ResMed Inc.
Q3 2020 Earnings Call Transcript

Published: 30 Apr 2020

[Operator:]

Welcome to the Q3 Fiscal Year 2020 ResMed Earnings Conference Call. My name is Diego, and I will be your operator for today's call. . Please note that this conference is being recorded. I will now turn the call over to Amy Wakeham, Vice President of Investor Relations and Corporate Communications. Thank you, Amy, you may begin.

[Amy Wakeham:]

Great. Thank you, Diego. Good afternoon, and good morning, everyone. Welcome to ResMed's Third Quarter Fiscal Year 2020 Earnings Call. We appreciate you joining us, and I hope you all remain healthy and safe during these times. This call is being webcast live and the replay, along with a copy of the earnings press release and our updated investor presentation, will be available on the Investor Relations section of our corporate website later today. Joining me on the call today to discuss our quarterly results from various remote locations across San Diego and Sydney are CEO, Mick Farrell; and CFO, Brett Sandercock; as well as other members of management who will be available during the Q&A portion of our call. During today's call, we will discuss several non-GAAP measures. For a reconciliation of these measures, please review the notes to today's earnings press release. And as a reminder, our discussion today may include forward-looking statements, including, but not limited to, expectations about ResMed's future performance. We believe these statements are based on reasonable assumptions. However, our actual results may differ, particularly in light of the highly uncertain global environment we are currently operating in and the effects of the COVID-19 coronavirus on our business. You are encouraged to review our SEC filings for a discussion of the risk factors that could cause our actual results to differ materially from any forward-looking statements made today. With that, I'd like to go ahead and now turn the call over to Mick.

[Michael Farrell:]

Thanks, Amy, and thank you all for joining us today. These are unprecedented times, as Amy just noted. We are in the midst of a global pandemic, which is having profound effects on public health, particularly the most vulnerable among us. During this time, our top 3 goals here at ResMed are simple. Goal one is the preservation of life, helping people breathe with world-class ResMed ventilators and ventilation masks, while their own immune system fights against this novel coronavirus and the disease it causes, COVID-19. Goal two is the safety and health of our amazing team of 7,500 ResMedians, providing solutions in 140 countries worldwide, because without our people, we can't help anyone breathe better. And goal three is the ongoing delivery of world-leading products and services to treat sleep apnea, chronic obstructive pulmonary disease and asthma as well as the ongoing production of market-leading software to take care of over 110 million people with care delivered by home medical equipment providers, skilled nursing facilities, nursing homes, hospice, and importantly, in the place where people prefer to be, their home.

[Brett Sandercock:]

