直覺手術 (ISRG) 2020 Q4 法說會逐字稿

Ladies and gentlemen, thank you for your patience in holding, and welcome to the Intuitive Fourth Quarter of 2020 Earnings Release. (Operator Instructions) Just a brief reminder, today's conference is being recorded.

女士們，先生們，感謝您的耐心等待，歡迎來到直觀的 2020 年第四季度收益發布。 （操作員說明）只是一個簡短的提醒，今天的會議正在錄製中。

Now happy to turn the conference over to Head of Investor Relations, Philip Kim.

現在很高興將會議轉交給投資者關係主管 Philip Kim。

Good afternoon, and welcome to Intuitive's fourth quarter earnings conference call. With me today, we have Gary Guthart, our CEO; and Marshall Mohr, our Chief Financial Officer.

下午好，歡迎參加 Intuitive 第四季度財報電話會議。今天和我在一起的是我們的首席執行官 Gary Guthart；和我們的首席財務官 Marshall Mohr。

Before we begin, I would like to inform you that comments mentioned on today's call may be deemed to contain forward-looking statements. Actual results may differ materially from those expressed or implied as a result of certain risks or uncertainties. These risks and uncertainties are described in detail in our Securities and Exchange Commission filings, including our most recent Form 10-K filed on February 7, 2020, and Form 10-Q filed on October 19, 2020. Our SEC filings can be found through our website or at the SEC's website.

在開始之前，我想通知您，今天電話會議中提到的評論可能被視為包含前瞻性陳述。由於某些風險或不確定性，實際結果可能與明示或暗示的結果大不相同。這些風險和不確定性在我們的證券交易委員會文件中有詳細描述，包括我們於 2020 年 2 月 7 日提交的最新 10-K 表格和 2020 年 10 月 19 日提交的 10-Q 表格。我們的 SEC 文件可通過以下方式找到我們的網站或 SEC 的網站。

Investors are cautioned not to place undue reliance on such forward-looking statements. Please note that this conference call will be available for audio replay on our website at intuitive.com on the Latest Events section under our Investor Relations page. Today's press release and supplementary financial data tables have been posted to our website.

告誡投資者不要過分依賴此類前瞻性陳述。請注意，本次電話會議將在我們的網站上進行音頻重播，網址為：intuitive.com，位於我們投資者關係頁面下的“最新活動”部分。今天的新聞稿和補充財務數據表已發佈到我們的網站。

Today's format will consist of providing you with highlights of our fourth quarter results as described in our press release announced earlier today, followed by a question-and-answer session. Gary will present the quarter's business and operational highlights. Marshall will provide a review of our financial results. Then I will discuss procedure and clinical highlights. And finally, we will host a question-and-answer session.

今天的形式將包括為您提供我們今天早些時候宣布的新聞稿中所述的第四季度業績的亮點，然後是問答環節。 Gary 將介紹本季度的業務和運營亮點。 Marshall 將對我們的財務業績進行審查。然後我將討論程序和臨床亮點。最後，我們將舉辦問答環節。

With that, I will turn it over to Gary.

有了這個，我會把它交給加里。

Thank you for joining us today. Our fourth quarter capped a year in which the pandemic challenged our customers and our business. It highlighted some core strengths for the company, introduced some obstacles to overcome and triggered some changes for us.

感謝您今天加入我們。我們的第四季度是大流行給我們的客戶和業務帶來挑戰的一年。它突出了公司的一些核心優勢，引入了一些需要克服的障礙，並引發了我們的一些變化。

To put the year and quarter in context, let me first review some of the numbers. Procedures grew 6% year-over-year for the fourth quarter and 1% for the full year over 2019, resulting in approximately 1.25 million procedures in 2020. We placed 326 systems in the quarter, down from 336 systems in Q4 of 2019. For the full year, we placed 936 systems in 2020, down from 1,119 systems in 2019. Finally, revenue fell 3% in 2020 as the result of delays in surgical procedures as hospitals focused on treating COVID patients.

為了將年份和季度放在上下文中，讓我首先回顧一些數字。第四季度的程序同比增長 6%，與 2019 年全年相比增長 1%，導致 2020 年的程序約為 125 萬台。我們在本季度放置了 326 個系統，低於 2019 年第四季度的 336 個系統。全年，我們在 2020 年放置了 936 個系統，低於 2019 年的 1,119 個系統。最後，由於醫院專注於治療 COVID 患者，外科手術延遲，導致 2020 年收入下降 3%。

Digging a little deeper, our core business remains healthy. After the first surge of COVID abated during this past summer, our customers returned to more routine use of our systems and solutions. We believe that the Intuitive ecosystem enabled increased access to and practice of high-quality minimally invasive surgery, which may have helped hospitals conserve valuable intensive care resources during the pandemic.

