. Your comments are as insightful as always. Today, I will focus my comments on our first-quarter financial results, related drivers and certain liquidity matters. Our detailed financial results have been provided in today's press release.

Our organic sales growth was 2.4% in the quarter. These results included U.S. growth of 2% and international growth of 3.3%, recognizing that approximately 75% of total sales, our business is significantly weighted in the U.S. As a reminder, this quarter included one additional selling day as compared to Q1 2019.

Pricing in the quarter was unfavorable 0.4% from the prior year quarter, while foreign currency had an unfavorable 0.9% impact on sales. During the quarter, our growth was significantly negatively impacted by reductions in elective surgeries that occurred in the last two weeks of March. This impact was most pronounced on our joint replacement procedures. In light of the current environment, we wanted to provide additional detail with respect to our businesses and geographies.

For the month of April, our U.S. Orthopedics and spine sales were down roughly 65%, while MedSurg and Neurotechnology posted declines of roughly 25%. Asia Pacific declined roughly 20%, while Europe was down nearly 55%. Our Latin American business was solid, delivering 20% growth for the month of April.

Our adjusted quarterly EPS of $1.84 represents a decline of 2.1% from Q1 2019. Our first quarter EPS was negatively impacted by $0.02 from foreign currency, which was slightly higher than our previous expectations, given currency fluctuations. Certain other factors resulted in disproportionately negative impacts on EPS, including the loss of higher-margin sales and a loss of leverage related to manufacturing and operational fixed costs. In addition, the lack of share buybacks in Q1 2020 resulted in a higher-than-average share count outstanding.

I will now provide some brief comments on segment sales. Orthopaedics had constant currency and organic decline of 1.2%. This included U.S. growth of 0.3%.

This growth included positive impacts from knees, trauma and extremities and Mako. Internationally, orthopedics had an organic decline of 4.3%, which primarily reflects an earlier downturn in certain geographies. MedSurg had constant currency growth of 7% and organic growth of 6.3%, which included a 5.6% increase in the U.S. Instruments had U.S.

organic sales growth of 10.8%, driven by gains in their surgical cutting blades, waste management, Steri-Shield, Surg account and smoke evacuation product lines. This performance was particularly impressive given the tough comps from Q1 2019 and further validates our decision to split the sales force into orthopedic instruments and surgical technologies. Endoscopy had a U.S. organic sales decline of 2.9%.

This reflects positive growth in its core video and general surgery products, offset by a slowdown in its communications and sports medicine businesses. The medical division had U.S. organic growth of 9.1%, reflecting strong demand across its bed and emergency care businesses, which accelerated meaningfully in the latter part of March, owing to demand tied to COVID-19. Internationally, MedSurg had organic sales growth of 9.1%, reflecting a slower impact to capital businesses in key geographies.

Neurotechnology and Spine had constant currency growth of 1.5% and an organic growth of 0.3%. Our U.S. Neurotech business posted constant currency growth of 0.2% and a 0.6% organic decline for the quarter. This reflects a slowdown in procedures in the latter half of March and some temporary supply disruptions during the quarter.

Internationally, Neurotechnology and Spine had organic growth of 9% and reflects balanced growth across most geographies and businesses. Now I will discuss operating metrics for the quarter. Our adjusted gross margin of 65.3% was unfavorable 50 basis points from the prior year quarter. Compared to the prior year, gross margin was unfavorably impacted by price, acquisitions, business mix and fixed cost absorption, the latter two of which were more pronounced during the second half of March.

Adjusted R&D spending was 6.4% of sales. Our adjusted SG&A was 34.8% of sales, which was 40 basis points unfavorable to the prior year quarter. Compared to the prior year, SG&A was unfavorably impacted by business mix, deleveraging of selling and marketing costs and foreign exchange, and this was partially offset by operating expense savings actions taken during March. In summary, for the quarter, our adjusted operating margin was 24% of sales.

Given the current environment, we enacted measures in March covering most of our discretionary spending. These included curtailments in hiring, travel, meetings, consultants as well as the idling of certain manufacturing lines and facilities, including furloughing the related workers. Subsequent to March, we also have enacted salary reductions impacting most of our leadership positions. Related to other income and expense, we saw a benefit in investment income, which was partially offset by increased interest expense related to the eurobond offering that was completed late last year.

Moving forward, though, given an unexpected decline in investment income earned on deposits and the impact of other rate changes, OI&E will increase by approximately $5 million to $8 million per quarter. This does not include the impact of any additional debt issuance for Wright Medical. Our first quarter had an adjusted effective tax rate of 14.3%. This included the benefit related to stock compensation expense and other discrete items.

Turning to cash flow and liquidity. We ended the first quarter with cash and marketable securities of $4 billion and generated approximately $591 million of cash from operations in the quarter. This is ahead of our internal targets and significantly more than in Q1 2019. This reflects increased earnings and a reduction in working capital, primarily driven by accounts receivable during the quarter.

As I noted in January, we did not repurchase any shares in Q1, nor do we plan to do so during the remainder of the year. In addition to the discretionary spending controls I previously outlined, we have also taken steps to conserve cash. Including reductions in planned capital expenditures and project spending, focusing on opportunities and accounts payable and slowing M&A activities. Considering our cash holdings and available credit lines, from a liquidity standpoint, we are well positioned.

We currently have available credit lines, none of which are drawn on at this time of approximately $3 billion. In addition, our investment-grade credit rating supports good access to the capital markets, and we would anticipate taking advantage of historically low rates to complete the funding for Wright Medical. In terms of future capital requirements, our quarterly dividend is approximately $215 million, and we have one $300 million bond maturity due in Q4. As it relates to guidance for Q2 and the full year, we reaffirm our previously announced decision to withdraw guidance, given the significance of uncertainties at this time.

We will continue to evaluate operating circumstances in the market environment for stability prior to reinstitution of guidance. And now, I will open up the call for Q&A.

Questions & Answers:

Operator

[Operator instructions] Your first call comes from the line of Bob Hopkins from Bank of America. You may proceed.

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

Thank you very much and thanks for taking the questions. Congrats to Katherine, 97 is a big number. Two quick things. One, first, Kevin, for you.

I'd love some help. And I think about your capital businesses. I'm curious, are there scenarios where you think the increase in demand that you're seeing lasts more than a few quarters? And then just generally, what could happen to growth on the other side of the demand surge?