Right. Thanks, Mick. In my remarks today, I'll provide an overview of our results for the third quarter of fiscal year 2020 and some remarks for our Q4 outlook. As Mick noted, we had a strong quarter. Group revenue for the March quarter was $769 million, an increase of 16% over the prior year quarter. In constant currency terms, revenue increased by 17% compared to the prior year quarter. Revenues for the third quarter were favorably impacted by significant sales of ventilator devices and accessories. We estimate that the incremental revenue benefit from COVID-19-related sales was in the order of $35 million. Excluding this incremental impact, our group revenue increased by 12% in constant currency terms. Taking a closer look at geographic distribution and excluding revenue from our software-as-a-service business, our sales in U.S., Canada and Latin America countries were $394 million, an increase of 12% over the prior year quarter. Sales in Europe, Asia and other markets totaled $286 million, an increase of 23% over the prior year quarter or, in constant currency terms, a 27% increase. By product segment, U.S., Canada and Latin America device sales were $196 million, an increase of 8% over the prior year quarter. Masks and other sales were $197 million, an increase of 17% over the prior year quarter. In Europe, Asia and other markets, device sales totaled $195 million, an increase of 26% over the prior year quarter or, in constant currency terms, a 29% increase. Mask and other sales in Europe, Asia and other markets were $91 million, an increase of 18% over the prior year quarter or, in constant currency terms, a 22% increase. Globally, in constant currency terms, both device sales and masks and other sales increased by 18% over the prior year quarter. Software-as-a-service revenue for the third quarter was $90 million, an increase of 12% over the prior year quarter. On a non-GAAP basis, SaaS revenue increased by 9%. During my commentary today, I will be referring to non-GAAP numbers. The non-GAAP measures adjust for the impact of amortization of acquired intangibles, the purchase accounting fair value adjustment to MatrixCare deferred revenue and an impairment of minority interest investments. We have provided a full reconciliation of the non-GAAP to GAAP numbers in our third quarter earnings press release. Our non-GAAP gross margin improved by 70 basis points to 60% in the March quarter compared to 59.3% in the same quarter last year. The increase is predominantly attributable to favorable product mix and manufacturing efficiencies, partially offset by typical declines in average selling prices. Moving to operating expenses. Our SG&A expenses for the third quarter were $172 million, an increase of 5% over the prior year quarter. In constant currency terms, SG&A expenses increased by 7% compared to the prior year period. SG&A expenses as a percentage of revenue improved to 22.4% compared to 24.8% reported in the prior year quarter. Given the volatility in potential future revenue outcomes, I will not provide our normal guidance with respect to SG&A as a percentage of revenue. However, looking forward, we expect SG&A expenses to increase in the low single digits compared to the year ago period. R&D expenses for the quarter were $51 million, an increase of 8% over the prior year quarter or on a constant currency basis, an increase of 11%. R&D expenses as a percentage of revenue was 6.7% compared to 7.2% in the prior year. We continue to invest in our business, particularly targeted at innovation. This is evidenced by the double-digit growth in R&D expenses in Q3. We believe our long-term commitment to innovation will deliver a sustained competitive advantage. Looking forward, we expect R&D expenses to continue to grow in the high single digits to low double digits, reflecting our commitment to innovation through the economic cycles. Total amortization of acquired intangibles was $20 million of the quarter, a decrease of 10% over the prior year quarter, reflecting historical intangible assets becoming fully amortized during the quarter. Stock-based compensation expense for the quarter was $14 million. Non-GAAP operating profit for the quarter was $238 million, an increase of 31% over the prior year quarter, reflecting strong top line growth, expansion of gross margin and well-managed operating expenses. Excluding the benefit from COVID-19 impacts, we still continue to experience solid operating leverage. Non-GAAP net income for the quarter was $188 million, an increase of 47% over the prior year quarter. On a GAAP basis, our effective tax rate for the March quarter was 14.9%, while on a non-GAAP basis our effective tax rate for the quarter was 15.1%. Looking forward, we estimate our effective tax rate for the fourth quarter and fiscal year 2021 will be in the range of 18% to 20%. Non-GAAP diluted earnings per share for the quarter were $1.29, an increase of 45% over the prior year quarter. Excluding the benefit from COVID-19 impacts, we estimate our diluted earnings per share were $1.16, an increase of 30% over the prior year quarter. Our GAAP diluted earnings per share for the quarter was $1.12. Additionally, during the quarter, we recognized write-downs of $9 million associated with minority equity investments. Cash flow from operations for the third quarter was $240 million, reflecting robust underlying earnings and working capital management. Capital expenditure for the quarter was $30 million. Depreciation and amortization for the March quarter totaled $46 million. During the quarter, we paid dividends of $56 million. During the quarter, we also completed the acquisition of our previously announced tuck-in acquisition of SnapWorx. The acquisition will be non-GAAP EPS neutral in year 1 and is expected to be accretive to non-GAAP EPS in year 2. However, overall, the impact will not be material to group earnings. We recorded equity losses of $5 million in our income statement in the March quarter associated with the Verily joint venture. We expect to record an underlying run rate of approximately $5 million of equity losses each quarter through fiscal year 2021, associated with the joint venture operations. Given the unprecedented nature of current events, I would like to make some comments on our financial health. Strong balance sheet has always been a hallmark of ResMed and is most valued by investors in times of economic uncertainty. We ended the third quarter with a cash balance of $353 million, having generated $240 million in operating cash flow during the third quarter and $472 million in the first 9 months of our fiscal year 2020. As of March 31, we have $1.4 billion in gross debt and $1 billion in net debt. We had total assets of $4.5 billion. Our debt levels remain modest. And at March 31, we had a further $895 million available for drawdown under our existing revolver facility. In summary, our liquidity position is strong. However, I also want to highlight that in these times of uncertainty, we are maintaining a disciplined approach, and we are tightly managing expenses, cash flow and liquidity. Today, our Board of Directors declared a quarterly dividend of $0.39 per share. Dividends are important to many of our shareholders, and the declaration of our dividend reflects the Board's confidence in our strong liquidity position and operating performance. Turning to our fourth quarter outlook. At a high level, we expect to see continued strong growth in our respiratory care business and expect incremental respiratory care revenue to significantly exceed in Q3. However, we expect to see a headwind in sleep device sales in Q4 in response to a temporary reduction in the diagnosis of new patients. Masks and accessories have shown resiliency over the past 3 months, which reflects the insulating value of the large patient installed base. Like many other companies, we are experiencing high uncertainty in the current environment with circumstances and information changing almost on a daily basis. And as a result, our forecast and possible future revenue outcomes remain dynamic. And with that, I will hand the call back to Amy.