再深入一點，我們的核心業務仍然健康。在去年夏天的第一次 COVID 激增減弱後，我們的客戶重新開始更常規地使用我們的系統和解決方案。我們相信 Intuitive 生態系統增加了獲得和實踐高質量微創手術的機會，這可能有助於醫院在大流行期間節省寶貴的重症監護資源。

Despite pressure on utilization of our systems due to COVID, our hospital customers continue to invest in building their Intuitive's robotics programs with additional systems, evidenced by a 7% increase in the clinical installed base in 2020. We saw committed customers strengthening their programs, likely due to their analysis of how well the Intuitive ecosystem satisfied their quadruple aim objectives, better outcomes, better care team experiences, better patient experiences and lower total cost to treat per patient episode. Lastly, we believe our investments in our analytics programs have helped customers routinely analyze their performance, supporting their programmatic insights in the year.

儘管 COVID 對我們的系統的使用造成了壓力，但我們的醫院客戶繼續投資於使用其他系統構建 Intuitive 的機器人程序，2020 年臨床安裝基數增加了 7% 就是明證。我們看到忠誠的客戶加強了他們的程序，可能由於他們分析了 Intuitive 生態系統如何滿足他們的四重目標、更好的結果、更好的護理團隊體驗、更好的患者體驗以及更低的每次患者治療的總成本。最後，我們相信我們對分析計劃的投資幫助客戶定期分析他們的績效，支持他們在這一年的計劃洞察力。

Our confidence in our core business and our long-term opportunity remains robust. In spite of near term uncertainty, which is as follows: first, the pandemic is resurgent in many regions, powered now by more contagious variants. While hospitals have better protocols to manage patients today than they did earlier in 2020, our weekly surgical data in December 2020 and continuing today shows another clamp down on surgeries.

我們對核心業務和長期機遇的信心依然強勁。儘管存在以下近期不確定性：首先，大流行在許多地區捲土重來，現在由更具傳染性的變種推動。儘管與 2020 年早些時候相比，醫院現在有更好的患者管理方案，但我們在 2020 年 12 月和今天繼續進行的每週手術數據顯示，手術再次受到壓制。

Furthermore, we believe diagnostic procedures are slowing in hard-hit regions. With diagnostic procedures running significantly below pre-pandemic levels, patients and hospitals will acutely feel the impact through disease progression and the more complex therapies necessary when patients do return for care. This delay in diagnostic pipelines will likely take several quarters to resolve, even after the threat of COVID begins to abate.

此外，我們認為在重災區的診斷程序正在放緩。隨著診斷程序的運行大大低於大流行前的水平，患者和醫院將通過疾病進展和患者返回接受治療時所需的更複雜的治療來敏銳地感受到影響。即使在 COVID 的威脅開始減弱之後，診斷管道的這種延遲也可能需要幾個季度才能解決。

Second, we know that future of new capital installs are highly sensitive to utilization rates. Delayed surgeries will also impact the growth of surgical departments, pressuring new system installs until excess capacity is consumed. Third, in countries where the government pays the health care bill, budget strain and economic fallout from COVID may impact health care spending in new and variable ways in different countries.

其次，我們知道未來的新資本安裝對利用率高度敏感。延遲手術也將影響外科部門的增長，迫使新系統安裝，直到消耗掉多餘的容量。第三，在政府支付醫療保健費用的國家，預算緊張和 COVID 帶來的經濟影響可能會以新的和多變的方式影響不同國家的醫療保健支出。

Lastly, the trend that started prior to the pandemic for increased data requirements and longer clearance time lines from regulators in the United States and Europe for our industry has continued this year. Taken together, these obstacles make predictions for the next several quarters difficult.

最後，在大流行之前開始的趨勢，即美國和歐洲監管機構對我們行業的數據要求增加和審批時間延長，這一趨勢今年仍在繼續。總而言之，這些障礙使未來幾個季度的預測變得困難。

As I mentioned earlier, 2020 has broadly eliminated some longer-term trends in health care that validate our thesis. The increased pressure on health care systems to conserve acute care resources for the sickest patients may have accelerated investments that enable patients to get the care they need with fast recovery, minimizing consumption of scarce hospital resources and reducing complications. The compounding value of analyzing real-time data and offline health care data to drive insights, to drive better care has become obvious this year. Lastly, we saw an acceleration of remote technology used to enable proctoring, learning and analysis.

正如我之前提到的，2020 年已經廣泛消除了一些驗證我們論點的醫療保健長期趨勢。為最嚴重的患者節省急症護理資源對醫療保健系統的壓力越來越大，這可能加速了投資，使患者能夠快速恢復獲得所需的護理，最大限度地減少對稀缺醫院資源的消耗並減少並發症。分析實時數據和離線醫療保健數據以推動洞察力、推動更好的醫療保健的複合價值在今年變得顯而易見。最後，我們看到了用於支持監考、學習和分析的遠程技術的加速發展。

I've heard it said that in good times, we develop ourselves to become who we want to be while hard times reveal who we really are. In the year, we set our priorities based on our values. We implemented community relief and customer relief, launched our extended use instruments program, mobilized local and remote training resources to support customers differently and continued to listen carefully to our customers to best understand their needs. We've seen positive customer response to this approach, which is reflected in our Net Promoter Score. You can find more information on these scores in our JPMorgan Healthcare Conference presentation from this month posted on our website.

