Omar Ishrak: Building Medtronic Globally

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1 N R E V : M A Y 1 3, B I L L G E O R G E N A T A L I E K I N D R E D Omar Ishrak: Building Medtronic Globally As he gazed out on the sea of 1,200 employees eagerly anticipating Medtronic s 52 nd consecutive holiday party, Chairman and CEO Omar Ishrak was moved by their dedication to Medtronic s mission of Contributing to human welfare by the application of biomedical engineering to alleviate pain, restore health, and extend life. As 5,000 more employees watched the event via webcast, the usually reserved Ishrak felt deep inner excitement as he prepared to introduce eight patients to share stories of ways their lives had been impacted by Medtronic products. This year s patients included former Medtronic President Thomas Holloran, who had provided stability, insight and mission focus to the company s board from Ishrak was equally interested to see how employees would respond to the nine-year-old girl from Colombia whose life had been transformed by Medtronic s spinal products after surviving 13 prior surgeries to correct her juvenile scoliosis. All eight patients had benefited from Medtronic s innovative medical therapies, created in conjunction with leading physicians. Ishrak had been recruited by the Medtronic board to restore the company s growth. In recent years revenue growth had slipped to near zero as markets declined for Medtronic s key product categories, cardiac rhythm management and spinal therapies. This was in sharp contrast to the 20 years from when the company had grown at a compound rate of 18%. As a result, Medtronic stock, which traded at 40 times earnings in the 1990s, was valued at only 11 times expected fiscal 2013 earnings, compared with the 15 times price-to-earnings ratio of the S&P 500. Ishrak was pleased with Medtronic s progress since he took the helm 18 months before. In his first year, revenue growth increased to 4% still well below shareholders requirements to value Medtronic as a growth stock rather than a value stock. He had focused on accelerating Medtronic s globalization and efforts in emerging markets; emphasized the need to demonstrate the economic (in addition to clinical) value of Medtronic s products; created several innovations in the company s business model; and acquired Kanghui Holdings, Medtronic s first acquisition in China. Yet Ishrak wondered whether he had done enough to restore growth. He asked himself, Will our global initiatives restore Medtronic s record of sustained growth? Should we make bolder moves? Professor Bill George and Global Research Group Senior Researcher Natalie Kindred prepared this case. HBS cases are developed solely as the basis for class discussion. Cases are not intended to serve as endorsements, sources of primary data, or illustrations of effective or ineffective management. Copyright 2013 President and Fellows of Harvard College. To order copies or request permission to reproduce materials, call , write Harvard Business School Publishing, Boston, MA 02163, or go to This publication may not be digitized, photocopied, or otherwise reproduced, posted, or transmitted, without the permission of Harvard Business School.

2 Omar Ishrak: Building Medtronic Globally Medtronic History In 1949, Earl Bakken and his brother-in-law, Palmer Hermundslie, founded Medtronic in Minneapolis, Minnesota, as a small medical equipment repair shop serving medical device manufacturers. In 1958, Dr. C. Walton Lillehei, a pioneer in open-heart surgery at the University of Minnesota, asked Bakken to develop an external wearable pacemaker to keep patients alive postsurgery, using electrical stimulation of cardiac muscle to regulate a patient s heartbeat. This groundbreaking invention reflected an approach to R&D partnering with doctors to meet patients needs that became central to Medtronic innovation. In 1960, Medtronic scientists helped create the world s first commercially produced implantable pacemaker. Despite its expanding global reach (with sales in Africa, Australia, Canada, Cuba, Europe, and South America) and revenue approaching $500,000, by the early 1960s Medtronic was running out of cash as revenues were insufficient to fund growth and required investments in R&D and manufacturing. Suffering a $144,000 loss in 1962 and virtually bankrupt, Bakken obtained $200,000 in funding from a newly-formed venture capital firm, Community Investment Enterprises. At its next board meeting, the board challenged Bakken to articulate what business the company was in. In response, he and Holloran sketched out the Medtronic mission with the overarching goal to alleviate pain, restore health, and extend life. The mission also called for good citizenship, long before corporate-social responsibility was widely embraced. For five decades the mission has served as the company s cultural touchstone and decision-making compass. (See Exhibits 1 and 2 for the mission and logo and Exhibit 3 for a historical timeline.) By 1974, Medtronic was selling in 70 countries. That year, the company faced a major crisis when battery failures led to the recall of tens of thousands of its Xytron pacemakers. Medtronic management failed to respond in a transparent manner, resulting in severe reputational damage and loss of market share. Still, the following year marked a milestone, with revenue of $100 million. In 1976 board member Dale Olseth, former CEO of the Tonka Toy Corporation, became CEO as Bakken remained as board chair. Amid several years of strong growth, in 1977 the company was listed on the New York Stock Exchange. With a foothold in neurological and cardiovascular devices, Medtronic attempted to diversify through acquisitions of medical technology companies. Key product introductions included long-lasting lithium pacemaker batteries and the world s first implantable, programmable drug pump to treat cancer pain. In 1979, Medtronic began serving India and other emerging markets. In 1985, Medtronic was listed on the Fortune 500, with $370 million in sales. That year, the company suffered its second major pacemaker quality issue. Multiple failures of its 6972 pacemaker lead, coupled with internal denials and investigations by the U.S. Food and Drug Administration, caused Medtronic s first sales and earnings decline in two decades. As a consequence, Olseth was replaced by board member Winston Wallin, former vice chairman of Pillsbury Company. Wallin saw innovation and product diversification as key to reinvigorating Medtronic. To spearhead Medtronic s technology renaissance and diversification, board member Glen Nelson, MD, became executive vice president. Allegations by Eli Lilly of infringement of its defibrillator patents slowed Medtronic s rebound until the U.S. Supreme Court ruled in Medtronic s favor in In 1989 Bill George was recruited from Honeywell as president and COO. When Wallin retired in 1991 at age 65, George was promoted to CEO, while Wallin continued as board chair until In the 1990s George invested heavily in ventures to create new medical therapies, increasing R&D from 9% to 12% of revenues for several years as Medtronic became known as an innovation machine. From 1998 to 2001 Medtronic spent $13 billion to purchase six companies in spine surgery, coronary stents, 2