[Amy Wakeham:]

Great. Thanks, Brett. Thanks, Mick. . Diego, we're now ready for the Q&A portion.

[Operator:]

. Our next question comes from Lyanne Harrison from Bank of America.

[Lyanne Harrison:]

Congratulations on a great result. I'm very interested in, I guess, the uplift that you did on ventilators, and you maybe mentioned you got $35 million tailwind for this quarter due to the threefold increase in the devices production in ventilators by far. Can you tell me whether or not you are able to increase your volume of production of ventilators as you go through quarter 4 and to meet any increased demand in other countries.

[Michael Farrell:]

Thanks, Lyanne. Thanks for the question. And yes, you're right. We had 2 separate metrics that we sort of laid out there. One that we sold an extra $35 million worth of ventilator in the quarter. Those were from our inventory and stuff that we produced in Q2 and some in Q3 and so that was a $35 million tailwind for our business, and we expect some of that certainly to continue as the surge continues worldwide into Q4. And then in addition to that, we tripled our production from a year ago, and we made over 52,000 noninvasive ventilators, bilevel devices and invasive ventilators. So your question of, can we continue and/or increase the production capacity? And the answer is absolutely yes. We are constrained on some key components for the invasive ventilators. So the Astral and Stellar have some significant constraints in the components that go into those invasive ventilators of the Astral and Stellar type products. Well, Astral is an invasive ventilator and Stellar is actually noninvasive ventilator. But we really don't have significant constraints to the Lumis STA other than some components around the alarms module and the extra components and the AirCurve ST. So those noninvasive ventilators can scale to 5x or 10x, and we can really scale to whatever the demand is. And so then it comes down to our ability to predict hospital-by-hospital, customer-by-customer, what those surges in demand are going to be as the virus moves around the world and to make sure that ResMed is there, getting an order and making sure we can deliver those invasive ventilators, but really importantly, those noninvasive ventilators and alternative therapies that are also used in the different levels of acuity for a patient with COVID-19. So the answer in short is, absolutely. We did all we could, and we tripled production in the quarter, and we are looking to do that and more in Q4 to deliver for the needs that continue worldwide.

[Lyanne Harrison:]

Okay. So just to clarify, . How much can you increase production on the ventilators .

[Michael Farrell:]

I am going to say, Lyanne, the audio wasn't fantastic during that, but I think I heard you say that how would we or how fast would we move from the sort of 3x increases to a 5x or 10x on AirCurve ST, that's going to be dependent upon our modeling of the different surges that happen city-by-city and country-by-country. And clearly, the masks are used far more rapidly because they are changed over pretty regularly certainly patient-to-patient, but often day-to-day with these non-vented ventilation masks. And so we expect the surge to continue and us to continue to be able to produce throughout Q4 and beyond for the needs as this goes -- as this virus goes around the world and continues to expand.

[Lyanne Harrison:]

So my question was, how much can we increase the ventilator masks

[Michael Farrell:]

Yes, I've got to say, I can't -- I think I heard you say, can we increase the ventilation mask production? We've increased it tenfold, and we'll continue to do so. I think we should go to the next question. Sorry, Lyanne.

[Operator:]

Our next question comes from Suraj Kalia with Northland Securities.

[Suraj Kalia:]

I hope everyone is safe and healthy. Mick, just one from my side. And forgive me if you all mentioned this. Can you help characterize your investment in Nyxoah. You all are thinking about the neuromod market specifically for sleep apnea? What is the construct of ResMed's investment? That will be greatly appreciated.