Kevin Lobo -- Chairman and Chief Executive Officer

So Bob, I'll take that, the first part, and then I'll pass it to Katherine. As it relates to large capital, I think Katherine provided you the breakdown of our large capital in her prepared remarks. The beds and stretchers are the ones experiencing kind of a spike in demand. And at this point, it's really too difficult to ascertain whether that's pull forward or whether that's just extra demand because there is this need to build stockpiles.

There is this need to have certain number of beds and expansion of beds, primarily related to coronavirus, but it may not be something that's just pull forward, it may be additional demand. As it relates to the other large capital communications, Mako and those other components, that's going to start to slow down, as you probably would imagine. We're not seeing orders being canceled, but there is a bit of deferral going on. And that I would expect would continue to pick up in the future.

And maybe I'll turn it to Katherine to talk about small capital.

Katherine Owen -- Vice President of Strategy and Investor Relations

Yes, Bob, first of all, thank you. I would say, if you look at small capital, that's about 16% of the total, and it does tend to track with surgeries. So that business has not benefited anywhere near to the same degree as the medical, particularly beds and stretchers have. So I think you're going to see that be more in line with our elective procedures come back on.

And some of it is going to be tied to hospital liquidity. And keep in mind, through Flex Financial, we have a lot of ability here to help hospitals think about different constructs to finance those purchases. So it's very different from the Great Recession in terms of how medical business is being impacted. But I do think there's going to be continued uncertainty around the pull forward because we just don't have a strong sense yet what the new norm is going to look like for stockpiling.

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

And I guess just one quick follow-up, sort of another big picture question. Kevin, a few of the other medical device CEOs have offered up that they think growth could return by the fourth quarter. And I'm just curious, from what you're seeing in the world and in terms of what you're seeing from your customers, do you share that optimism? Or are you a little bit more cautious? Thank you.

Kevin Lobo -- Chairman and Chief Executive Officer

Well, thanks, Bob. As you can imagine, we've run a lot of scenarios, and I don't have a crystal ball, but certainly, that is a scenario that we think could very well happen. The pent-up demand is there. I think the recovery will probably come in waves.

So you have a number of employees that are furloughed that would love to get their procedures done now while they have healthcare coverage, worried about what could happen in the future. That could be a first wave of resumption of procedures. And then you also have people who have taken time off and that may not be able to take time off later, so that could cause a slight dip and then a resumption again. But it really is going to relate to how the overall economy recovers and how the virus evolves in the future.

But that certainly is a scenario that we believe could happen. But again, this is unchartered water. So we'll see.

Operator

Your next call comes from the line of David Lewis from Morgan Stanley.

David Lewis -- Morgan Stanley -- Analyst

I'm going to echo Bob's comments, Katherine. Congratulations. Just a couple of quick questions for me. I wanted to follow up a little bit on maybe a different way of focusing on Bob's question.

But there's a view, Kevin, right now that among some of your peers, economic exposure to recon is somehow different, so first, there's other device procedures that are more or less deferrable, orthopedics is sort of more deferrable. What are your thoughts around the economic sensitivity of hips and knees be? It's sort of the perception that they are very economically sensitive but the data is not exactly clear initially into a notion that people think ortho would recover after other types of medical device implantable procedures. What's your view on that economic exposure and your recovery relative to other med tech?

Kevin Lobo -- Chairman and Chief Executive Officer

Well, David, I mean, obviously, this is uncharted waters, as I mentioned at the end of my answer to Bob's question. But what I would say is the hospitals are very motivated to do our procedures. If you think about orthopedics and spine procedures, they are moneymakers for hospitals. And the hospitals who are treating coronavirus patients now are bleeding in their P&LS.

So there's a financial motivation. Also, patients certainly that are suffering would like to get those procedures done. So I'm not in some of the other spaces of other elective procedures, so it's hard for me to do a compare and contrast. But the hospital CEOs and the surgeons that I've spoken to are all absolutely gearing up to start bringing back their patients.

And the surveys they've done with patients have suggested that patients are very comfortable coming back. As soon as the hospitals say it's going to be safe for them, I think those patients will be coming back. So I don't believe that there's something unique about orthopedic surgery that would cause that to be pushed to the back of the line. On the contrary, given its economic impact to the hospitals, I think it could be moved earlier in the chain.

David Lewis -- Morgan Stanley -- Analyst

OK. Very helpful. And then just a related question. Just Glenn gave us some numbers on the percent decline in April procedures.

So a couple of questions there were just have you seen in recent days or a rolling seven-day average, a recovery or any kind of bounce off the trough for your orthopedic procedures? And there's been a lot of discussion around inpatient versus outpatient. Have you seen a difference in terms of how procedures are recovering if they are in inpatient versus outpatient? Is there an opportunity to use this particular pandemic as a way of pushing more procedures to the outpatient market?

Glenn Boehnlein -- Chief Financial Officer

Yes, David, there's a couple of questions in that. I think the first one, the percentages that I gave you are absolutely up to date. And so I don't have any sort of further data or information that would support a bifurcation of that. In terms of looking at what's going to outpatient or what's inpatient, I think it's still too early and it's still dynamic, and it's evolving in the moment.

So it's something that we obviously are watching very closely. And as soon as we have data or monitoring on it, we would provide that. But I'll let Katherine comment on that as well.

Katherine Owen -- Vice President of Strategy and Investor Relations

Yes. I just would follow-up, David. Just keep in mind, the shift to recon procedures in the ASC setting is already under way. This probably continues us down that path, but there's only so much capacity.

There are about 300 ASCs in the U.S. that are doing hip and knee procedures. They are essentially running at full capacity. Now they may be able to do more by staying later on working weekends.

But that is really dwarfed by the number of hospitals in the U.S., which is about 5,000. So I think you're going to see the shift continue, but I wouldn't expect some massive climate change in the trend because the capacity just isn't there to absorb it.

Operator

Your next call comes from the line of Vijay Kumar from Evercore ISI. Please proceed.

Vijay Kumar -- Evercore ISI -- Analyst

Hey guys. Thanks for taking my question. Maybe one on the robotics side. I know it falls into the large capital bucket.

Is there a view that either hospitals see this as a differentiated investment as a way of differentiating themselves from peers. So when we think about in the post-COVID world, that demand should normalize for something like Mako? Or just maybe give us some color on how we should be thinking of what Mako, because there is a view of that as systems are capacity constrained, maybe utilization of robotics might lag a little bit here.