我聽說過，在好的時候，我們發展自己成為我們想成為的人，而在困難的時候，我們會發現我們的真實身份。在這一年裡，我們根據我們的價值觀確定了我們的優先事項。我們實施了社區救濟和客戶救濟，啟動了我們的擴展使用儀器計劃，調動本地和遠程培訓資源以不同方式支持客戶，並繼續仔細傾聽客戶的意見，以最好地了解他們的需求。我們已經看到客戶對這種方法的積極反應，這反映在我們的淨推薦值中。您可以在我們網站上發布的本月摩根大通醫療保健會議演示文稿中找到有關這些分數的更多信息。

Over the past several years, we've been building our capabilities in different countries to better serve their health care systems. I'd like to take a moment to take you through how we performed outside the United States in the year.

在過去的幾年裡，我們一直在建立我們在不同國家的能力，以更好地服務於他們的醫療保健系統。我想花點時間帶你了解一下我們這一年在美國以外的表現。

Turning first to Asia. Our business in Japan is moving beyond urology, given reimbursements for a broad slate of procedures obtained in Japan in 2018 and 2020. Government hospitals in Japan have been conserving resources for COVID care, and the pandemic has introduced noticeable delays as the health care system reacts to outbreaks.

首先轉向亞洲。鑑於 2018 年和 2020 年在日本獲得的一系列程序的報銷，我們在日本的業務正在超越泌尿外科。日本的政府醫院一直在為 COVID 護理節省資源，隨著醫療保健系統的反應，大流行造成了明顯的延誤到爆發。

In Korea, our business continues to be dynamic with an innovation-oriented customer group adopting new products like our da Vinci SP. In China, we saw accelerated customer acceptance of our partnership with Fosun Pharma and our products, with growth in procedures and the business overall outpacing our pre-pandemic plans. In 2020, China emerged as our #2 procedure market.

在韓國，我們的業務繼續充滿活力，以創新為導向的客戶群採用了我們的達芬奇 SP 等新產品。在中國，我們看到客戶對我們與復星醫藥的合作夥伴關係和我們的產品的接受度加快，程序和業務的整體增長超過了我們大流行前的計劃。 2020 年，中國成為我們的第二大手術市場。

Turning to Europe. Our team in Germany has had success in engaging larger German hospital groups with increased system placements broadening our market access. Constraints on elective surgery have been implemented assertively in Germany in light of COVID.

轉向歐洲。我們在德國的團隊成功地與更大的德國醫院集團合作，增加了系統佈局，拓寬了我們的市場准入。鑑於 COVID，德國已果斷地實施了對擇期手術的限制。

In Germany, France, U.K., Italy and the Nordics, our goals have been to broaden da Vinci use beyond Urology. Progress therein has been hampered significantly by COVID. Lastly, we see relatively low public sector reimbursements in Europe for benign procedures. Innovations from Intuitive like da Vinci S and our extended use instruments are providing an option for more price-sensitive customers in these markets.

在德國、法國、英國、意大利和北歐，我們的目標是將達芬奇的應用範圍擴大到泌尿外科之外。 COVID 嚴重阻礙了其中的進展。最後，我們看到歐洲公共部門對良性程序的報銷相對較低。來自 Intuitive 的創新（如 da Vinci S 和我們的擴展使用儀器）為這些市場中對價格更敏感的客戶提供了一種選擇。

With regard to our innovation and product engines, we spent time walking through our progress at the JPMorgan Healthcare Conference this month and our presentation is available online at our website, intuitive.com. I'd recommend to the interested listener a review of those materials for greater insight into our progress.

關於我們的創新和產品引擎，我們在本月的摩根大通醫療保健會議上花時間回顧了我們的進展，我們的演示文稿可在我們的網站直觀.com 上在線獲取。我建議感興趣的聽眾回顧一下這些材料，以便更深入地了解我們的進展。

Summarizing briefly here, we're making good progress in advancing many elements of our ecosystem, including our advanced instruments, deepening our imaging and informatics programs, including our augmented reality program, Iris, and extending the launches of our new platforms. We grew the installed base in procedures for our single-port platform, da Vinci SP. We're focused on advancing clinical indications for SP in several regions as well as extending its instrument and accessory portfolio.

在這裡簡要總結一下，我們在推進生態系統的許多要素（包括我們的先進儀器）、深化我們的成像和信息學計劃（包括我們的增強現實計劃 Iris）以及擴展我們新平台的發布方面都取得了良好進展。我們增加了單端口平台 da Vinci SP 的安裝基礎。我們專注於在多個地區推進 SP 的臨床適應症，並擴展其儀器和附件組合。

For our flexible robotics platform, Ion, we saw strong clinical results and demand in the year but met manufacturing and supply performance challenges in the fourth quarter as catheter demand outpaced our forecasting models, and the need for important quality improvement implementations and COVID quarantines hampered our production. We are currently shipping Ion product and expect to meet the demand curve in the first half of 2021.