[Michael Farrell:]

Thanks, Suraj. It's a great question. And as you know, you followed our stock for a long time. We look at a portfolio of investments to treat sleep apnea. And around 10 years ago, we actually invested in the 3D printing of a sleep apnea dental device called Narval, and that's now a great part of our portfolio and treats a great number of patients in France and across Northern Europe. The neurostimulation market is an interesting one and Nyxoah, we think, is a leader in that space, and we decided to make a minority equity investment in them. I'll actually hand over to Jim Hollingshead, who's the President of our Global Sleep business, to talk about how neurostim, dental, CPAP and how it all fits together.

[James Hollingshead:]

Thanks, Mick. Just very briefly, since I know we're probably short on time now. The gold standard therapy for sleep apnea continues to be CPAP therapy. And that -- we think that will continue for the foreseeable future. We get a chance to see a wide range of technologies as they emerge. And we always look very carefully at anything we think is an alternative. And as Mick mentioned, we obviously have a fantastic oral device, which we sell in Europe very successfully. The Narval device, high-tech, 3D printed, very low volume of the mouth, very comfortable. We've looked at the neurostim space for quite a long time. There have been a number of companies that have tried to succeed in the neurostim space. We think Nyxoah has a novel offer and is potentially disruptive, but it's very early days. It's a minority investment in what's effectively a start-up company. So we like the technology. We like to play, but we'll have to see how it plays out.

[Operator:]

Thank you. Our next question comes from Chris Cooper with Goldman Sachs.

[Chris Cooper:]

Mick, can you just remind us of the approximate payer mix in the sleep apnea business, please? And I appreciate this is a highly dynamic situation, but can you just share your thoughts on how you expect the higher rates of unemployment we're seeing in the U.S. to impact that business, please?

[Michael Farrell:]

Yes, Chris, thanks for the question. And yes, certainly, every country around the world is different. I presume you're asking about the U.S. payer mix, Chris? Maybe you're on mute, but I'll start with the U.S.

[Chris Cooper:]

Okay, primarily, year-on-year.

[Michael Farrell:]

Okay. So obviously, we sell in 140 countries outside the U.S. and on the reimbursed part of our business, the non-SaaS part, it's close to that 60-40 range, 60% being within the U.S. and 40% being beyond that. And if you include SaaS businesses, it's more like 65% of our global business in the U.S. So I'll start with that. So we don't have contracts directly with payers, but our portfolio of home medical equipment customers do. And there's around 5,000 customers in the U.S home medical equipment providers, and their payer mix for the field of sleep apnea and COPD that we serve is around 20%, maybe 25% for some regions, Medicare; and around 75%, 80%, private pay. And as we've seen through the COVID-19 crisis, we have seen ongoing payments from the -- both the government and private payers through to ResMed. We are carefully watching our accounts receivable. And as Brett said, we're carefully watching our cash flow to make sure that payers pay on time and with time, but we haven't seen any issues as yet. Clearly, unemployment has increased in the country from single digits to double digits through this crisis, and it's something that all companies are looking at very carefully. But we haven't seen any issues as yet, but we are watching the cash flow very carefully to make sure that we have continuing flow of capital and cash through our business.

[Operator:]

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

[Michael Matson:]

So I guess first, I just wanted to ask about the resupply business. Wondering why you think that, that's been so strong? Is there any kind of demand pull forward happening there? Do you think that can be sustained as long as the pandemic continues?

[Michael Farrell:]