Kevin Lobo -- Chairman and Chief Executive Officer

Yes. Thanks for the question. I would say that those surgeons that are believers in Mako or believers in robotics will resume their normal amount of work. We had terrific momentum.

You can even see if you look at the line of other Orthopedics, it performed very well in the quarter. We did see a bit of a slowdown in some of the Mako orders being delayed a little bit. So liquidity of the hospitals is important when you're outlaying large amounts of money. But we see tremendous signs of continued interest.

No order is being canceled, just being delayed a little bit until elective surgeries resumes. And yes, hospitals do see it as a differentiator, and we continue to be very bullish about the prospects of Mako. Underscoring what Katherine said earlier about Flex Financial, I think that's something that we're going to use even more probably as ASCs want to acquire Makos, and they don't typically have the same size of capital budgets, but we have a number of different vehicles to help them finance their capital. And so we do expect to Mako to absolutely resume the kind of trajectory we're on once the elective surgery comes back in force.

Vijay Kumar -- Evercore ISI -- Analyst

That's helpful, Kevin. And maybe one for Glenn. On the cost structure, fixed versus variable, how should we think about decremental margins here as you think about the next, call it, three to 12 months?

Thank you.

Glenn Boehnlein -- Chief Financial Officer

Yes. At this point, just given sort of the fluidity of the situation and looking forward, I'm not sure that I can guide you to an exact sort of margin number. I will say that to the extent expenses are discretionary, what I've mentioned, travel meetings, consulting and many other things, we have curtailed those or discontinued those. We discontinued most of our hiring, and we furloughed manufacturing employees that are at facilities where we've slowed down or stopped certain lines.

It's really difficult to sort of predict our exact operating state. I do think some of those expenses, obviously, will come back as we ramp back up. But at this point in time, as I think about our future cost structure, I do anticipate that many of these things will be impacted and we'll feel the impact from them throughout the remainder of this year and, frankly, on into 2021.

Operator

Your next call comes from the line of Matt Miksic from Credit Suisse. You may proceed.

Matt Miksic -- Credit Suisse -- Analyst

Hi. Thanks for taking the questions. Just one follow-up, if I could, on ASC for Katherine, your comments on the number of orthopedic-oriented sort of ASCs out there. Could you talk a little bit about the potential impact on spine? And then I had one follow-up.

Kevin Lobo -- Chairman and Chief Executive Officer

Yes. Sure. I can take the first part of that. OK.

Sorry, Katherine. I'll start that. So spine procedures are done in the ASCs, but they tend to be the more basic procedures like ACDS. So it's not an enormous part of the overall spine market, and we think we're well positioned there to be able to deliver the products need for those procedures.

Sorry, Katherine, go ahead.

Katherine Owen -- Vice President of Strategy and Investor Relations

No, nothing additional. Just to say, it's probably low single digits, the percent of spine procedures that are done in the ASC setting at this time.

Matt Miksic -- Credit Suisse -- Analyst

Got it. OK. And then on just some of the point about the bulk of the lift here in terms of returning to elective orthopedic procedures, sounds like from your description, needs to happen in acute care centers. What are the next steps that you see happening there? What are the constraints, I guess? States are just starting to open up.

Is it the middle of May? Is it some percentage of utilization that we start to see? What would be the things that you expect to see over the next several weeks to help us understand if that's happening and to what degree?

Katherine Owen -- Vice President of Strategy and Investor Relations

I think it's going to be very gradual. We're seeing states, and not just in the U.S., overseas, they're moving slowly, and it really just depends where they are in meeting guidelines, where they are in peak cases. So we don't have a perfect formula to tell you what it's going to look like. It just seems to be pointing in the direction, and this is uncharted territory, but pointing in the direction that we're going to continue to see more and more states resume elective procedures.

Those patients need to be treated. As Kevin indicated, it's a profitable procedure for hospitals. And so I think it's just going to be gradual. So we're probably in a better position a month from now than we are today, but it's also very much a wait and see as hospitals get increasingly comfortable and start to recognize the new normal of how they deal with COVID patients while also recognizing they have to treat the broader spectrum of patients.

Kevin Lobo -- Chairman and Chief Executive Officer

Yes. The only thing I'd add to that comment is a lot of hospitals are actually gearing up to be able to work extra hours even on weekends. They won't do that day one. Obviously, they're going to gradually start to bring patients back, but that's something that they're planning for in the back half of the year.

And so I do expect, as I mentioned before, seeing this recovery come back in waves is pretty likely.

Operator

Your next call comes from the line of Larry Biegelsen from Wells Fargo. You may proceed.

Larry Biegelsen -- Wells Fargo Securities -- Analyst

Thanks guys. Thanks for taking the questions. One product question and one kind of big picture question. Just on the April trend of negative 25%, I think, for Neurotechnology and Spine, did that apply to your neurovascular business as well? Or has that been more resilient? And I had one follow-up.

Kevin Lobo -- Chairman and Chief Executive Officer

Yes, Hi Larry. Yes, that did include our neurovascular business as well in that statistic.

Larry Biegelsen -- Wells Fargo Securities -- Analyst

Got it. And Kevin, just taking a step back, what do you think the long-term implications are of coronavirus for med tech? And how are you positioning Stryker for success in a post coronavirus world?

Kevin Lobo -- Chairman and Chief Executive Officer

No, thanks. That's a big question. I would tell you that I think we are very well-positioned given the diversification of our portfolio. Obviously, elective surgeries are very important to us, but we're not only an elective surgery company.

And the fact that MedSurg is the largest of our three segments certainly helps protect us and insulate us from the full effect. I think that diversification will serve us well, and we believe still in our strategy. And this is not going to cause a change in our strategy of category leadership and leading positions in all the segments we choose to play in. It's not going to take us off our approach to M&A.

We will emerge from this, and we believe the fact that we've stayed and conserved a fairly conservative balance sheet has really helped us. And even with the upcoming Wright Medical acquisition, we have a very good and strong financial position. Things will change. There will be a lot less travel.

I could tell you that we've learned a lot about technology. The way we're engaging with customers through this has been amazing for me to watch, surgeon engagement, hospital engagement. And even our employees, we tend to be a high-touch culture and we're learning that technologies, you can do a lot of really amazing education things with technology. So that, I think, will become a more permanent thing.

