Some site functionality may be unavailable due to site maintenance from 01:00 until 09:00 Sunday 21st April. We apologise for any inconvenience caused.

A rare opportunity to invest in one of the highest quality companies on the ASX

Vinay Ranjan of Airlie Funds Management outlines the case for an unloved healthcare stock.

During the quarter, we added ResMed (RMD.ASX) to our top ten holdings. ResMed is the global leader in sleep and respiratory care primarily focused on the development and sale of positive airway pressure devices and accessories for the treatment of obstructive sleep apnoea (OSA). ResMed’s share price has fallen 30% since the release of its FY23 results in August largely in response to concerns GLP-1 (Glucagon-Like Peptide-1) drugs may reduce its addressable market. In this article, we discuss the business in more detail and why we think the GLP-1 concerns are overdone.

 

What is Obstructive Sleep Apnoea (OSA)?

Obstructive sleep apnoea is a chronic illness that occurs when the muscles that support tissues in the back of the throat relax during sleep, blocking or narrowing the upper airway. This obstruction leads to impaired breathing for a short period (usually 10-20 seconds), which results in lower oxygen in the blood. The brain senses the impaired breathing, causing the individual to subconsciously rouse from sleep in order to reopen the airway. The severity of OSA is characterised by the number of events per hour: Normal < 5; Moderate 15-30; Severe > 30.

Continuous Positive Airway Pressure (CPAP) devices are the accepted standard of care for treating OSA, delivering a stream of pressurised air through a mask to prevent the collapse of the upper airway during sleep. ResMed is the largest manufacturer of these products and we estimate the company currently has ~80% market share with its major competitor Philips out of the market for the past two years due to an FDA-imposed product recall.

 

Large, undiagnosed addressable market

The OSA market is large and mostly undiagnosed. According to the company, there are 936 million people globally with sleep apnoea and 424 million of these suffer from severe sleep apnoea. The size of the addressable market is evidenced by the fact ResMed had grown its device revenue at over 9% p.a. in the six years prior to the Philips recall (FY13-FY19). Recent growth rates have been even higher. ResMed estimates that penetration currently sits at 20% in the US and well below this percentage globally, which implies a long runway for future device and mask sales.

 

Figure 1 – ResMed device revenue (US$)

 

One of the highest-quality companies on the ASX

As with any new position, we tested ResMed against our key investment criteria and consider the business to be high quality based on the following factors:

  • Financial strength: ResMed has a strong balance sheet with less than 1x ND/EBITDA
  • Business quality: ResMed has a dominant market position (~80% share), sells defensive products that improve patient quality of life and are reimbursed by Medicare/health insurers in the US, and earns high returns on capital (22% average over last 5 years).
  • Management quality: We consider ResMed a “founder-led” business. Founder Peter Farrell is Chair Emeritus, and his son, CEO and Chair Mick Farrell, has presided over an exceptional track record in product development and market share gains in his 10+ years as CEO.

 

GLP-1 concerns and valuation

ResMed has historically traded on a forward multiple of 28x PE but is currently trading on less than 21x PE due to market concerns about GLP-1 drugs reducing ResMed’s addressable market.

 

Figure 2 – ResMed NTM Rolling PE

 

GLP-1 drugs (branded as Ozempic, Wegovy and Mounjaro) act by mimicking hormones that are released into the gastrointestinal tract in response to eating. These drugs were initially developed to target type 2 diabetes by stimulating more insulin production but have evolved to potential applications in weight management and cardiovascular indications. Given obesity is a key risk factor for OSA (see Figures 3 and 4), there is a view that significant weight reduction from taking GLP-1s may result in reduced demand for CPAP therapy.