對於我們靈活的機器人平台 Ion，我們在今年看到了強勁的臨床結果和需求，但在第四季度遇到了製造和供應性能挑戰，因為導管需求超過了我們的預測模型，並且對重要的質量改進實施和 COVID 隔離的需求阻礙了我們生產。我們目前正在發貨 Ion 產品，預計將在 2021 年上半年滿足需求曲線。

Before Marshall takes you through our finances in detail, I'd like to touch on our financial strategy. Our operating model withstood the strains of 2020 well, starting with our decision several years ago to shift to greater flexibility in system placement models, the incorporation of sales, leasing and risk-shared models allowed us to meet customers' needs during a disruptive time.

在馬歇爾詳細介紹我們的財務之前，我想先談談我們的財務戰略。我們的運營模式很好地經受住了 2020 年的壓力，從幾年前我們決定轉向更大的系統部署模式靈活性開始，銷售、租賃和風險分擔模式的結合使我們能夠在顛覆性時期滿足客戶的需求。

Our investments in advanced instruments, including stapling and energy have been fruitful with growing revenues, improving margins and growing customer appreciation for advanced instruments. We've been investing capital in our manufacturing methods to increase quality and lower our costs, which in turn has allowed us to extend savings to our customers to allow them greater flexibility and deploying our products in more cost-sensitive environments. This has triggered a virtuous cycle that allows us greater volume, which in turn gives us greater ability to invest in higher volume processes. We'll continue to invest in this cycle going forward.

我們對先進儀器（包括訂書機和能源）的投資取得了豐碩的成果，收入不斷增長，利潤率提高，客戶對先進儀器的認可度不斷提高。我們一直在對我們的製造方法進行投資，以提高質量並降低成本，這反過來又使我們能夠為客戶節省更多資金，從而使他們具有更大的靈活性並在對成本更加敏感的環境中部署我們的產品。這引發了一個良性循環，使我們能夠獲得更大的產量，這反過來又使我們有更大的能力投資於更高產量的流程。我們將繼續投資於這個週期。

We believe we are still in the early innings of a long opportunity to substantially improve the quadruple aim in acute medical interventions using robotics, computing, advanced imaging and informatics. As a result, we continue to invest in our innovation engines to create and pursue these opportunities.

我們相信，我們仍處於利用機器人技術、計算、先進成像和信息學大幅改善急性醫療干預的四重目標的長期機會的早期階段。因此，我們繼續投資於我們的創新引擎，以創造和追求這些機會。

In closing, our priorities for 2021 are as follows: first, we'll support our customers' recovery of surgery during and post-pandemic; second, we'll focus on outstanding regional performance; third, we'll advance our priority programs and launches, SP, Ion, imaging and analytics, including new indications; and finally, continued expansion of clinical, economic and analytical evidence base for key procedures and countries.

最後，我們 2021 年的優先事項如下：首先，我們將支持客戶在大流行期間和之後的手術恢復；二是突出區域業績突出；第三，我們將推進我們的優先項目和發布、SP、Ion、成像和分析，包括新的適應症；最後，繼續擴大關鍵程序和國家的臨床、經濟和分析證據基礎。

I'll now turn the call over to Marshall, who will take you through financial matters in greater detail.

我現在將把電話轉給馬歇爾，他將帶你更詳細地了解財務問題。

Good afternoon. I will describe the highlights of our performance on a non-GAAP or pro forma basis. I will also summarize our GAAP performance later in my prepared remarks. A reconciliation between our pro forma and GAAP results is posted on our website. Revenue and procedures are consistent with our preliminary press release of January 13.

下午好。我將在非公認會計原則或備考基礎上描述我們表現的亮點。稍後我還將在準備好的評論中總結我們的 GAAP 表現。我們的備考結果和公認會計原則結果之間的對賬發佈在我們的網站上。收入和程序與我們 1 月 13 日的初步新聞稿一致。

Key business metrics for the fourth quarter were as follows: fourth quarter 2020 procedures increased approximately 6% compared with the fourth quarter of 2019 and increased approximately 10% compared with last quarter. Fourth quarter system placements of 326 systems decreased 3% compared with 336 systems last year and increased 67% compared with 195 systems last quarter. We expanded our installed base of da Vinci Systems over last year by 7% to approximately 5,989 systems. This growth rate compares with 8% in the last quarter and 12% last year.