And our R&D teams are learning how to work very, very effectively, including surgeon collaborations virtually. So those are the things that will be more, I think, more permanent. The trend to ASCs will only accelerate. But as Katherine mentioned, a long way to go still.

But that pace will increase. Those are probably the two things I would point out to. But other than that, I think we're just going to be getting back to the regular offense that we had before.

Operator

Your next call comes from the line of Pito Chickering from Deutsche Bank. You may proceed.

Pito Chickering -- Deutsche Bank -- Analyst

Good afternoon guys. Thanks for taking my questions. I want to echo thanks to Katherine for lots of your help over the years. First question is, as several states are moving to allow surgeries to start happening again, what is your sales force in those states telling you about what the doctors are planning? And how does OR block schedules look in those states?

Katherine Owen -- Vice President of Strategy and Investor Relations

Thanks, Pito. I don't have any definitive data because it really does vary. You have hospitals, even in New York, where we know they're gearing up to resume procedures, elective procedures, hip and knees, in particular, in May. And I think it's really going to depend on the type of hospital or teaching institution or where they're located geographically.

So they may be doing more procedures over the weekends, more procedures in the evening. I think they are all going to be highly motivated. We do know that their waitlist of patients is pretty high. We are hearing that the patients -- I know there's some concerns.

Will they be willing to go back to hospitals, what we are hearing when we talk to customers, their waitlist remain healthy and patients are listening to their doctors. They listen to them when they said, don't have the surgery right now. And when they tell them it's safe to come back in and they realize they're not going to be going in to get their hip and need done through the emergency room, where their concerns are much greater, they're comfortable with it. But there's no perfect model to say this is how they're going to deal with it.

I think there's going to be flexibility and a number of different methods that take place to address the backlog of these patients that need to be treated.

Pito Chickering -- Deutsche Bank -- Analyst

Great. And then for neuro, like you mentioned that there are some supply disruptions that you saw for neuro supply. Can you look at that a little more and talk about which other facilities you idled and like how are your inventory levels for these products?

Kevin Lobo -- Chairman and Chief Executive Officer

Yes, sure. We had, as you probably heard, an earthquake in Salt Lake City, which is one of our manufacturing facilities for neurovascular. That caused a slight disruption in that business. And then we also had a bit of supply challenges with the neuro powered instruments portfolio.

And those, again, are temporary nature. This happens to us from time to time over the years. You hear this. In one quarter, we might have a slight disruption in supply.

And so those are the two things that hit the Neurotechnology business, both of which are largely resolved or will be resolved certainly by the time we get to Q3, Q4.

Operator

Your next call comes from the line of Kaila Krum from SunTrust. You may proceed.

Kaila Krum -- SunTrust Robinson Humphrey -- Analyst

Thanks guys for taking our questions. So you mentioned that you have made several cost-cutting adjustments. So my question is, if demand does return sort of fairly quickly in the second part of this year, are you comfortable that you have the infrastructure, supply and manufacturing employees in place to support that demand?

Kevin Lobo -- Chairman and Chief Executive Officer

Yes. Thanks, Kaila. It's one of the things that literally we are meeting almost every other day on in terms of how do we need to position ourselves to ramp back up and getting a good feel for what products will be in demand and where are we from an inventory standpoint with those products. And also, how are we preparing for our employees to come back to work so that we can meet that demand.

So I do feel like we are positioning ourselves very well, and we have a pretty good understanding of where we think demand will peak, and we are doing all we can to be ready for that to happen.

Kaila Krum -- SunTrust Robinson Humphrey -- Analyst

OK. That's helpful. And then you guys mentioned you're slowing M&A activity. Does that effectively mean we shouldn't expect any M&A activity outside of Wright for the rest of the year? Or what would be sort of a catalyst to push you guys to be more sort of opportunistic on M&A in this environment?

Kevin Lobo -- Chairman and Chief Executive Officer

Yes. And you mentioned Wright, we actually have the biggest M&A going on right now that we've ever had ever. So that's one thing that we obviously are focused on. I guess I would say that business development remains sort of an ongoing part of our long-term strategy.

And obviously, we'll balance potential opportunities with our liquidity position and where we want to be even next year and the following year on liquidity. But I could see that we would get back to smaller tuck-in acquisitions. We have slowed it. We have paused it.

We have not turned it off. We're keeping close to the market just to understand. But I think, in some ways, it will allow us to have more time over target and be smarter about where we are choosing to execute on M&A opportunities.

Operator

Your next call comes from the line of Robbie Marcus from JP Morgan. You may proceed.

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

Great. Thanks for taking the question. I wanted to ask about MedSurg. You gave some great clarity into the areas that are benefiting.

And Kevin, I think you said it really well, you don't have a crystal ball, you don't know what's going to happen. But maybe in the two scenarios, one where there is a second wave, one where there is not, is this a business that you think saw stockpiling or acceleration of purchases here? Or do you think there's still a lot more to come through the rest of the year? Should we see another wave of infections?

Kevin Lobo -- Chairman and Chief Executive Officer

Yes. I think the demand in some of our categories, we're selling everything we can make right now. So I would say we're a long way from having filled up any stockpiles. So I think if this coronavirus continues at an accelerated pace or if there's a second wave, I would expect a commensurate increase in the sales of those products, be it the flight protection, system and instruments or the majority of the medical portfolio.

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

Great. And maybe on the financial side, how should we be thinking about free cash flow this year relative to earnings? Are you going to be building inventory here? Anything that we should pay attention to that would change the conversion rate materially from net income to free cash flow?

Kevin Lobo -- Chairman and Chief Executive Officer

Yes. I think, Robbie, the single biggest thing we're going to feel in the coming quarters related to free cash flow is just going to be reduced earnings. And frankly, if there's less sale, there's less accounts receivable to collect. And so that will be the single biggest impact, I think, that we'll feel.

With manufacturing slowed and certain manufacturing lines idled, we're mindful of not building inventories and where we do think that we might have to build inventories. We are very selective in terms of how we think that will come back. So I really think, given the uncertainties that we will be facing, we're making very prudent decisions relative to cash conservation.

Operator

Your next call comes from the line of Rick Wise from Stifel. You may proceed.

Rick Wise -- Stifel Financial Corp. -- Analyst

Hi Kevin and Rick. Congratulations, Katherine. We'll miss you. First, Kevin, maybe you could expand on your comments on the international business generally.