3 Omar Ishrak: Building Medtronic Globally neurosurgery, cardiovascular surgery, and diabetes pumps to become the world s leading medical technology company. As a result, its market capitalization tripled to $60 billion. In 2001 George completed his 10 years as CEO and was succeeded by COO Art Collins. From 2001 to 2007, Medtronic s R&D investments paid off handsomely as new therapies for heart failure, cardiac surgery, incontinence, Parkinson s disease, and spine surgery fueled a renewed growth surge. Medtronic s earnings continued to grow during this period, but its stock price was flat as its price-toearnings multiple declined sharply. In 2007, COO Bill Hawkins replaced Collins as CEO, taking the reins at a difficult time, when the markets for Medtronic s core products were no longer growing. Hawkins, who retired in mid-2011 after 3½ years, focused on initiating several new technology acquisitions. Omar Ishrak Omar Ishrak became chairman and CEO of Medtronic in June 2011, after 16 years with General Electric (GE). He was born in India before the British-colonized Indian subcontinent was partitioned in 1947, making the Hindu-majority West Bengal part of India and the Muslim-majority East Bengal part of Pakistan. His father s family lived in East Bengal, where Ishrak spent his youth, while his mother s family lived in West Bengal. As a teen, Ishrak moved to West Bengal, where his father worked for the government. At 18, Ishrak went to London to pursue undergraduate and doctoral degrees in electrical engineering at King s College. His doctoral thesis focused on ultrasound technology. At the age of 22, the thought of being able to image inside objects using sound was fascinating, he explained. I focused on optics technologies and wave mechanics and the physics of electronics. After graduating, he went to work for the Dutch conglomerate Philips s ultrasound subsidiary in Santa Ana, California. I knew I wanted to work in the U.S., Ishrak recalled. In California being an engineer was not only prestigious, but also exciting. People thought engineering was the thing to do. Aspiring to an impactful career, he did not envision an executive path. In those days, he said, even managing an engineering department seemed like a stretch. During his time at Philips Ishrak got interested in management: I wanted to work on something important to the company. Pure research was too detached. By transferring technology from Holland to the U.S. and being responsible for manufacturing, he gained a sense for business and customers. After eight years at Philips, he moved to Diasonics, the up-and-coming ultrasound leader. Since Philips was a Dutch company, he explained, you couldn t advance unless you were Dutch. At a smaller American company like Diasonics I felt I could have greater impact. During five years at Diasonics, Ishrak went from thinking that engineering is all I could ever do to wanting to run a company. He built deep relationships with customers engineering teams and used these insights to influence product development and marketing. The intellectual connection with customers in the medical field is fruitful, and you gain credibility a salesperson never can get. By helping customers solve problems, ultimately you sell, but that s not the intent. Lessons from GE In 1995, Ishrak began running GE s struggling ultrasound business, part of GE Medical Systems, in Milwaukee, Wisconsin. GE customers suggested Ishrak for the job, believing his knowledge of ultrasound technology and customers could help address flaws in GE s existing offerings. Asked to 3

4 Omar Ishrak: Building Medtronic Globally diagnose problems with its ultrasound products, he told management, They are too expensive. You put in all these things no one cares about, but you re missing the things customers actually want. GE s strategy in emerging markets was to create joint ventures with local companies by providing technology in exchange for building GE s regional sales footprint. While pushing its unpopular highcost ultrasound in the U.S., GE had small joint ventures in India, Japan, and Korea offering low-cost ultrasound. Ishrak saw enormous potential in the low-cost technology that GE had overlooked. We fixed GE s technology, Ishrak said, by taking three low-cost platforms from Asia and integrating them into a single global business providing a tiered set of products. Ishrak s use of multiple product development centers in developing countries met with resistance because it ran counter to GE s policy of centralized R&D. GE s mindset was to consolidate engineering to save money, he explained. Instead, we created a global business with parallel centers, using diverse engineers in different countries to come up with new ultrasound ideas, while running different tiers from a common hardware platform. Ishrak s success attracted the attention of CEO Jack Welch, who encouraged him to sustain his strategy and pursue acquisitions, leading to the 1997 purchase of Diasonics. By 2000 Ishrak was named an officer for transforming GE into the global ultrasound leader. In 2005, he was promoted to CEO of GE Clinical Systems, which included ultrasound, anesthesia, and patient monitoring. In 2009 Ishrak was named CEO of the $12 billion GE Healthcare Systems. Reflecting on his time at GE, Ishrak saw ultrasound as his formative experience: It influenced my thinking around globalization, using innovation to reduce product costs with common hardware platforms, and having product centers run by people who understood their segment of the market. (Exhibits 4 and 5 describe Ishrak s philosophy of reverse innovation. ) Restoring Medtronic s Growth The appointment of the 55-year-old Ishrak as CEO was unprecedented for Medtronic, as all previous CEOs had come from the board or were promoted from within. He assumed the position two months after Medtronic s 2011 fiscal year closed with $15.5 billion in revenue just 1% growth. At the time Medtronic was cutting its workforce and selling its external defibrillator unit. Ishrak was attracted to Medtronic s mission and sense of purpose, which he found rare at large companies, as well as its breadth of technology and customers. He knew his mandate to get the company back on a sustainable growth trajectory would not be easy, but he was undeterred. I knew how to grow businesses, because that s what I d always done before, he said. Investors hoped Ishrak would put the company on a growth path and restore shareholder value. Forecasting that 62% of Medtronic s sales were in businesses unlikely to grow in the next three to five years, they anticipated a difficult road ahead. The question from here is, what is Ishrak s mandate? posited one analyst. Is it same strategy, better execution? Or are there more aggressive plans for Medtronic? Our expectation is the former is much more likely than the latter. The structural issues here are difficult for anyone to deal with, said another. The market is slowing, and without innovation they ve lost share, so they ve been doubly hit. Added a third, The market for devices has pricing pressure and market pressure. Your job as CEO is to deal with that. As he dug into data on the company s key markets, Ishrak became concerned about the magnitude of his task. The company s three largest markets cardiac rhythm, spinal, and coronary vascular were not growing. Markets for Medtronic s most profitable businesses of pacemakers and 4