第四季度的主要業務指標如下： 2020 年第四季度的程序與 2019 年第四季度相比增加了約 6%，與上一季度相比增加了約 10%。與去年同期的 336 個系統相比，第四季度 326 個系統的系統佈局減少了 3%，與上一季度的 195 個系統相比增加了 67%。與去年相比，我們將達芬奇系統的安裝基礎擴大了 7%，達到約 5,989 個系統。這一增長率與上一季度的 8% 和去年的 12% 相比。

Utilization of clinical systems in the field, measured by procedures per system, declined approximately 2% compared with last year and increased 8% compared with last quarter. The impact of COVID on da Vinci procedures vary by region. Resurgence of COVID in parts of Europe had significant impacts on procedures, including in Italy, U.K., Nordics and France. While the impact of COVID on procedures in the Asia Pacific region, including China, Japan and Korea, was far less significant.

按每個系統的程序衡量，該領域臨床系統的利用率與去年相比下降了約 2%，與上一季度相比增加了 8%。 COVID 對達芬奇程序的影響因地區而異。 COVID 在歐洲部分地區的死灰復燃對程序產生了重大影響，包括意大利、英國、北歐和法國。儘管 COVID 對包括中國、日本和韓國在內的亞太地區程序的影響要小得多。

In the U.S., fourth quarter procedure growth was impacted by the COVID resurgence, resulting in 5% year-over-year growth compared to 7% growth in the third quarter. The resurgence in U.S. and Europe was more acute and had a greater impact on procedures late in the quarter, a trend that continued into January.

在美國，第四季度的手術增長受到 COVID 復甦的影響，同比增長 5%，而第三季度的增長為 7%。美國和歐洲的複蘇更為嚴重，對本季度末的程序產生了更大的影響，這一趨勢一直持續到 1 月份。

The impact of a resurgence can be significant. For example, in California, the fourth quarter COVID resurgence turned a year-over-year da Vinci procedure growth in October of 8% to a year-over-year decline of 6% in December.

復甦的影響可能是巨大的。例如，在加利福尼亞州，第四季度 COVID 復甦將 10 月份達芬奇程序同比增長 8% 轉變為 12 月份同比下降 6%。

We also believe that reduced diagnosis reflecting patient concern over COVID exposure has impacted certain procedures globally. This has had its most pronounced effect on prostatectomies.

我們還認為，反映患者對 COVID 暴露擔憂的診斷減少已經影響了全球某些程序。這對前列腺切除術產生了最顯著的影響。

Despite the fact that hospitals are better equipped to handle COVID patients today compared to the outset of the pandemic, COVID-19 resurgences like those currently being experienced in parts of Europe and the U.S. have challenged hospital care capabilities and have negatively impacted da Vinci procedures. In addition, delays in diagnosis and treatment of underlying conditions will also continue to negatively impact da Vinci procedures.

儘管與大流行開始時相比，今天的醫院有更好的能力來處理 COVID 患者，但像歐洲和美國部分地區目前正在經歷的 COVID-19 死灰復燃已經對醫院護理能力提出了挑戰，並對達芬奇手術產生了負面影響。此外，基礎疾病診斷和治療的延誤也將繼續對達芬奇手術產生負面影響。

Uncertainties in this COVID environment are not predictable, and the vaccine rollout and its impact on controlling COVID spread is also not predictable. Given these uncertainties, we are not providing procedure guidance at this time. Philip will provide additional procedure commentary later in this call.

這種 COVID 環境中的不確定性是不可預測的，疫苗的推出及其對控制 COVID 傳播的影響也是不可預測的。鑑於這些不確定性，我們目前不提供程序指導。菲利普將在本次電話會議稍後提供額外的程序評論。

Fourth quarter capital placements exceeded our expectations, reflecting several factors. In certain cases, hospitals exhausted 2020 budgets and spend capacities. And in some cases, hospitals purchased systems in preparation for post-pandemic environment. We also experienced a higher level of trade-ins of SI systems for fourth generation systems, reflecting hospital desire to standardize fleet and to avail themselves to fourth generation technology of lower cost extended use instruments.

第四季度的資本配置超出了我們的預期，反映了幾個因素。在某些情況下，醫院用盡了 2020 年的預算和支出能力。在某些情況下，醫院購買系統是為了為大流行後的環境做準備。我們還經歷了第四代系統的更高水平的 SI 系統以舊換新，這反映了醫院希望標準化車隊並利用低成本擴展使用儀器的第四代技術。

Looking forward, we see the following capital revenue headwinds. Utilization declined 2% year-over-year, resulting in excess system capacity at hospitals. We expect customers to fill existing system capacity before purchasing additional capital. Some of the fourth quarter capital placements reflected hospitals exhausting 2020 budgets. As budgets reset for 2021, hospitals could reduce their capital spend, particularly as COVID strains hospital profitability.

展望未來，我們看到以下資本收入逆風。利用率同比下降 2%，導致醫院系統容量過剩。我們希望客戶在購買額外資金之前填補現有系統容量。第四季度的一些資本配置反映了醫院用盡了 2020 年的預算。隨著 2021 年預算的重新設置，醫院可能會減少資本支出，尤其是在新冠疫情影響醫院盈利能力的情況下。

We expect leasing to continue to increase as a percentage of overall placements. Macroeconomic conditions created by COVID could also impact hospital capital spending. And as we face competition in various markets, we may experience longer selling cycles and price pressures.