You highlighted, obviously, China was the weakest in the first quarter internationally. And you gave us the April down 35% to 40%. I think that was a worldwide. Now I wasn't sure if that was worldwide or U.S.

But regardless, are you seeing any signs of recovery in some of the weakest international markets? If yes, maybe you could just give us a little additional color about how you expect those weaker international areas to recover and whether that informs your thinking at all about the U.S.?

Kevin Lobo -- Chairman and Chief Executive Officer

Yes. Thanks, Rick. What I would say is, certainly, China was the most negative in the first quarter. The 35% to 40% number I gave was a global number.

So that's what April is finishing, but I don't have the exact number because, is it the last day? We haven't closed a month, but it will be in that 35% to 40% range. What we saw in the first quarter, certainly, China was very negative. That is recovering. I think they're back to roughly 60% to 70% of where they normally were prior to the virus.

And it's sort of gradually improving. So China is getting healthier. Japan, we had a terrific first quarter in Japan, and I think that will get marginally worse in the second quarter. But they've done a very good job of managing it.

Same thing with South Korea. We had a very good first quarter, and we're not seeing South Korea slow down. The big wildcard in the international market is Europe. And even Australia, to some degree, where Australia had initially said that they were going to cancel all elective surgeries for the entire quarter.

And now two weeks later, 25% of the procedures are now back and being scheduled. So that's how fluid it is. Just in two weeks, they went from nothing for the whole quarter to back to 25%. So all this to say, it's going to be difficult to predict what happens in the U.K., what's going to happen in Germany.

And so Europe is the wildcard area. I think it's certainly going to be worse than it was in the first quarter. And how much worse, it's hard to say right now. I think for us, Europe was something in the 55% down range in April.

And I think that's likely going to continue throughout this quarter. It should get better toward the end of the quarter. But again, it's hard to predict.

Rick Wise -- Stifel Financial Corp. -- Analyst

And just as a follow-up on the knee business. Maybe you could just again give us a little more color and your high-level thinking. I know we don't have all the numbers yet, more to come, but your U.S. knee business held up relatively well.

I mean, honestly. And maybe talk about some of the initiatives that you're pursuing to sustain what would have seemed to be likely outperformance in the first quarter and even under challenging conditions in the second quarter. Some of the detailed initiatives that you're undertaking with surgeons using Mako. Just any additional commentary would be very welcome.

Thank you so much.

Kevin Lobo -- Chairman and Chief Executive Officer

OK. Thanks, Rick. I'll start. Maybe Katherine can add to it.

What I would say is there's nothing magical about our first quarter knee. It's the continuation of the trend of the last four years or five years where we've been consistently taking market share. I'm very proud of the work that our team has done on Mako as well as cementless. Both of which, as you saw over the last two or three years, have had steep increases in their adoption rates.

And that continued in the first quarter. I could tell you, at the end of February, we were feeling really, really good about our knee number. And then just like everybody else, there was a falloff that occurred about midway through March. The fact that it still ended the quarter in a positive territory for U.S.

knees is pretty incredible. We're really pleased with that. And so again, it's just continued amazing momentum with Mako and with cementless, which are both huge portions of the knee sales that we have. And surgeons are very, very loyal to both Mako and to cementless based on the great outcomes they're getting with their patients.

Operator

Your next call comes from the line of Matt O'Brien from Piper Sandler. You may proceed.

Patrick Bartoski -- Piper Sandler -- Analyst

Good afternoon. This is Patrick on for Matt. I'd like to start on your spine business. In 2019, you made a lot of good progress integrating K2M and getting that business up and running.

So prior to the COVID-19 disruptions, I'd love to hear more color as to the dynamics that was happening within that business in January and February.

Kevin Lobo -- Chairman and Chief Executive Officer

Thank you. Yes, I am very pleased with how our spine business is progressing. Certainly, in the international markets, you see very good numbers. We even posted pretty good numbers in the first quarter.

That's a continuation of what we saw last year. In the U.S., we started to see the improvement really in the November, sort of December time frame. That was continuing into January and February, and a number of new products were launched in the first quarter. Unfortunately, that got derailed, just like everybody else's spine business, around the middle of March, and we're not immune from that.

But I would say I feel as good as I felt about our spine business since the acquisition of K2M. Every day, we sort of continue to build momentum. And even the Mobius business, which we acquired toward the end of last year, is seeing tremendous demand as some hospitals are actually using it to do x-rays of the chest for the coronavirus. So we're actually trying to ramp our capacity of Mobius, which is, as you know, a mobile CT scan and really the only one in the market that's mobile, and they're using it for coronavirus.

So we're actually ramping that capacity. So overall, the outlook for the future for spine is positive, as positive as we felt kind of entering the year.

Patrick Bartoski -- Piper Sandler -- Analyst

Great. That's really helpful color. And I had a quick follow-up, if you don't mind. I'd like to talk about clinical trials.

We're hearing from other med tech peers that they're seeing anywhere from six months of delays on some of their trials. I know Stryker has had a great track record of new product introductions and has a lot of clinical trial catalysts. So is there anything material we need to think about from a clinical trial or new product perspective? And is six months the right way to think about some delays due to coronavirus?

Kevin Lobo -- Chairman and Chief Executive Officer

Thank you. Yes. We're actually pretty fortunate that we don't have any major launches upcoming that are contingent to clinical trials. It's always a timing issue.

If you just look at where our neurovascular or our PMA products portfolios are in their life cycle, we really don't have anything major pending. I think six months is a good way to look at it. We do have some minor delays in approvals. So some products, just getting them approved.

If you think about our aspiration products in neurovascular, getting them approved in Europe. They are approved in the U.S. and we had a limited launch in the first quarter, which is proving very successful, but those aren't yet approved in Europe. So Europe is just overwhelmed with UMDR and other product approval site.

That's more probably in the three-month time frame than six-month. But what's affecting us, at least in the short term, is more around getting products approved outside of clinical trials, and there really isn't anything major that's holding us back from a clinical trial standpoint.

Operator

Your next call comes from the line of Kristen Stewart from Barclays. You may proceed.

Kristen Stewart -- Barclays Capital, Inc. -- Analyst

Hi thanks everyone for taking my question. I'll echo the commentary on Katherine. It's been really great, knowing you both from the sell-side perspective and on the company perspective. You've done a great job just in your role, both on the IR and on the business development front.