 

Figure 3 – OSA severity by AHI (>5 mild) and (>15 moderate)

Figure 4 – Prevalence of sleep apnoea in morbidly obese patients who presented for weight loss surgery evaluation

 

While we are not medical experts, we consider the significant de-rate to be an overreaction for the following reasons:

  • GLP-1 drugs have been around for almost a decade in managing blood sugar, and other competing therapies such as oral devices and bariatric surgery have not been able to displace CPAP as the standard of care. We note CPAP also has the advantage of being able to track patient adherence and compliance through cloud-connected devices. We believe this data is valuable to third-party payors.
  • While we acknowledge weight gain is a leading risk factor in developing OSA, it is not the only cause. Based on our conversations with sleep physicians and the company we estimate one-third of OSA patients are not obese. While the remaining two-thirds of the patient pool is highly likely to test GLP-1 drugs (as they become more accessible and affordable) we don’t expect adherence to be 100% given the potential for side effects such as nausea and the impact on lifestyle. We also don’t expect GLP-1s to fully eliminate OSA in all cases (the drugs may simply reduce severity). As a result, we think it’s more likely you could have a scenario where a combination of GLP-1 drugs and CPAP therapy are prescribed as treatment.
  • Finally, these drugs with an average retail price of ~US$1,000/month are currently unaffordable for most patients. Pricing will need to come down significantly to attract broader reimbursement and mass adoption.

 

Conclusion

Overall, we think the uncertainty as to the potential penetration and success of these drugs in treating OSA has created a rare opportunity to invest in one of the highest quality companies on the ASX. While we are unlikely to pick the bottom, we believe the company is trading well below its intrinsic value.

 

Learn how the industry leaders are navigating today's market every morning at 6am. Access Livewire Markets Today.

 

 

All prices and analysis at 23 October 2023.  This document was originally published in Livewire Markets on 23 October 2023. This information has been prepared by Magellan Asset Management Limited ABN 31 120 593 946 AFS Licence No. 304 301 trading as Airlie Funds Management (‘Airlie’).   

The content is distributed by WealthHub Securities Limited (WSL) (ABN 83 089 718 249)(AFSL No. 230704). WSL is a Market Participant under the ASIC Market Integrity Rules and a wholly owned subsidiary of National Australia Bank Limited (ABN 12 004 044 937)(AFSL No. 230686) (NAB). NAB doesn’t guarantee its subsidiaries’ obligations or performance, or the products or services its subsidiaries offer.  This material is intended to provide general advice only. It has been prepared without having regard to or taking into account any particular investor’s objectives, financial situation and/or needs. All investors should therefore consider the appropriateness of the advice, in light of their own objectives, financial situation and/or needs, before acting on the advice.  Past performance is not a reliable indicator of future performance.  Any comments, suggestions or views presented do not reflect the views of WSL and/or NAB.  Subject to any terms implied by law and which cannot be excluded, neither WSL nor NAB shall be liable for any errors, omissions, defects or misrepresentations in the information or general advice including any third party sourced data (including by reasons of negligence, negligent misstatement or otherwise) or for any loss or damage (whether direct or indirect) suffered by persons who use or rely on the general advice or information. If any law prohibits the exclusion of such liability, WSL and NAB limit its liability to the re-supply of the information, provided that such limitation is permitted by law and is fair and reasonable. For more information, please click here.

 


About the Author
Livewire Markets

Livewire Markets is Australia’s leading source of investment insights and analysis. Over 700 of Australia's most experienced and qualified decision-makers share their views directly with you on all things investing. These are highly vetted investment professionals with years of real market experience, including Chief Investment Officers, Portfolio Managers, Analysts and Economists. And now, Market Index has joined forces with Livewire to become Australia’s largest source of dedicated investment information. You’ll never be left behind with more expert analysis and data to help you make the best investment decisions.

  1. Expert analysis and insights to make more informed investment decisions.
  2. Free analysis and insights from 700+ of Australia's top financial leaders
  3. Access to performance data on over 250 managed funds
  4. Curated investment insights delivered every morning
  5. Never miss an update or opportunity

Learn how the industry leaders are navigating today's market every morning at 6am. Access Livewire Markets Today.