我們預計租賃佔整體安置的百分比將繼續增加。 COVID 創造的宏觀經濟條件也可能影響醫院的資本支出。而當我們面臨不同市場的競爭時，我們可能會經歷更長的銷售週期和價格壓力。

Additional revenue statistics and trends are as follows: total fourth quarter revenue was $1.329 billion, representing a 4% increase from last year and a 23% increase from last quarter. Fourth quarter revenue benefited from U.S. customer stocking of extended use instruments and higher-than-expected system placements.

其他收入統計和趨勢如下：第四季度總收入為 13.29 億美元，比去年增長 4%，比上一季度增長 23%。第四季度收入受益於美國客戶對延長使用儀器的庫存和高於預期的系統佈局。

Leasing represented 37% of current quarter placements compared with 35% last quarter. Fourth quarter placements included some larger IDN transactions where the IDN prefers purchase transactions. Excluding those transactions, leasing as a percentage of total placements would have been several percentage points higher. In an environment of COVID-19 as economic pressures increase, we anticipate more customers will seek leasing or alternative financing arrangements than reflected in historical run rates.

租賃佔當前季度安置的 37%，而上一季度為 35%。第四季度的安置包括一些 IDN 更喜歡購買交易的大型 IDN 交易。排除這些交易，租賃佔總配售的百分比會高出幾個百分點。在 COVID-19 的環境中，隨著經濟壓力的增加，我們預計將有更多的客戶尋求租賃或替代融資安排，而不是歷史運行率所反映的。

Approximately half of the systems placed in the fourth quarter involve trade-ins, which is higher than the 40% last quarter and higher than the average over the last couple of years. Trade-in activity can fluctuate and be difficult to predict.

第四季度放置的系統中約有一半涉及以舊換新，高於上一季度的 40%，也高於過去幾年的平均水平。以舊換新活動可能會波動且難以預測。

Fourth quarter average selling prices declined to $1.43 million from $1.61 million last year and $1.55 million in the third quarter. The decrease relative to last year reflects a lower mix of systems placed in China and Japan and a higher proportion of trade transactions. The decrease relative to last quarter reflects a higher proportion of trade-in transactions and a higher mix of indirect market placements.

第四季度平均售價從去年的 161 萬美元和第三季度的 155 萬美元降至 143 萬美元。與去年相比的下降反映了中國和日本的系統組合減少以及貿易交易比例較高。相對於上一季度的下降反映了以舊換新交易的比例更高以及間接市場配售的更高組合。

We recognized $14 million of lease buyout revenue in the fourth quarter compared with $17 million last quarter and $34 million last year. Lease buyout revenue has varied significantly quarter-to-quarter and will likely continue to do so.

我們在第四季度確認了 1400 萬美元的租賃收購收入，而上一季度為 1700 萬美元，去年為 3400 萬美元。租賃收購收入在每個季度之間變化很大，並且可能會繼續如此。

Instrument and accessory revenue per procedure increased to approximately $2,060 per procedure compared with $1,910 per procedure in the third quarter of 2020 and $1,980 realized in the fourth quarter of last year.

與 2020 年第三季度的每項程序的 1,910 美元和去年第四季度的 1,980 美元相比，每項程序的儀器和附件收入增加到每項程序約 2,060 美元。

The entirety of the increase compared to the third quarter reflects U.S. hospital stocking extended use instruments. We launched extended use instruments early in the quarter in the U.S. and mid-quarter in Europe. We will launch extended use instruments in other markets in 2021 and 2022, depending on regulatory requirements.

與第三季度相比的全部增長反映了美國醫院庫存延長使用器械。我們在本季度初在美國和本季度中期在歐洲推出了擴展使用工具。我們將在 2021 年和 2022 年在其他市場推出擴展使用儀器，具體取決於監管要求。

Going forward, we expect customers to adjust their instrument buying patterns and reduce their inventory levels to reflect the additional uses per instrument. In addition, extended use instruments and lower instrument pricing will result in lower I&A revenue per procedure to Intuitive.

展望未來，我們希望客戶調整他們的儀器購買模式並降低庫存水平，以反映每台儀器的額外用途。此外，延長使用儀器和降低儀器定價將導致 Intuitive 的每個程序的 I&A 收入降低。

The impact and timing of customer buying patterns and lower per-use revenue will likely begin to impact revenues in the first quarter but will depend on customer inventory practices and procedure volumes. While we expect price elasticity associated with extended use instruments to enable greater penetration into available markets, that benefit will be delayed by COVID and, otherwise, will take time.