So I guess, one, I just wanted to go back to the question on this Medsurg and Neurotech down 25 because I would imagine a lot of different moving parts within those two kind of categories. Is there any way just to kind of give us a little bit more detail there to just kind of help us understand some of the puts and takes out of imagine on the medical side, you're seeing quite a bit of a benefit probably within the neurovascular. As Larry was kind of saying, it's probably one that's pretty defensive. And then maybe within some other areas within MedSurg, you're probably seeing a little bit more of a downtick just as some of that's more kind of capital.

So any way to just kind of frame some of those moving parts or quantify some of the benefit that you're seeing from COVID? That would be really helpful. And I have one follow-up.

Glenn Boehnlein -- Chief Financial Officer

OK. Yes. I think why you did a pretty good summary. But I guess what I would say is, as you look at the number, you're right, medical is showing fairly strong positive numbers.

I would say, across the rest of the portfolio, it was negative and it ranged anywhere, negative from 20% to as much as maybe 40% or 50%, depending on the business. Capital is a little lumpy, too. So some of the capital businesses were able to deliver and make deliveries during the month of April. And so they saw a little more favorability.

I do think that as we move into May, we'll continue to see some of those downturns in that similar trend that we saw in April. And it might be a little more pronounced as some of the capital businesses trail off.

Kristen Stewart -- Barclays Capital, Inc. -- Analyst

Any way to quantify medical? And then my follow-up would just be on gross margins, how should we just think about as some of the plants are seeing lower throughput and you have some sitting idle, are you going to be expensing some of those the manufacturing absorption costs as period costs? Or will some of that be capitalized into inventory? And will that be a drag that will just kind of sit there and be recognized through cost of goods sold in future periods? Thanks.

Glenn Boehnlein -- Chief Financial Officer

OK. Sure. Yes. On the medical, I mean, let's leave it that it's positive.

And that in the short term, we do sort of see that demand will still be heavy. Moving out, I think medical will be impacted, especially their beds and stretchers business. To the extent that, that's large capital and there could be liquidity issues with hospitals. On the gross margin question, you're absolutely right, the single biggest thing that will probably be a big impact in Q2 will be fixed cost absorption.

And right now, we don't see that we would be capitalizing that in the balance sheet. We would only be able to capitalize to the extent we actually produce the inventory. And so you'll see that flow through the P&L, and that will be more significant and more pronounced than it certainly was in Q1.

Operator

Your next question comes from the line of Raj Denhoy from Jefferies. You may proceed.

Raj Denhoy -- Jefferies -- Analyst

Hi thanks. I just really had one question, just a follow-up to the earlier question on the ASC or the ambulatory surgery center side. I appreciate that the capacity there is still somewhat limited, but I think one of the trends people are hearing about with COVID is that perhaps more volume will shift there over time. And so one of the things I was curious about is if you could maybe just ground us in kind of what the pricing environment is, the profitability environment is for you guys when you sell joint into that channel.

Kevin Lobo -- Chairman and Chief Executive Officer

Yes, thanks. Right now, the profit profile is very similar to what we see in the hospitals. Most ASCs are affiliated with hospitals. Hospitals have a partial ownership, of course, in the ASC.

And they tend to buy the implants on the same price contract that we have for their hospitals. So for us, the profit profile is very similar to what we see in the hospital. Keep in mind that the biggest savings that they have, they make more money in procedures in the ASC. The surgeon usually has a part ownership, so they're very motivated.

But the EBITDA of ASCs is higher than hospital, and the big reason is the savings and the facility costs. That's really why they make more money in the procedure. They don't need to drive down our implant prices to be able to drive that higher degree of profitability. Obviously, they are different kind of facilities.

You have to make life easy for them in terms of buying. We've created an entire offense around the ASC that I'm really excited about. If you asked me three or four, five years ago, I was kind of concerned about ASCs, not sure how it would be for Stryker's business. Now I'm actually believing that it's going to be a very good thing for us because we have the booms, the lights, the operating tables, the Makos, all the capital power tools, Neptune waste management, everything that they need for their surgery, we can help them, and we have the disposables and the implants.

And wrapping that up in a financing solution gives us a really tremendous advantage as more and more procedures go to the ASCs. So really, as of this point, we haven't seen much in the way of severe price pressure.

Raj Denhoy -- Jefferies -- Analyst

It's helpful. Thank you.

Operator

Your next call comes from the line of Richard Newitter from SVB Silicon Valley. You may proceed.

Richard Newitter -- SVB Leerink -- Analyst

Hi. Thanks for taking my questions. I wanted to ask any protocol changes that are happening or that you're hearing about from your customers with respect to reps and the way you deliver your implant businesses to the physicians being allowed in the ORs and the hospital. How is that going to change, if at all? And then I have a follow-up.

Thank you.

Kevin Lobo -- Chairman and Chief Executive Officer

Yes. So far, we haven't really seen any change. As you know, today, many of our reps are in the hospitals, our trauma reps, our neurovascular reps. So today, and even if you think about revision surgery or oncology surgeon within joint replacement, our reps are in the operating room today, arm and arm with the medical staff doing those procedures.

And so we have heard that there could be some testing required for our sales reps in some places. It's very, very early, making sure they have the right PPE, that they're equipped correctly to make sure that they're not transmitting the coronavirus. But other than that, we haven't heard, really, any discussion about a blocking access or limiting access. Again, it's pretty early.

Hospitals are preparing their plans. But mostly what we've heard so far is PPE and are they trained. And do they know how to put the proper PPE on and potentially having some degree of testing. The same expectation that they would have for their own staff who would be attending those surgeries.

Richard Newitter -- SVB Leerink -- Analyst

Great. And then just on the big ticket capital items, I was just curious, you said no one's really canceling as right now is more a postponement. I'm curious, what are they saying that they're going to need to see as you have the conversations? What do they need to see to potentially resume their decision-making process? And are you getting the sense these are six- to 12-month delays or truly just indefinite?

Kevin Lobo -- Chairman and Chief Executive Officer

Yes. I think they're temporary delays. I don't think they're indefinite. Look, there's a lot of uncertainty right now.

They don't know if they're going to get a bolus of new patients for coronavirus. And the hospitals that are, let's say, New Jersey, New York, those that are at the epicenter or even Detroit, they lose a lot of money while their hospitals are not having elective surgery and while they're treating coronavirus patients. So obviously, the first $30 billion has been doled out to the hospitals. The next $30 billion is coming.