Yes, Mike, thanks for the question. And certainly, there's -- it's quite interesting. As you know, you've followed us for a long time, too, Mike. Our installed base of CPAP patients, sleep apnea patients is a very strong part of our mask business. We're talking north of 80-plus percent of our masks sales across the U.S. are to that installed base, the diagnosed patient who loves their therapies, changed their life and they're going to go and reorder every time. I think the focus of COVID-19, and that it's a respiratory medical issue and that has raised the importance of making sure that your lungs are well taken care of and that you breathe well and your overall health is well, has increased people to make sure they get their prescriptions for everything, including heart attack. Post heart attack patients are getting more prescription pills. As I noted earlier, the Propeller side, COPD medicines and asthma medicines, we're seeing increased use of those in respiratory medical health. And we've seen a similar thing, I think, in the CPAP mask side, where when you are capable of getting a mask, you are more likely to click, yes, I would like that. And we haven't seen any reduction in people saying, "Oh the co-pay is too high or I don't want to go there." We've seen actually the reverse where people are saying, "wow, it's been 90 days, I'm due for a therapy, for a CPAP mask, tubing, et cetera." And they're clicking yes, and they're getting those devices delivered to them. So very strong ballast in the boat for our HME customers. And the HME customers themselves are really focusing on this part of their business because it's a good opportunity for them. We think -- look, there will be some deceleration if there is some sort of that surge of the sort of the toilet paper model where I'm going to over inventory, you all going to make sure I've got enough masks. That might decelerate somewhat, but we don't think -- we think there's a lot of ballast in that. And people who are on CPAP therapy and loving the CPAP therapy are going to want to get new masks. And through COVID and beyond, the importance of respiratory medicine will only be increased because of this. So we think that part of that business is very steady through the crisis and even stronger beyond. I think it will change behaviors that will last well beyond COVID-19 surge.

[Michael Matson:]

Okay. And then just with regard to sleep diagnostic testing. Can you provide any more detail around the declines that you're seeing kind of late in the March quarter? And then to what degree could increased use of home testing kind of some sort of remote telemedicine model offset that? And are you doing anything to try to enable the CPAPs to implement -- to ramp up, I guess, their home sleep testing?

[Michael Farrell:]

Yes. Great follow-up question, Mike. And we're doing a lot in that space. I'm focused a lot with Rob Douglas on our global task force on COVID-19 and ventilators. Jim Hollingshead, at the same time, has been running our sleep business strongly. Jim, do you want to follow up on the -- follow-up there on home sleep apnea testing and scale?

[James Hollingshead:]

Sure. Thanks, Mick. I think it's very difficult to quantify the effects and the balances of decline in in-lab testing and increase of home sleep testing in general. And it's very different country by country, both because of the timing of the pandemic and then how different health care systems are structured and so on. So trying to get a quantification, I think, is quite difficult. What we do know is we have seen some decline in in-lab testing. That's not a surprise. Health care systems around the world have shifted their focus to COVID-19. Many countries have gone in lockdown. Much of the U.S. has gone in lockdown. So we know that in-lab testing has declined and dipped. We have some evidence to suggest it stabilized at a lower level. It's hard to know exactly what that level is, but we think it's potentially stabilized at this point. But in parallel, we also know there's been an increase in home sleep testing and remote testing. A number of the labs around the U.S. have increased their use of home sleep testing devices and routines. And where that's done in Europe and can be down in Europe, it continues to be done, and we think it will turn on faster in Europe. And then the final point of your question is what are we doing? We're actually working very hard to enable home sleep testing to figure out how to help our lab customers and our physician customers virtualize their model, not just to our device offerings, but through workflows, through webinars and trainings, and we're working hard to see if we can virtualize some of that with software, which will take a little bit more time. And we do think that a shift to home sleep testing is, which has been going on worldwide for years, will be accelerated by this. And just as Mick said in his prepared comments, one of the things that we think will come out of the crisis generally for the sleep business is increased adoption of our already very broad offerings, virtualized care offerings. And so we think that will accelerate through the crisis and then have a new normal coming out of the crisis.

[Operator:]

Our next question comes from Margaret Kaczor with William Blair.

[Malgorzata Kaczor:]

Just wanted to follow up on the comment you guys have on production of NIVs and LSVs. I think I heard you guys say you've produced 52,000 of those devices in the quarter, which I know you guys don't give ASPs, but it seems like it could be $200 million or $300 million worth of products in the device side versus the $35 million benefit you saw in the quarter. So I guess, long and short, but the question is, were those made-to-order or in advance of demand? And how should we think about that product entering the field?