5 Omar Ishrak: Building Medtronic Globally defibrillators, accounting for 30% of revenues, were declining 1% and 7%, respectively. The spinal products market, which made up 21% of revenues, was flat. Medtronic s third largest business, coronary vascular (10% of revenues) was declining 3% per year. Nor did the future look better. Pressure to slow growth of healthcare costs had led to increased scrutiny on hospital spending. Given uncertainty about healthcare reform, patients were forgoing elective medical care and hospitals were delaying capital purchases. Moreover, U.S. device makers were bracing for a 2.3% excise tax in 2013 as part of the Affordable Care Act. Geographically, Medtronic s global footprint raised even more concerns. Slower growing developed markets accounted for 86% of Medtronic sales. The U.S. market, which represented 54% of company revenues, was declining 1% per annum. Western Europe, Canada, and Japan, accounting for 32% of revenues, were growing at a modest 2-3%. In contrast to many medical companies that built large businesses in emerging markets, Medtronic s emerging market revenues amounted to only 14%. (Exhibit 6 provides company financials in selected years from 1985 to Exhibits 7 and 8 show Medtronic s revenue by product category and geography. Exhibits 9 and 10 describe Medtronic s performance in the context of overall market size and growth.) New Medical Therapies One of Ishrak s goals was to restore the company s product innovation engine. Its once-robust R&D pipeline, which churned out a slew of growth-fueling medical therapies in the 1990s, had few exciting prospects. R&D spending was high, but we weren t growing. The board was frustrated we were spending so much money on R&D and not getting results, Ishrak explained. In studying Medtronic s history, Ishrak observed that its strongest growth came from new medical therapies, not product improvements aimed at keeping ahead of existing competitors. In the past decade 90% of its R&D budget had been devoted to replacement products, as its venture organizations were disbanded or folded into existing business units. Consequently, he accelerated R&D funding for several promising innovations in breakthrough medical therapies. (Exhibit 11 has a list of Medtronic therapies.) Yet he recognized it would take several years before such innovative therapies became mainstream medical practice. He also noted that in order to address the changing healthcare environment, medical technology needed to not only improve clinical outcomes and maintain high standards of quality, but also address the challenges of global access and cost pressures. He explained that the company needed to focus on the economic value of its products and demonstrate their financial benefit for each stakeholder: Increasingly people will demand economic data, because all stakeholders in healthcare are concerned about costs. Even when a country s spending as a percent of GDP is low, there is great sensitivity to escalating healthcare costs in an uncontrolled fashion. So the need to translate the clinical value of products into their economic value is critical to accelerate their commercial adoption. We are seeing early results of our economic value strategy as we actively work with prominent payers and providers to structure partnerships through which these efforts will reduce costs in the system while delivering measurable revenue growth. Ishrak was excited about several promising innovations Medtronic was developing for new medical therapies for which Medtronic had recently received European Community approval for commercial marketing. Using a minimally invasive, catheter-based procedure, the company acquired and developed a renal denervation system to reduce blood pressure in patients with treatment- 5

6 Omar Ishrak: Building Medtronic Globally resistant hypertension. Initial trial results, presented at the American College of Cardiology in March 2012, indicated a highly significant reduction in blood pressure after three years. Health economic studies indicated a $3,000 per patient savings per quality-adjusted life year. Models also projected a 30% reduction in cardiovascular mortality. Ishrak believed this technology represented a major breakthrough in medical therapy, something the company hadn t produced for several years. Every doctor I ve spoken to thinks this will revolutionize medicine, he said. Other innovations that excited Ishrak included the CareLink Express Service and the CoreValve. CareLink was a remote monitoring system that enabled clinicians treating patients with chronic heart disease to obtain data about the patients and their devices and reduce patient wait times by 80%. The trans-catheter CoreValve was a minimally-invasive technology with the potential to replace openheart surgery in valve replacement. Early clinical trials indicated significant improvements in patients health scores with high survival rates. Ishrak was also positive about the continuous glucose monitoring system Medtronic developed for Type 1 diabetes patients in order to eliminate finger pricking to test blood glucose. Clinical trials were also promising for its low glucose suspension process to improve control of insulin delivery to avoid hypoglycemia. Medtronic was developing a closed-loop diabetes treatment that functioned like an artificial pancreas a primary goal when the diabetes unit was acquired in Globalizing the Medtronic Organization Shortly after becoming CEO, Ishrak initiated significant structural changes to transform Medtronic into a global organization from a multinational. He recognized Medtronic had deep knowledge of emerging markets within its far-flung operations, but this had not been fully tapped. Seeing Medtronic needed a new business model for growth, he decided to shift greater emphasis to the emerging markets, while seeking ways to increase Medtronic revenues in developed markets. Many employees and outsiders saw the company as organized around the pillars of U.S. and Other. SBUs had P&L responsibility for developed markets, while the international division had responsibility for emerging markets. With no direct line to managers in emerging markets, SBU heads had to work through the EVP, international. Country heads in emerging markets had little influence on the highest levels of corporate strategy. The old structure was well intended, recalled Chris O Connell, president, restorative therapies group, but it was unwieldy and deepened the us versus them culture between the international regions and the U.S.-based business units. Ishrak s first step was to clarify Medtronic s confusing matrix organization. He assigned full responsibility for revenues and profits to SBU heads and aligned global sales teams with their respective businesses with dotted-line reporting to their country managers. When Medtronic s head of international resigned in early 2012, Ishrak restructured the organization to have the heads of all global units report directly to him, eliminating a management layer that had kept him a level removed from regional operations. He also expanded the company s powerful executive committee from 12 to 18 members, including seven who were non-american born. The new geographic structure divided the world into seven operating regions: Asia-Pacific; Europe, Middle East, Africa (EMEA) and Canada; Greater China; Japan; Latin America; South Asia; and U.S. Each region had a president reporting to the CEO who was accountable for the P&L for all business in their region. Regional presidents were responsible for executing the plan developed by the business units, but regional business unit managers reported to their respective SBU heads. 6