The general allocation method didn't provide extra money to those patients, those hospitals that were treating coronavirus patients. $10 billion of the next $30 billion is going to be disproportionately pushed to those hospitals. So waiting to receive the money and seeing how much each hospital get is very important to their overall liquidity profile. And then as they resume elective surgeries, as I mentioned earlier, that is really going to help shore up their financial situation.

And so that's what they're waiting for. If the governors declare delays in the elective surgery ramp, their financial situation deteriorates, just like ours does. And so that uncertainty has to be sort of lifted. And even if they're not back to 100%, if they're back doing elective procedures and they have some line of sight to financial stability, then they'll be inclined to start to make those purchases because they do want to differentiate themselves.

They do want to deliver great service to their customers. And so it's just the uncertainty around their financial stability and their liquidity, which is -- which they're waiting to resolve.

Operator

Your next call comes from the line of Joanne Wuensch from Citibank. You may proceed.

Joanne Wuensch -- Citi -- Analyst

Thank you very much for taking the question and Katherine, congratulations. I have two questions that are related. How do you think about the recovery in the procedures that have been postponed? Another management team thought that maybe 0% to 15% would come back in the back half of this year. Can you comment on that? And then big picture in your portfolio, which ones of your procedures come back first? Thank you.

Kevin Lobo -- Chairman and Chief Executive Officer

I'm not sure I got the first part, Joanne, 0% to 15% of procedures...

Joanne Wuensch -- Citi -- Analyst

Those procedures that have been delayed. So if you had 100 procedures that have been delayed in the month of April or March, what percentage of them come back this year or next year or ever?

Kevin Lobo -- Chairman and Chief Executive Officer

I think in the procedures that we operate in, virtually all of these procedures come back. I mean osteoarthritis is a degenerative condition. These people are going to need these procedures. And so I would expect that they would come back, at least in hips and knees and spine.

What we're seeing a little bit in the stroke area, which is kind of sad, is a lot of patients are afraid of going to the ER. And so we thought that, that would be largely protected, just like trauma cases. That's actually not true. And so they're actually suffering with strokes at home.

And so part of that is actually elective, which I would never have guessed. As they get more comfort and as the incident rates and death rates start or continue to decline, which they're doing in many locations, they'll start to get more comfortable going to the ER, and you'll see that volume resume. But to me, 0% to 15% seems like a historically low number. We would expect a lot more to come back.

What I can't predict is how fast will they come back.

Joanne Wuensch -- Citi -- Analyst

I'm sorry, that 0% to 15% had to do with those coming back in 2020.

Kevin Lobo -- Chairman and Chief Executive Officer

Yes. Again, I believe, to me, that seems awfully low. I mean, with the surgeon surveys that are surgeons in hospitals that I've spoken to, the patients that are on the waiting lists, they don't want to leave the waiting list, they would like to get their procedures done. But the big wild card is just how deep is this recession and if there are more layoffs, will those people get their procedures.

Those are things I can't predict. But to me, that sounds low in my view. Again, I don't have a crystal ball. But that sounds awfully low to me.

I don't know, Katherine, if you'd want to add anything?

Katherine Owen -- Vice President of Strategy and Investor Relations

No, I agree, Kevin. I think we just have to wait and see how it plays out if this is a V or a U-shaped recovery. It has different implications. But I don't think we could give any more granularity or specificity.

Joanne Wuensch -- Citi -- Analyst

And then of your procedures, which ones come back first.

Kevin Lobo -- Chairman and Chief Executive Officer

Thank you. Again, I can't really answer that because it really depends on the locations, the hospitals. Are they equipped. Can they have a separate facility that's separate from their coronavirus patients? If they can, they'll do whatever procedures they've got the equipment for in those ORs.

So for us, I'm hearing a lot of pent-up demand certainly in the orthopedic side. A lot of those physicians are not employed by hospitals. They might have an affiliation with the hospital, but they're not employed and they are very eager to get back to work. And they are very lucrative procedures for hospitals.

So I do believe those procedures will come back fairly quickly.

Operator

Your next call comes from the line of Ryan Zimmerman from BTIG. You may proceed.

Ryan Zimmerman -- BTIG -- Analyst

Thank you for taking the question. I just want to follow-up on Raj's earlier question, and it's really around pricing. MedSurg came in positive the first time, and I think eight quarters on pricing. And it just seems that pricing is a little less pronounced right now.

And is that a function of hospitals maybe taking their foot off the gas there? And kind of what are your expectations for pricing in the back half of the year, maybe when they have a little more time to focus on it? Could we see that increase a little bit? And then the second one is a follow-up to that. And you didn't call out pricing in spine in the press release. I'm just curious if you could comment on some of the pricing dynamics there in that segment of the market. Thank you.

Kevin Lobo -- Chairman and Chief Executive Officer

Sure. So first off, in terms of pricing and you think about our portfolio of businesses, generally, on the orthopedic side, we have more pricing pressure than on the MedSurg side. And actually, even within MedSurg, if you look at some of our businesses that largely sometimes have positive pricing, medical, it would be one of those businesses. So I would say that as you look at Q1 or you think about Q2, business mix is going to really influence where pricing is going to land.

And if there's sort of less ortho and more MedSurg, I would say pricing would be a little muted. I do think, though, moving forward, the same controls and pricing, sort of procedures and functions that exist in the hospitals will always continue to exist. We have always felt pricing pressure and I don't expect that, that will let off at all. So I do think that it's not really a function of hospitals getting back to it for us.

It's really going to be a function of sort of business mix within our sales line. And then on the spine front, I don't have any real specific guidance on spine pricing. I mean, spine is probably within orthopedics. One of the most sort of price sensitive product lines that we sell.

There's loads of spine companies. I would say, if anything, maybe the current environment will drive out some of the spine competitors. And so with less competitors, maybe spine pricing will level out a little bit. But it's really uncertain at this point.

Operator

Thank you. Your next question comes from the line of Josh Jennings from Cowen. You may proceed.

Josh Jennings -- Cowen and Company -- Analyst

Thanks a lot. Just two quick questions. First is, just wanted to check in on development programs, particularly the Mako new indication development. Spine and extremity, I think you have talked about historically, you haven't provided time lines, but this crisis delay, any time lines, even though we don't know what they are at this point for one.

And then second, just Kevin, being the chairman of AdvaMed, any core initiatives the group is pursuing to support the med tech industry?