[Michael Farrell:]

Margaret, that's a great question. And yes, certainly, we did -- you heard correctly. We made 52,000 noninvasive ventilators and invasive ventilators. So that includes everything across the Astral, Stellar, Lumis, Flexo, GA and AirCurve, all those devices. So we included across all that group, 52,000, and they have very different pricing. But clearly, it's a lot more than just the $35 million of sales in that quarter. So we are prepared for demand ahead. The only thing I'm really willing to say on a public call like this is that we have a public capability with the U.S. government through HHS and FEMA of over $30 million contract. And so that's a fixed contract that we will fulfill, mostly in Astrals. And -- but we have many other contracts with hospitals, states, governments, nations around the world. I'm not going to go in and quantify any of those. They're usually one to one directly to those countries and directly to those hospitals. But what I can tell you is all the demand that they have and all the supply that we have, our supplies just cannot keep up with the demand as it moves around the world. And so what we're doing is maximizing production in advance and then making sure we get through the peak and through the surge, but not have an over amount of inventory at the other side. And so we're carefully managing the peak, the surge, the flattening and then making sure we get back to normal COPD, neuromuscular disease, ALS and other sales with those ventilators because those patients will be there beyond. And that's how we're looking at it, Margaret. But yes, clearly, we are preparing for more sales in the future of those ventilators and ventilation masks. That -- those tailwinds will last through Q4 and likely beyond.

[James Hollingshead:]

Yes. I'll just add quickly, Mick. Margaret, yes, there's a lot -- there's a meaningful amount that's in transit mode so to speak, as we're trying to get those into our DCs and then ultimately to customers. So there's that -- that impacts it as well. So -- but we'll continue to produce. And as Mick said, the demand is there. It's just a matter of getting it through the logistics.

[Operator:]

Our next question is from Steve Wheen with Evans & Partners.

[Steven Wheen:]

I just had a question on the FDA in terms of its response to COVID-19. It was alluding to the use of CPAP as being something that could be utilized. Just wondered what the experience was there? And then the other item that the FDA had done was to remove ventilators from the competitive bidding process. I just -- and there has -- appears to be some pressure to delay competitive bidding in the latest round. Just any comments on any of those 3 things would be very useful.

[Michael Farrell:]

Yes, Steve, those are great questions. And I've had actually quite a lot of conference calls with the FDA commissioner, Hahn; and HHS secretary, Azar, during this crisis. ResMed was part of a Defense Production Act that was put in place by the White House to secure component supply for our ventilator so that we could supply HHS, FEMA and beyond. And so I had a lot of interaction there. Look, the FDA have really been a great partner through this process. They helped us get Emergency Use Authorization, EUA, for a number of our products to be used in different context. So for instance, our noninvasive ventilators, which were very scalable. And as we talked about, we made tens of thousands this quarter. We had doctors wanting to use them in various ways, invasive ways and others. And so the doctors needed an EUA to be able to do that, and they have got that. And the FDA were very quick to us and other manufacturers in providing those Emergency Use Authorizations. Simultaneously, Secretary, Azar, over at Health and Human Services and CMS, they did take noninvasive ventilators out of competitive bidding around 2021, and that was a very good change for our HME customers. It really took a load off for them knowing that these NIV and ventilation businesses will be good ongoing concerns for them. So we saw a good partnership from both the FDA and HHS as part of this crisis. And HHS also worked with FEMA to make sure that we got the demand, and that was the $30-plus million contract I talked about to us, and there were 5 other manufacturers who got contracts as well. I think the government, not just in the U.S., but in all 100-plus countries that we're working with through this crisis, have done a great job in contacting us, working with us, helping us with supply chains and helping us with delivery of ventilators to people in the need for this crisis.

[Steven Wheen:]

And sorry, the final part was just the pressure that's being or the attempt to delay competitive bidding, the likelihood of that?

[Michael Farrell:]

Yes. I'll hand that over to Dave. He's got more insight on that, David Pendarvis?

[David Pendarvis:]

Yes. So thanks, Steve. We, along with the rest of the industry, have been suggesting to CMS that they either delay for a year the introduction of the 2021 round entirely or at least the respiratory offerings, respiratory product codes within that offering of the 2021 round of competitive bidding. We have had a dialogue with CMS on that topic, so they are listening. But I can't really handicap the likelihood that it will happen or not. I would echo what Mick said earlier, that CMS has been very responsive, and I think it has highlighted the importance of DME and home-based care in ensuring that as few people are in the hospital is not. And that's a real positive. And we hope that, that cooperative working relationship will continue.