7 Omar Ishrak: Building Medtronic Globally The global spine SBU president has the power to shift resources from Europe to Greater China, O Connell explained, but the head of Greater China can t shift resources from the vascular business group to the spinal group. Within the regions, country managers leveraged local expertise to drive strategy and execution at the country level, where they oversaw local business heads. To cultivate a global mindset at Medtronic s highest levels, Ishrak and his senior executives held quarterly strategy meetings in global locations such as Shanghai and Mumbai. Ishrak s 18-member executive committee included three group presidents, seven regional presidents, and seven functional heads. For the first time, emerging markets had a voice at Medtronic s highest executive council, as the committee, which previously had only one non- American, now included seven non-americans. (Exhibit 12 shows members of the executive committee.) The magic of what Omar did was to create a structure in which both the business units and the regions are essential to each other, and neither can act independently, explained O Connell. After the regional heads joined the executive committee, the dialogue changed dramatically. Before, it was a business unit-centric conversation. Considerations of local markets were an afterthought. Now, you have as much input from a regional perspective as from a business perspective. It gives us a greater appreciation of the impact of resource allocation tradeoffs. Omar is extremely inclusive in the executive committee, Rob ten Hoedt, president of Europe, Middle East, Africa, and Canada, noted. It s hard for people from some cultures to be assertive, but Omar insists that everyone speaks up. He tells Americans to use less slang, like U.S. sports analogies. No longer are the Americans just talking to each other with the international people being spectators. However, O Connell saw some drawbacks. Omar s execution mantra, born of his GE experience, is to host regular reviews of every business, every region, he said. We have a six-quarter rolling forecast, with replanning every quarter. So much time is spent in reviews that we don t have time for customers. We re talking to ourselves more and our customers less than ever before. O Connell s counterpart, Mike Coyle, president, cardiac and vascular group, expressed similar concerns. The benefit of the new structure is that business unit leaders get granular views on needs for their products in each region, he said. This is a more expensive model requiring added layers of staff and is more complicated for geographies as each business competes for resources. We spend more time refereeing conflicts than ever before, which means less time with customers. Ishrak recognized that evolving to the regional organizational structure and requisite review processes would involve growing pains. But, he also knew that as the team continued to streamline the internal operating mechanisms and processes, it would become part of the organization s natural discipline, freeing people from an internal focus on process to an external focus on global customers and partners. Ishrak added, We are also seeing a rebalancing of the types of customers we spend time with. It s true that our leadership team is spending less time with certain customers in certain regions, such as the U.S. But we are spending far more time with customers in other regions of the world. Before we implemented a greater focus on emerging markets, many of our business leaders had rarely, or never, visited China and/or India. Innovative Business Models A believer in reverse innovation from his years running GE Healthcare Systems, Ishrak challenged SBU heads to experiment with innovative business models and new products tailored to the needs of 7

8 Omar Ishrak: Building Medtronic Globally their respective markets. This was a distinct shift from Medtronic s established practice of exporting both products and marketing methods from the U.S. to developed and emerging markets. In 1995 Medtronic had initiated a major expansion in emerging markets. Its efforts included establishing a wholly-owned company in Pudong, China, with a modest research and manufacturing facility, expanding Asian operations, increasing India manufacturing, and building direct subsidiaries in Latin America, Eastern Europe, Middle East and Africa. In 2002 Medtronic introduced the Champion pacemaker for China s value segment. Priced at less than 20% of U.S. prices, sales were disappointing as physicians preferred Medtronic s full-featured, more sophisticated products. When Ishrak took over 16 years later, emerging markets accounted for only 14% of corporate sales. While organization issues accounted for some problems, Ishrak identified larger issues with Medtronic s approach to the market. For example, the Chinese vascular market had shifted from domination by multinationals to local producers. As a 2012 report noted, Medtronic, Boston Scientific, Johnson & Johnson and Abbott Laboratories historically dominated the premium segment in China s vascular market (with) ~70% market share. In the mid-2000s, local players such as MicroPort Scientific, Lepu Medical Technology, and Jewel entered the fray. Today, they command ~60% of the overall market. This massive shift in share occurred because locals created products that were perceived as good enough, not only for the mid-tier but also for the premium segment. a Ishrak explained, What I learned at Medtronic about globalization was brand new. It caused me to think differently about globalization. He continued: The conventional wisdom is to make low-cost products in local product centers, cut prices, use local marketing teams, and you will globalize. Instead, I found the products we had were not being used by people who could afford them. If those who could afford our products used them at the same rate as in developed markets, the opportunity was massive even without low-cost products. So my globalization priority shifted from developing low-cost products to education, training, patient and physician awareness, and building infrastructure. This required new business models to tap into the opportunities. By getting our brand name established, we could create the industry, and find openings to reach the rest of the population. Patient Access Acceleration Tool Shortly after arriving at Medtronic, Ishrak uncovered a sophisticated software tool for market expansion called Patient Access Acceleration (PAA) that could pinpoint relevant barriers to adoption. It was being shelved because people didn t see its value an outstanding tool that could give us precisely the data we needed to expand was being killed. PAA produced sophisticated country-level analyses of market opportunities, including the market size and Medtronic s potential share. Its granular approach revealed surprising, locally nuanced insights. For example, patients seemingly unable to afford medical care might be able to pay in installments if that option was available. In another case, public health insurance became viable when patients could afford out-of-pocket payments while waiting for reimbursement. Adoption barriers related to medical providers were often misunderstood. A common barrier was lack of awareness about diseases Medtronic treated and available treatment options. Even patients a Nicholas Donoghoe, Ajay Gupta, Rob Linden, Palash Mitra and Ingo Beyer Von Morgenstern, Medical Device Growth In Emerging Markets: Lessons From Other Industries, In Vivo: The Business & Medicine Report (June 2012): 6, via Elsevier Business Intelligence, accessed May