客戶購買模式的影響和時機以及較低的每次使用收入可能會開始影響第一季度的收入，但這將取決於客戶的庫存實踐和程序量。雖然我們預計與擴展使用工具相關的價格彈性能夠更大程度地滲透到可用市場，但這種好處將被 COVID 延遲，否則將需要時間。

12 of the systems placed in the fourth quarter were SP systems, reflecting continued measured rollout of SP and the impact of COVID-19. Our installed base of SP systems is now 69: 8 in Korea and 61 in the U.S. Our rollout of the SP surgical system will continue to be measured, putting systems in the hands of experienced da Vinci users, while we pursue additional indications and optimize training pathways in our supply chain. We expect to initiate first cases associated with a U.S. colorectal clinical trial this quarter.

第四季度放置的系統中有 12 個是 SP 系統，反映了 SP 的持續測量推出和 COVID-19 的影響。我們的 SP 系統安裝基數現在在韓國為 69：8，在美國為 61。我們將繼續衡量我們推出的 SP 手術系統，將系統交到有經驗的達芬奇用戶手中，同時我們追求更多適應症並優化培訓我們供應鏈中的路徑。我們預計本季度將啟動與美國結直腸臨床試驗相關的第一例病例。

We placed 4 Ion systems in the quarter, beginning -- bringing the installed base to 36 systems. Ion system placements and procedures are excluded from our overall system and procedure counts. Ion system placements were affected by supply chain issues described by Gary earlier in the call. We expect to remediate these supply issues in the first half of 2021. Our rollout of Ion will continue to be measured while we optimize training pathways in our supply chain. Procedures under the PRECISE study are expected to complete in the second quarter of 2021.

我們在本季度開始安裝了 4 個 Ion 系統——使安裝基礎達到 36 個系統。離子系統放置和程序不包括在我們的整體系統和程序計數中。離子系統的佈置受到 Gary 早些時候在電話會議中描述的供應鏈問題的影響。我們預計將在 2021 年上半年解決這些供應問題。在我們優化供應鏈中的培訓途徑的同時，我們將繼續衡量 Ion 的推出。 PRECISE 研究下的程序預計將於 2021 年第二季度完成。

Outside the U.S., we placed 130 systems in the fourth quarter compared with 140 in the fourth quarter of 2019 and 79 systems last quarter. Current quarter system placements included 54 into Europe, 22 into Japan and 13 into China compared with 54 into Europe, 26 into Japan and 39 into China in the fourth quarter of 2019. System placements into China in the fourth quarter of 2019 were higher as hospitals accelerated tenders in anticipation of the possibility of higher tariffs.

在美國以外，我們在第四季度放置了 130 個系統，而 2019 年第四季度為 140 個，上一季度為 79 個。當前季度的系統安置包括歐洲 54 個、日本 22 個和中國 13 個，而 2019 年第四季度歐洲有 54 個、日本 26 個和中國 39 個。2019 年第四季度進入中國的系統安置較高，因為醫院為提高關稅的可能性而加速招標。

Moving on to gross margin and operating expenses. Pro forma gross margin for the fourth quarter of 2020 was 69.7% compared with 72.2% for the fourth quarter 2019 and 70.2% last quarter. The fourth quarter of 2020 included higher period costs associated with lower production and higher excess and obsolete inventory charges. The decrease relative to the fourth quarter of 2019 reflects higher period costs associated with lower production, higher excess and obsolete inventory charges and lower system ASPs.

繼續討論毛利率和運營費用。 2020 年第四季度的備考毛利率為 69.7%，而 2019 年第四季度為 72.2%，上一季度為 70.2%。 2020 年第四季度包括與較低產量以及較高的過剩和過時庫存費用相關的較高期間成本。相對於 2019 年第四季度的下降反映了與較低產量、較高的過剩和過時庫存費用以及較低的系統平均售價相關的期間成本較高。

As revenues are pressured by COVID-19, production levels may operate at below normal levels, which may result in higher labor costs and under-absorbed overhead and reduced product margins. In addition, product and customer mix fluctuate quarter-to-quarter and could cause fluctuations in gross margins.

由於 COVID-19 給收入帶來壓力，生產水平可能低於正常水平，這可能導致勞動力成本上升、間接費用吸收不足和產品利潤率下降。此外，產品和客戶組合按季度波動，可能導致毛利率波動。

Pro forma operating expenses decreased 6% compared with the fourth quarter of 2019 and increased 11% compared with the third quarter of 2020. The fourth quarter of 2020 includes a $25 million contribution to the Intuitive Foundation compared with a $5 million contribution in the fourth quarter of 2019 and no contribution last quarter.

與 2019 年第四季度相比，備考運營費用減少 6%，與 2020 年第三季度相比增加 11%。2020 年第四季度包括向 Intuitive Foundation 捐款 2500 萬美元，而第四季度為 500 萬美元2019 年，上個季度沒有貢獻。

Fourth quarter operating expenses continued to reflect reduced spending on activities directly impacted by COVID-19, including marketing events, travel and in-person training as well as lower variable compensation. These costs will naturally increase as the impact of COVID declines.