[Operator:]

Our next question comes from David Low with JPMorgan.

[David Low:]

Mick, can I just follow-up on the use of bilevel device to treat COVID-19 patients. I mean there's clearly the aerosol issue and the safety issue there. I have seen some efforts to overcome that. Do you think that's going to be on -- I mean -- and I heard your comments, excuse me, about the amount of manufacturing capacity you have. Is your expectation that there will be continued strong demand for that utilization model?

[Michael Farrell:]

Yes. Look, it's a great question, David. And certainly, through this crisis, one of the leading countries early on this was the U.K. and the National Institute -- the National Health Service there, the NHS. And they created a protocol, which looked at the various acuity levels of COVID-19 patient because the disease -- the coronavirus gets into the lungs and then causes the COVID-19 disease, which is where mucus builds up as the alveoli react and try to fight off the virus, and it creates mucus in the lungs and builds it up. And so at different levels of buildup, different levels of acuity, different therapies are needed. And so the NHS created a very strong protocol of using both CPAP with some supplemental oxygen from the wall as well as bilevel therapy and then upgrading to more aggressive noninvasive ventilation therapy because bilevel is noninvasive positive pressure ventilation therapy. But then upgrading to higher levels of noninvasive ventilation therapy and even upgrading all the way to the full intubation through the trachea of invasive mechanical ventilation. And all those different modes can be moved up and down by the doctor as they move through the process. Your question about -- and it was a big question and concern early on that, oh, gosh, what if we have some contagion that some of the COVID-19 will come out? Well, before you put on an invasive mechanical ventilator, if a patient coughs or sneezes, the room is already contaminated. So even with invasive inhalation, there are some contamination protocols. And so what you need is a COVID-19 ward, you need PPE for everybody and you need to establish this floor of the hospital is for COVID-19 with negative pressure and take care of it that way. And that's what they've done in the U.K.. And actually, that moved to different parts of New York, New Jersey. And as we see this go around the world, people are learning to do that. What you have is a non-vented mask, so a ventilation mask with an inlet and outlet and then a filter on the outlet of the device. And so our Chief Medical Officer, Carlos -- Dr. Carlos Nunez, has been working with key opinion leaders worldwide, and we have a clinical white paper with best practice from Wuhan, from Milan, from London, from Munich, but they're doing it really well in Germany and from New York and around the world. And that protocol does include CPAP, it does include bilevel, it does include noninvasive ventilation with positive pressure, all with specific masks and specific circuit set up all the way up to invasive mechanical ventilation. Now the second part of your question, after the crisis will people continue to use more noninvasive ventilation? I think the answer is yes. I think it's going to be similar to digital health, where we've had to use home sleep apnea testing, you've had to use remote patient monitoring during this crisis. And you don't want to go to a patient's home. You don't want them to have to come to a hospital. And so that's driven digital health. I think people, doctors in critical care units have seen how noninvasive ventilation, including bilevel has very well treated patients with COVID-19, why can't it very well treat COPD patients? Well, guess what? It can. So I think the adoption of NIV will increase post COVID-19 because of the learnings during COVID-19. I can't quantify that exactly. It's more a medium, long-term thing. But anyway, I hope that answers your question, David. It's a very good one. It deserves a longer answer. And I know we're 10 minutes over, we might just take two more questions and let everyone get back to their work day, 3 more questions. Okay.

[Operator:]

Our next question comes from Matthew Mishan with KeyBanc.

[Matthew Mishan:]

And also it's really remarkable, the efforts of you and the employees of your company to support this crisis. So thank you for that as well. I'll just leave it to 1 because most of my questions have been asked. I've heard that there's potentially long-term respiratory implications from COVID-19 exposure. How do you see that patient transition to post-acute?

[Michael Farrell:]

Yes, it's a great question, Matthew. I'll hand that to our President and Chief Operating Officer, Rob, to talk about post COVID-19 discharge. What are the next steps, Rob?