9 Omar Ishrak: Building Medtronic Globally living near medical facilities frequently lacked access to required medical care. Many rural medical facilities lacked the equipment, personnel, expertise, and trust of their local communities. In many regions, clinicians were not trained in diagnosing the medical conditions targeted by Medtronic s products. Even clinicians with access to sophisticated equipment frequently did not know how to use it. Some regions lacked referral systems to send diagnosed patients to capable specialists. The PAA tool played a critical role in helping the businesses understand opportunities in emerging markets. Geoff Martha, head of strategy and business development, explained, It s hard to do something new when people are stuck in old paradigms. Our businesses resist diverting resources toward emerging markets when they have to hit aggressive net income goals. We re trying to deliver results to our investors even though our core markets are down or flat, and we re investing in the future at the same time. This tool helps crystallize the opportunities for us. When used comprehensively across our company, the PAA tool gives us an investment prioritization methodology and linkage to expected growth rates, said Ishrak. To grow in developing markets, you have to invest in overcoming multiple barriers to gain access for Medtronic therapies. He continued: With PAA, the relationship between investment and growth becomes clearer. If the barrier to entry isn t cost but patient awareness and access, working on low-cost products means you re investing in the wrong thing. I was amazed at how many people in emerging markets who could afford our products didn t have access to them. With such large populations, if even 15% can afford our products, the opportunity is massive. We asked ourselves, how can we create awareness so people will use Medtronic s existing products? Business Model Innovation While lowering adoption barriers identified by the PAA tool required structural changes beyond Medtronic s traditional business model, Medtronic saw opportunities to create unconventional and innovative business models to increase access to care. Beginning in 2011, the company dedicated financial and human resources to design, test, and scale business model innovations in several key markets. These innovations involving activities atypical of medical technology producers sought to address the gaps preventing a country s healthcare system from functioning effectively. The nerve center of this effort was Medtronic s Business Model Innovation (BMI) Center of Excellence in Singapore. The center, under Martha s strategy group, was comprised of a small team of highly trained consultants that were embedded in the regions to collaborate with local teams. They identified market opportunities and devised new business models. Instead of starting with a solution, we use the PAA tool to identify the barriers, and then apply our BMI toolkit to find a way around those barriers, Martha explained. We ve set aside BMI funds to help the businesses do this, and at some point they take it over. The business units own the offerings while the regions are responsible for wrapping new business models around those offerings that work for that region. The BMI team was a sought-after resource within Medtronic. Martha noted, Normally, there is a lot of skepticism about corporate initiatives like BMI. After the successes we ve had with BMI, both business units and the regions are eager to use it. In our strategic review, all the regions had built BMI into their strategies. (Exhibit 13 describes the business model innovation framework.) Medtronic in China Medtronic s Greater China unit was headed by Simon Li. A native of Hong Kong, Li worked on the mainland in the 1970s, selling antibiotics for Eli Lilly. At the time most people were afraid to go into China immediately after the Cultural Revolution, he recalled. 9

10 Omar Ishrak: Building Medtronic Globally Since Li became China country head in 2006, revenues had grown from $170 million to $780 million, the employee base expanded from 400 to 1,500, and annual turnover had fallen from 35% to 11%. Medtronic had four manufacturing facilities in China and an R&D center focused on designing value products for China s second- and third-tier cities, whose medical systems were significantly less developed than those of Beijing and Shanghai. Li foresaw future opportunities to export products from China to other emerging markets. In parallel, Medtronic was focusing on adoption of its high-tech products among the millions of Chinese who could afford them. Thanks to PAA, this strategy focused on local barriers to adoption, which included low patient and physician awareness of relevant medical conditions and therapies, insufficient physician training, inadequate government support, and weak hospital management. To improve physician awareness and education, Medtronic established Medtronic University in Pudong, China. The organization, fully funded by Medtronic, offered physician-led training to other physicians at its facility in Pudong, at area hospitals, and online. In China, after the student graduates as a doctor, there s no follow-up training, Li explained. The idea of Medtronic University is to narrow the gap by providing continuing education into Medtronic-specific medical therapies. The university included the Cardiovascular Academy and Diabetes Academy, whose curriculums were developed by Medtronic employees in collaboration with advisory groups of professors, doctors, and key opinion leaders. Training programs included online courses, multi-day workshops, and hands-on, lab-based courses for specific procedures. While sharpening the skills of participating physicians, Medtronic University also boosted its standing with the Chinese government. The Ministry of Health incorporated Medtronic University s annual report into its publications, which were distributed to a wide range of Chinese hospitals and government departments. Beijing Patient Care Center In China, 260 million people struggled with chronic disease but were often unaware of potential medical therapies to treat it. To bridge this education gap, Medtronic opened a Patient Care Center in 2010 in a popular retail district of Beijing. Designed as an open, accessible education resource, the center s goal was to expand access to healthcare education and enable patients to make informed treatment decisions. It used a familiar, retail store-like format: individuals walked in and explored at their leisure, engaging with hands-on tools such as threedimensional heart models and interactive videos that conveyed information about the signs, symptoms, and treatment options for cardiovascular diseases and other chronic illnesses. Li elaborated: The concept is like Apple stores. We use high-tech, interactive technology to teach the patient about diseases and the options to treat the disease. The patient center is run by Medtronic, but is a joint effort with the Ministry of Health. We provide the funding while they provide doctors to conduct patient education. So far, we have trained 40,000 patients in the facility. The center is often visited by hospital presidents, government officials, and others. Many hospital CEOs are seeking our help to set up patient care centers in their hospitals. Healthy Heart for All According to Milind Shah, head of Medtronic s South Asia unit, Medtronic s biggest obstacle to growth in the Indian market was that most patients paid for care outof-pocket. A 2011 report in The Lancet noted only 10% of Indians had some form of insurance, and the country s public health expenditures were less than 1% of GDP. Shah explained that ability to pay was even difficult for Indians with medical insurance: 10