Kevin Lobo -- Chairman and Chief Executive Officer

Sure. On the first front, I would tell you, if you look at the R&D spend we had in the first quarter, it was very much in line with our normal spend. We are not taking our foot off the gas at all with respect to our R&D pipeline, and that includes Mako and future indications. We aren't going to get specific about time lines yet because we're not really ready to do so, and we'll keep you posted, but full speed ahead with all of our R&D.

As it relates to AdvaMed, yes, it's been a very busy time. I happen to be Chairman. This is going to my second year of my two-year term. And so we're on weekly calls with all of our CEOs within the industry.

I would say the first big focus was ventilators, as you could probably imagine. And now the major focus is on testing because the diagnostic companies are also members of AdvaMed. And really just working with the administration and FEMA, in particular, to make sure that they have a clear supply signal and trying to get them to get the demand signal, so we can kind of have some kind of matching. And obviously, it's not our job to define the protocols for when do you do live virus testing and when is antibody testing appropriate and serology testing and what companies should do.

But we're in active discussions, and I would say testing is it's moved away from ventilators. And PPE is still a common topic that we're talking about, but much more of the focus right now has shifted to testing as governments around the world are trying to figure out and states are trying to figure out how to bring people back to work. So that's the big focus right now on testing and when you're part of that trade association, it makes you appreciate this industry. It's an amazing industry that does so much for people, especially in these kind of trying times.

And I'm really proud of how the industry has stepped forward to really to help our customers.

Operator

Your next call comes from the line of Matt Taylor from UBS. You may proceed.

Xuyang Li -- UBS -- Analyst

Hi. This is actually young Xuyang Li for Matt. Maybe just one question. I was wondering, when it comes to your hospital customer finances, do you have a view on maybe how many of them are a little bit distressed in this environment? And how can that disrupt the recovery curve?

Kevin Lobo -- Chairman and Chief Executive Officer

Yes. I don't have insights into what hospitals may be distressed. I mean my guess is that, obviously, their cash flow of most hospitals is under stress just because they don't earn as much money treating COVID patients as they might during elected procedures. I do think that between government grants, external financing, once hospitals can demonstrate positive cash flow again.

And even our own programs with Flex finance, there's plenty of capital availability for hospitals. And so I think that moving forward, once things settle down and we see sort of a trajectory ahead, that a lot of those programs will kick in and allow hospitals to sort of reinstate capital buying programs.

Operator

Thank you. Your last question comes from the line of Kyle Rose from Canaccord.

Kyle Rose -- Canaccord Genuity -- Analyst

Great. So just wanted to talk just a little bit about maybe the commercial structure, it's particularly with the backdrop of some of the cost changes you've discussed. Are you seeing any big picture trends with respect to changing, I guess, the support level or the requirements for what the sales rep does on a case-by-case basis. And I guess, the secondary question that's coming out of that is we've seen the potential for rep-less models or maybe there's a virtual model in the operating room.

What does that do from the cost structure of what the SG&A line looks from a long-term perspective.

Kevin Lobo -- Chairman and Chief Executive Officer

So look, at this point in time, we're not really seeing any change to the way our reps provide service and support our customers. I think what we're learning about virtual tools is they can be additive to our offense. The idea of completely replacing our sales reps, you know companies have tried this in the past, and it has met with pretty big failure. But I do think there is a role for technology.

We are seeing a little bit of this in Japan. And so I think technology can be an additional tool in our arsenal, certainly for training. And even in terms of support that it could provide some benefits, potentially some benefits in SG&A. But I would say those are very modest at this time.

It's very early. And I think as things resume, it's going to resume much more in the manner that we saw prior to coronavirus and then potentially you could see acceleration afterwards. I think rehab, for sure, the patients are very comfortable going home and trying to do their rehab at home and using virtual tools. I think you're going to see a lot more of that.

There has been some movement. That's increasing. I think the surgeon consultations that used to occur in surgeon offices, that's going to be a lot more virtual, that's happening now. And certainly, the payers are a lot more comfortable paying for that, which they weren't before.

But as it relates to the nuts and bolts of our procedures in the operating room, I don't see any dramatic change at this time.

Kyle Rose -- Canaccord Genuity -- Analyst

Just one follow-up on a pricing perspective. I appreciate the earlier commentary around spine. You talked a lot about physicians in hospitals coming under financial distress. Are there any expectations for potentially some increased price pressure, specifically when you think about the recon side of the business?

Kevin Lobo -- Chairman and Chief Executive Officer

We haven't seen any sort of step change impetus for price change within implants. And this has been going on for some time. Certainly, our prices go down every year. They have moderated.

There really isn't -- this is not a new impetus to drive significantly reduced pricing. And so I don't I think our price outlook will stay very similar moving forward.

Operator

There are no further questions at this time. I will now turn the conference back over to Mr. Kevin Lobo for any closing remarks.

Kevin Lobo -- Chairman and Chief Executive Officer

As I said in my opening remarks, I would like to once again thank the frontline healthcare professionals and first responders for everything that they have done and continue to do. I'm also proud of the efforts of our employees who are showing great resiliency in continuing to serve our customers in this difficult time. Thank you all for joining our call. We look forward to sharing our Q2 results with you in July.

Operator

[Operator signoff]

Duration: 77 minutes

Call participants:

Kevin Lobo -- Chairman and Chief Executive Officer

Katherine Owen -- Vice President of Strategy and Investor Relations

Glenn Boehnlein -- Chief Financial Officer

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

David Lewis -- Morgan Stanley -- Analyst

Vijay Kumar -- Evercore ISI -- Analyst

Matt Miksic -- Credit Suisse -- Analyst

Larry Biegelsen -- Wells Fargo Securities -- Analyst

Pito Chickering -- Deutsche Bank -- Analyst

Kaila Krum -- SunTrust Robinson Humphrey -- Analyst

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

Rick Wise -- Stifel Financial Corp. -- Analyst

Patrick Bartoski -- Piper Sandler -- Analyst

Kristen Stewart -- Barclays Capital, Inc. -- Analyst

Raj Denhoy -- Jefferies -- Analyst

Richard Newitter -- SVB Leerink -- Analyst

Joanne Wuensch -- Citi -- Analyst

Ryan Zimmerman -- BTIG -- Analyst

Josh Jennings -- Cowen and Company -- Analyst

Xuyang Li -- UBS -- Analyst

Kyle Rose -- Canaccord Genuity -- Analyst

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