[Robert Douglas:]

Yes. Thanks, Matthew. That's a good question. It's still an uncertain world in terms of what these post protocols are going to be across the board. We're seeing different trials and tests being carried out. In some areas, we are seeing patients get discharged with oxygen, and we are noticing an uptick in demand for oxygen around the place. And in other areas, we are seeing some discharges with more CPAP. But I think it's still way too early to say, probably the earliest data we've got is in China where things are normalizing a little bit. The sleep labs aren't yet open, but we're seeing continued ongoing demand for longer-term ventilation. So it's probably leading off the dynamic, that Mick mentioned earlier, that ventilation is noninvasive ventilation and chronic ventilation is recognized as a more relevant treatment than what it had been before.

[Operator:]

Our next question comes from Sean Laaman with Morgan Stanley.

[Sean Laaman:]

Well done, Mick, clearly doing a great job navigating. Sorry if I've missed it, but my question is, the $35 million of COVID revenue, was there any geographic sort of breakup of that? And just to clarify, what's that all vent revenue?

[Michael Farrell:]

Sean, that's a great question. Not comfortable going into details of where the $35 million came from. That's sort of our global number. And it's truly an estimate. It's -- the vast majority of it is ventilation. And so it's Astrals, Stellars, Lumis, AirCurve ST types of products. I'll hand over to Brett Sandercock, our CFO, to see if he wants to provide any further detail on that $35 million.

[Brett Sandercock:]

Yes. Thanks, Mick. I mean the only -- there is some -- there will be some mask and accessories things in that as well. You'd estimate making -- maybe that accounts for kind of 10% of that number and the rest would be devices.

[Operator:]

Your last question comes from Gretel Janu with Crédit Suisse.

[Gretel Janu:]

So you mentioned the double-digit declines in the diagnosis rates in the quarter due to lockdowns. I'm just wondering whether you saw any slowdown in the actual fleet new patient setups in the third quarter? Or will most of that impact from the slower sleep diagnosis impact the fourth quarter?

[Michael Farrell:]

Yes, Gretel, thanks a lot. Look, as you can understand, there's a lot of moving pieces going on right at the moment, and we're watching it through the quarter. And in different countries, and even in some countries in the world, we've seen that decline. Like in China, we saw that decline in January, February, and we're actually starting to pick up on the rates as we started to exit the quarter, and some regions of China starting to open up and then diagnosis is starting to open up again. But -- and similarly in South Korea and some other areas that have COVID-19 under control now. But I'll hand over to Jim Hollingshead to see if he wants to provide any further details the sort of kinetics of the double-digit reduction in diagnostics and any impact on sort of that headwind, I guess, of sleep device sales, while we have the neutral element of sleep masks continuing through. Jim?

[James Hollingshead:]

Yes. Thanks, Mick. Thanks, Gretel. With a little bit of a lag, you can also see bit of a drop-off in new patient starts, which we have the ability through our connected solutions to see -- as I said before, I think we're seeing diagnosis stabilize a bit, and I expect some countries to start to turn back on in the near term. And we're seeing new patient starts also stabilize a bit. So hopefully, we'll -- hopefully, we get a bounce off of the floor here. It's very difficult to predict what that will look like. It will be different country-by-country and even metro area by metro area.

[Michael Farrell:]

Great. Well, thanks for all the questions, and thanks to everyone for continuing the 15 minutes over here. I think we'll all agree this was a very unique quarter for not just ResMed, but for all companies worldwide. Look, I'll go with the close now, I think, here and close on up. I'd like to thank again to all our shareholders who've joined us for this call. I'd also like to shout out again to the 7,500 Resmedians helping people in 140 countries. You guys are also shareholders in the most part, and I want to thank you for your dedication and hard work, helping people breathe better, sleep better and live better lives outside the hospital. Thanks for all that you do all day, every day. Thanks, especially to those frontline heroes, the people making the products, distributing the products and getting those vents to those 140 countries to somebody who's suffocating and needs our help. I look forward to talking to all of our stakeholders again here in 90 days. And with that, we'll close it up. Thank you, Diego.

[Amy Wakeham:]

Great. Thanks, Mick. Thank you all again for joining us today. And just a reminder, if you have any additional questions, please don't hesitate to reach out to me or to Investor Relations. And as previously mentioned, all the documents, along with the transcript and a replay will be available on our website later today. Thanks, Diego. You can now close the call.

[Operator:]

Thank you. This concludes ResMed's third quarter of fiscal year 2020 earnings live webcast. You may now disconnect.