11 Omar Ishrak: Building Medtronic Globally Today, out of a 1.2 billion population, about 100 million people have limited coverage through an employer, the government, or their own insurance. Many major therapies cost more than what is covered by employers. Insurance for government employees technically covers the entire cost of the therapy, but the approval process is very difficult for expensive therapies. Even if an implantable defibrillator is covered, the doctor has to refer, then get multiple signatures, and wait for approval. Some patients die before they get approved. Using the PAA tool, Shah and his team discovered that many Indian patients were able to pay in installments over time. They have a cash flow challenge, he explained. To expand access to cardiac therapies, Medtronic piloted a creative new program, Healthy Heart for All, in several Indian cities. Medtronic took the unorthodox step of guaranteeing bank loans provided to patients to finance their medical care. It was India s first financing plan for medical devices. The Healthy Heart for All team partnered with local hospitals and community organizations to raise public awareness of cardiac disease, options for treating it, and the financing opportunities the program offered. Through the PAA tool, Medtronic management realized many patients in India with cardiac disease were not getting diagnosed. As part of the program, Medtronic created diagnostic camps to provide health screenings for low-income populations in rural villages. Technicians used a low-cost electrocardiogram patch to screen patients, and then wirelessly sent the results to a remote monitoring station, using a third-party service on a subscription basis, with interpretation by trained physicians. According to Coyle, By getting granular with the PAA tool, we identified what the real barrier was. The patient pays for the patch and two weeks of monitoring. Once they have been diagnosed with cardiac disease, they go to an implant center that we have set up. Now we are looking at bringing this approach back to the U.S. and European markets. Additional services included an information hotline and website, and dissemination of educational materials. The program was highly successful, as device implants to treat cardiac rhythm disease and cardiovascular conditions doubled in the pilot period. Looking forward, the company planned to expand the program in India and roll it out in other emerging markets. When we find something that works, like Healthy Heart for All, we look for other regions with the same barriers and create adapted versions for them, explained Martha. Running hospital catheterization labs in Europe Not all of Medtronic s business model innovations were in emerging markets. Healthcare systems in mature markets also had constraints that inhibited care delivery, as well as Medtronic s growth potential. Rob ten Hoedt described an innovative business model in which Medtronic owned the capital equipment in hospital catheterization labs (cath labs) that was required for a wide variety of cardiovascular procedures, many of which utilized Medtronic products. Many hospitals in Europe have severe constraints on capital equipment purchases, ten Hoedt explained. They cannot afford the investment to build the cath lab infrastructure. To expand our market share, we developed a model where we own the cath lab infrastructure for the hospitals, including the equipment, and their doctors do the procedures. It s a wonderful model because we re becoming part of the solution to rising healthcare costs. Medtronic signed its first such contract with a German hospital in 2012, with six additional contracts expected to be signed across Europe in Medtronic was paid a fixed fee per procedure that covered cath lab depreciation, pacemakers, and other costs. By leveraging our balance sheet to help hospitals, we ve found our market share increases substantially. The most efficient option for the hospitals is to use as many Medtronic products in that cath lab as possible, said ten Hoedt. 11

12 Omar Ishrak: Building Medtronic Globally NayaMed Another Europe-based business model innovation was NayaMed, Medtronic s new value brand introduced in NayaMed s lower-cost model scaled back product features and services associated with Medtronic s high-end pacemakers and defibrillators to make treatment available to more patients in a price-constrained environment. Martha explained: NayaMed is a new brand, new company, new offering as Medtronic s value brand. Products have fewer features, but the real innovation is the go-to-market strategy. Instead of our traditional people-intensive strategy of providing personnel support for every pacemaker implant, NayaMed offers a business model where you don t get all the service. The primary Medtronic-brand customer is the physician who wants all the features and support. NayaMed s primary customer is the hospital CFO, who tends to only want the bare bones. Medtronic s First Chinese Acquisition In 2007, Medtronic established a joint venture with Weigao Orthopedics in which Medtronic had 51% ownership, but did not have operational control. At the end of 2012, Medtronic and Weigao reached a mutual agreement to dissolve the joint venture. In studying what to do with the joint venture, recalled O Connell, we recognized we needed a different strategy in China. In September 2012, Medtronic announced the acquisition of China Kanghui Holdings for $816 million. Founded in 1997 and headquartered in Changzhou, Kanghui was one of China s leading orthopedics device producers. In the first half of 2012, Kanghui generated $29.3 million in revenues and $10.3 million in net income. It first started offering products in orthopedic trauma and expanded to a full product portfolio of reconstructive joints, hips, knees and spine. Since this was Medtronic s first move into the global orthopedics market, Ishrak assigned the acquired company global responsibility to develop this sector out of its Chinese headquarters, making it Medtronic s first SBU located outside the U.S. This agreement is directly aligned with our corporate strategies of globalization and economic value, said Ishrak. Kanghui represents a significant investment in China, accelerating Medtronic s overall globalization strategy with an established value segment distribution network and strong R&D and operational capabilities. When the acquisition was completed, Ishrak and O Connell decided that Kanghui would retain its existing management team and become Medtronic s first fully integrated business unit outside the U.S. O Connell assigned a full-time integration leader for Kanghui. Although Kanghui only has revenues around $60 million, we are treating it as a division of Medtronic, reporting to me, said O Connell. He continued, It is a fully integrated business with its own R&D, manufacturing, product lines, and global distribution, with 20% of revenues from outside China. Eight of Kanghui s top 15 executives have multinational experience. Kanghui CEO Libo Yang was formerly head of J&J Orthopedics in China and educated at the Thunderbird School in Arizona. The new orthopedics SBU in China was seen as a platform through which Medtronic could execute reverse innovation. Coyle explained, We used to develop new products and marketing approaches in developed markets and apply them to emerging markets. With all the cost pressures today, we are asking whether we can apply what we learn in emerging markets to developed markets. As hospital budgets get compressed, this is an avenue toward reverse innovation to enable us to deliver the same level of care more efficiently in developed markets. 12

13 Omar Ishrak: Building Medtronic Globally Conclusion Reflecting on his first 18 months as CEO, Ishrak felt confident that he had brought the company a renewed sense of vigor through emphasis on globalization, demonstrating the economic value of its products, and improved execution. The company s growth had turned positive, with 4% revenue growth in 2012, but this was still below what he hoped to achieve as his strategies began to materialize. With the U.S. market declining by 1% and other developed markets growing at 2-3%, Ishrak wondered how much growth he could count on from developed markets. Following several years of decline, Medtronic s stock had partially recovered from its $38 share price when Ishrak joined the firm to its present level of $45, closely paralleling the S&P 500 index. Ishrak recognized Medtronic s stock price historically was closely correlated to its growth rate and trading well below its historic highs. With key analysts considering it more of a value stock than a growth stock, Medtronic was unlikely to be accorded the price-to-earnings premium it had enjoyed historically. (See Exhibit 14 for Medtronic s stock chart.) Ishrak wondered whether he should take further steps to accelerate Medtronic s growth. Would expansion in emerging markets be sufficient to restore growth? Was it time to apply the business model innovations to the U.S. market to combat pressure on healthcare costs? He also contemplated alternative strategies, such as focusing on increasing market share or an allout push to develop new medical therapies that would create new markets. Or he could deploy Medtronic s high operating cash flow to make acquisitions to expand into high-growth medical therapies, as the company did in the late 1990s. He decided to set up a special executive committee off-site meeting to discuss these options. 13

14 Omar Ishrak: Building Medtronic Globally Exhibit 1 The Medtronic Mission To contribute to human welfare by application of biomedical engineering in the research, design, manufacture, and sale of instruments or appliances that alleviate pain, restore health, and extend life. To direct our growth in the areas of biomedical engineering where we display maximum strength and ability; to gather people and facilities that tend to augment these areas; to continuously build on these areas through education and knowledge assimilation; to avoid participation in areas where we cannot make unique and worthy contributions. To strive without reserve for the greatest possible reliability and quality in our products; to be the unsurpassed standard of comparison and to be recognized as a company of dedication, honesty, integrity, and service. To make a fair profit on current operations to meet our obligations, sustain our growth, and reach our goals. To recognize the personal worth of employees by providing an employment framework that allows personal satisfaction in work accomplished, security, advancement opportunity, and means to share in the company s success. To maintain good citizenship as a company. Source: Company documents. Exhibit 2 Medtronic Logo and Employee Medallion Every new Medtronic employee received a medallion as a reminder of their role and responsibility in fulfilling the company s mission. The front of the medallion displayed the Medtronic logo: a human figure shifting in stages to an upright standing position, representing the restoration of health. The other side of the medallion displayed a message: Contributing to human welfare by the application of biomedical engineering to alleviate pain, restore health, and extend life. Source: Company documents. 14

15 Omar Ishrak: Building Medtronic Globally Exhibit 3 Key Events in Medtronic s History 1949 Founded by Earl Bakken and Palmer Hermundslie for medical equipment repair 1958 Bakken invents external wearable pacemaker, in conjunction with Dr. C. Walton Lillehei at University of Minnesota 1962 Out of cash and nearing bankruptcy, Medtronic obtains $200,000 in funding from Community Investment Enterprises 1962 Bakken creates Medtronic mission, in conjunction with President Thomas Holloran 1970 Geographic expansion in The Netherlands, Puerto Rico, France, Brazil and Japan 1974 Xytron battery failures lead to reputational damage and loss of market share 1976 Board member Dale Olseth becomes CEO as Holloran returns to law practice 1977 Medtronic stock listed on New York Stock Exchange 1985 Failures of 6972 pacemaker lead create crisis of confidence and FDA investigation 1985 Board member Winston Wallin becomes CEO, replacing Olseth 1986 Board member Glen Nelson, MD, becomes executive vice president, later vice chair 1989 Honeywell executive vice president Bill George becomes president and COO; Medtronic market capitalization exceeds $1 billion 1990 U.S. Supreme Court rules in favor of Medtronic over Eli Lilly, opening implantable defibrillator market to Medtronic 1991 George becomes CEO as Wallin retires as CEO; Medtronic revenues exceed $1 billion 1992 Patent settlement with Siemens for $500 million used for creating medical therapies 1996 George becomes chair when Wallin retires from board Medtronic acquires six companies for total of $13 billion to expand into spine surgery, neuro-surgery, coronary stents, cardiovascular surgery, diabetes pumps 2000 Medtronic market capitalization exceeds $60 billion 2001 COO Art Collins becomes CEO as George completes 10-year term 2007 COO Bill Hawkins becomes CEO as Collins retires 2011 Former GE executive Omar Ishrak becomes CEO as Hawkins retires Source: Created by casewriters. For a more comprehensive timeline, see 15

16 Omar Ishrak: Building Medtronic Globally Exhibit 4 Reverse Innovation at GE Healthcare: Creating an Ultrasound for the China Market GE Healthcare has been a leading supplier of big, powerful, premium-priced ultrasound scanners since the 1980s. Looking to stimulate growth, the company sought additional markets overseas. China, with its population of more than one billion, offered huge potential. So, the company did what seemed natural. It created a sales and distribution center in China, with the goal of distributing global products locally. This was a classic glocalization move. After ten years in the market, GE Healthcare was unable to unlock China s potential. Sales were a mere $5 million negligible in GE terms and growth was slow. The company remained a marginal player. All this changed during the first decade of the twenty-first century. In 2002, GE introduced its first portable ultrasound scanner in China. By 2008, the product was offered for just $15,000, a mere 15% of the cost of the low-end traditional ultrasound unit. Performance was not as good, of course, but it was certainly much better than a 15% solution, and performance has since improved. How did GE get there? By letting go of the glocalization model and recognizing that reverse innovation was the only way to address unique market needs: Ultra-low cost. More than 90% of the Chinese population is served by poorly funded, lowtech hospitals or basic clinics in rural villages. For these patients, the cost of receiving care is the first consideration. Portability. Clinics in rural areas lack sophisticated imaging technology, and transportation to urban hospitals is difficult, especially for the sick. Many patients in China can t travel to the ultrasound machine, so the machine must be able to travel to them. Ease of use. Rural Chinese doctors are not specialists in narrow fields, as is customary in the rich world. Instead, they must be jacks-of-all-trades. They need ultrasound devices that are very easy to use. GE entrusted development of the Chinese ultrasound machine to Omar Ishrak.... Ishrak had sufficient clout both to ensure the autonomy of a local engineering team that had its own P&L and to facilitate the team s access to necessary global resources. The team was able to build on a conceptual breakthrough from a GE product-development group in Israel that had discovered radical cost savings by transferring the operational muscle of ultrasound technology from expensive custom hardware to far less expensive software. Today, the portable machine is the growth engine for GE s ultrasound business in China. Between 2002 and 2008, worldwide sales from portable ultrasound products skyrocketed from $4 million to around $278 million, an average annual compounded growth rate of 50 to 60%. And for the team members who did the engineering work, there is satisfaction in knowing they improved lives.... A pleasant surprise for Ishrak and his colleagues was the immediate ease with which they were able to find opportunities for the new device in the rich world. Those opportunities were in marginalized markets (rich-world markets that, by themselves, are too small to justify a major innovation effort). Source: Vijay Govindarajan and Chris Trimble, Reverse Innovation: Create Far From Home, Win Everywhere (Boston: Harvard Business Review Press, 2012), pp

17 Omar Ishrak: Building Medtronic Globally Exhibit 5 Dominant Logic of Glocalization versus Reverse Innovation Strategies The authors of Reverse Innovation describe the ability to execute reverse innovation defined as any innovation that is adopted first in the developing world as a competitive necessity for firms accustomed to innovating for and deriving most revenues from mature markets. Many large Western multinationals have long operated with the assumption that they can successfully tap emerging markets by exporting modified, lower-end versions of products created for rich-world customers. The authors contrast this strategy, termed glocalization, with reverse innovation in the table below. Executing reverse innovation requires a change in mindset. The authors argue that firms must facilitate clean-slate innovation, free of the assumptions that drove strategy and product development in the past. Steps required to achieve this include identifying and challenging old assumptions, moving resources and decision-making authority to emerging markets, creating separate business scorecards for developing markets, and highlighting the importance of emerging markets through CEO-level actions and communications, as well as corporate events, expatriate assignments, etc. Moreover, the authors argue for empowering multifunctional local growth teams in emerging markets with significant authority over strategy and innovation for their local area. Glocalization Optimize products for the developed-world customer Cutting-edge, technologically sophisticated, performance-rich products with many features, new and fancy applications Take the simplest-possible approach to designing offerings for emerging markets; remove features to reduce cost Premium-price, high-margin orientation Technology push; product-out approach Look for customers to sell products to Sell products to current consumers of the product Gain market share Leverage current core competencies Exploitation mindset for emerging economies Use developed-world products to transform emerging markets Reverse Innovation Best solution for the emerging-market customer Frugal, functional, good-enough quality products Reinvent the product from the ground up; clean-slate innovation Low-price, high-volume orientation Customer-centric, market-back approach Identify customer pain points, and develop products to solve customer problems Create new consumption among noncustomers Create the market Build new core competencies Exploration mindset for emerging economies Build new global growth platforms based in emerging markets Source: Vijay Govindarajan and Chris Trimble, Reverse Innovation: Create Far From Home, Win Everywhere (Boston: Harvard Business Review Press, 2012), Table 3-1, p. 36. Text from pp. 4, 48,

18 Omar Ishrak: Building Medtronic Globally Exhibit 6 Medtronic, Inc. Consolidated Statements of Earnings, Selected Years, Fiscal Year (in millions, except per share data) Net sales $379 $1,742 $10,054 $15,392 $15,508 $16,184 Costs and expenses: Cost of products sold ,446 3,582 3,700 3,889 Research and development expense N/A ,424 1,472 1,490 Selling, general, and administrative expense ,214 5,282 5,427 5,623 Restructuring charges, net N/A N/A N/A Certain litigation charges, net N/A N/A Acquisition-related items N/A N/A N/A Amortization of intangible assets N/A N/A N/A Other expense, net N/A N/A Interest (income)/expense N/A (6) (45) Total costs and expenses 314* 1,300 7,511 11,448 11,844 12,039 Earnings from continuing operations before income taxes ,543 3,944 3,664 4,145 Provision for income taxes Earnings from continuing operations ,804 3,083 3,055 3,415 Earnings from discontinued operations Net earnings $47 $294 $1,804 $3,099 $3,096 $3,617 Basic earnings per share Earnings from continuing operations $0.05 $0.32 $1.49 $2.79 $2.84 $3.24 Net earnings $0.04 $0.32 $1.49 $2.80 $2.87 $3.43 Diluted earnings per share Earnings from continuing operations $0.05 $0.31 $1.48 $2.78 $2.82 $3.22 Net earnings $0.04 $0.31 $1.48 $2.79 $2.86 $3.41 Basic weighted average shares outstanding , , , ,053.9 Diluted weighted average shares outstanding , , , ,059.9 Cash dividends declared per common share $0.01 $0.05 $0.34 $0.82 $0.90 $0.97 Source: Compiled from Medtronic 2012 and 2005 annual reports, Standard & Poor s Research Insight, and Capital IQ, accessed January * Note: Financial data not available in some instances due to changes in reporting over time. Some costs and expenses not shown in 1985 due to changes in reporting. Early years may not reflect later acquisitions. 18

19 Omar Ishrak: Building Medtronic Globally Exhibit 7 Medtronic Business Revenue Mix, 2012 Source: Company documents. Exhibit 8 Medtronic Geographic Revenue Mix, 2012 Source: Adapted from company documents. 19

20 Omar Ishrak: Building Medtronic Globally Exhibit 9 Medtronic s Key Businesses Size and Growth Data (FY 2012 unless otherwise stated) SBU Market Size ($B) *Market Growth (%) ( 11-12) Medtronic Revenue ($B) *Medtronic Revenue Growth (%) Medtronic Market Share (%) Total CRDM $13.5-2% $5.0 0% ~37% Pacemakers $4.5-1% $2.0 +4% ~45% Defibrillators $6.5-7% $2.8-5% ~45% AF & Other $2.5 +9% $ % ~10% Coronary Vascular $6.5-3% $1.6 +6% ~25% Stents ($4.4) +1% ($1.1) +8% ~24% Endovascular $ % $ % ~19% Structural Heart $3.9 +8% $ % ~28% Spine $9.7 0% $3.3-4% ~35% Neuromodulation $2.4 +8% $1.7 +7% ~70% Diabetes $ % $ % ~65% Surgical Technologies $5.2 +7% $ % ~25% Total MDT $ % $ % ~34% Source: Compiled from company documents, citing Medtronic reports and analyst and industry research reports. * All growth rates are given in constant currency. Exhibit 10 Medtronic s Key Geographies Size and Growth Data (FY 2012 unless otherwise stated) Geography Market Size ($B) *Market Growth (%) ( 11-12) Medtronic Revenue ($B) *Medtronic Revenue Growth (%) Medtronic Market Share (%) U.S. $25.0-1% $8.8-1% ~35% Western Europe & Canada $ % $4.3 +4% ~40% Latin America $1.6 +9% $ % ~20% Central/Eastern Europe $ % $ % ~40% Middle East and Africa $0.7 +9% $ % ~40% Greater China $ % $ % ~25% Asia Pacific $5.6 +4% $1.6 Japan $3.8 +3% $0.9 +3% ~30% Other Asia Pacific $1.8 +5% $0.7 +3% ~40% South Asia $ % $ % ~40% Total $ % $ % ~35% Source: Compiled from company documents, citing Medtronic reports and analyst and industry research reports. * All growth rates are given in constant currency. Data in this exhibit are estimated. 20

21 Exhibit 11 Medtronic Therapies Source: Compiled from company documents.

22 Omar Ishrak: Building Medtronic Globally Exhibit 12 Medtronic Executive Committee Source: Compiled from company documents. Note: On January 1, 2013, Simon Li retired as head of Greater China and was replaced by Chris Lee. Caroline Stockdale departed Medtronic on February 1,

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