第四季度運營費用繼續反映受 COVID-19 直接影響的活動支出減少，包括營銷活動、旅行和麵對面培訓以及較低的可變薪酬。隨著 COVID 的影響下降，這些成本自然會增加。

We continue to believe we have a unique opportunity to expand the benefits of computer-aided surgery and acute interventions around the world, and we'll continue to invest in the business for the long term. During this period of COVID, we continue to invest in product development activities, including informatics, advanced imaging, advanced instruments and our Ion and SP platforms. Accordingly, you should expect the growth rate of R&D expenses in 2021 to significantly exceed the 2020 growth rate. We expect the growth rate of SG&A expenses to also increase significantly in 2021 compared to 2020.

我們仍然相信我們有一個獨特的機會來擴大全球計算機輔助手術和急性干預的好處，我們將繼續長期投資於該業務。在 COVID 期間，我們繼續投資於產品開發活動，包括信息學、先進成像、先進儀器以及我們的 Ion 和 SP 平台。因此，您應該預計 2021 年研發費用的增長率將大大超過 2020 年的增長率。與 2020 年相比，我們預計 2021 年 SG&A 費用的增長率也將顯著增加。

SG&A spending can be categorized as follows: investments in OUS markets will increase over 2020 spend as we expand our capabilities and investment in clinical data. Variable compensation will increase over 2020 as we reset goals and targets. Core spending on resources and infrastructure will increase over 2020 to prepare for a post-COVID environment. Spend on activities impacted by COVID like travel, marketing events and in-person training will increase as the impact of COVID declines.

SG&A 支出可分為以下幾類：隨著我們擴大能力和對臨床數據的投資，對 OUS 市場的投資將比 2020 年的支出增加。隨著我們重新設定目標和指標，可變薪酬將在 2020 年增加。資源和基礎設施的核心支出將在 2020 年增加，為後 COVID 環境做準備。隨著 COVID 的影響下降，在旅行、營銷活動和麵對面培訓等受 COVID 影響的活動上的支出將增加。

Our pro forma effective tax rate for the fourth quarter was 20.7% compared with our expectations of 20% to 21%, primarily reflecting the geographic mix of income. Our actual tax rate will fluctuate with changes in the geographic mix of income, changes in taxation made by local authorities and with the impact of onetime items. Our fourth quarter 2020 pro forma net income was $436 million or $3.58 per share compared with $426 million or $3.48 per share for the fourth quarter of 2019 and $341 million or $2.77 per share for last quarter.

我們第四季度的備考有效稅率為 20.7%，而我們的預期為 20% 至 21%，主要反映了收入的地域組合。我們的實際稅率將隨著收入地理組合的變化、地方當局的稅收變化以及一次性項目的影響而波動。我們 2020 年第四季度的備考淨收入為 4.36 億美元或每股 3.58 美元，而 2019 年第四季度為 4.26 億美元或每股 3.48 美元，上一季度為 3.41 億美元或每股 2.77 美元。

I will now summarize our GAAP results. GAAP net income was $364 million or $3.02 per share for the fourth quarter of 2020 compared with GAAP net income of $363 million or $2.99 per share for the fourth quarter of 2019 and GAAP net income of $317 million or $2.60 per share for last quarter. The adjustments between pro forma and GAAP net income are outlined and quantified on our website and include excess tax benefits associated with employee stock awards, employee stock-based compensation and IP charges, amortization of intangibles and acquisition-related items and legal settlements.

我現在將總結我們的 GAAP 結果。 2020 年第四季度 GAAP 淨收入為 3.64 億美元或每股 3.02 美元，而 2019 年第四季度 GAAP 淨收入為 3.63 億美元或每股 2.99 美元，上一季度 GAAP 淨收入為 3.17 億美元或每股 2.60 美元。備考和 GAAP 淨收入之間的調整在我們的網站上進行了概述和量化，包括與員工股票獎勵、員工股票薪酬和知識產權費用、無形資產攤銷和收購相關項目以及法律和解相關的超額稅收優惠。

GAAP net income for the fourth quarter and third quarters of 2020 also included pretax gains of $4.7 million and $61.7 million on our investments in private entities, resulting from our purchases of certain technologies. The EPS impact of these gains net of tax was $0.03 per share in the fourth quarter and $0.39 per share in the third quarter. These gains are excluded from our pro forma results.

2020 年第四季度和第三季度的 GAAP 淨收入還包括我們因購買某些技術而對私營實體的投資產生的 470 萬美元和 6170 萬美元的稅前收益。這些收益的稅後每股收益影響在第四季度為每股 0.03 美元，在第三季度為每股 0.39 美元。這些收益不包括在我們的備考結果中。

We ended the quarter with cash and investments of $6.9 billion compared with $6.4 billion at September 30, 2020 and $5.8 billion at December 31, 2019. The increase in cash in the fourth quarter reflected cash from operations, a reduction in inventory and overall working capital and stock exercises. We repurchased $34 million of shares in the quarter with an average price of -- at an average price of $661.10 per share.

截至本季度末，我們的現金和投資為 69 億美元，而 2020 年 9 月 30 日為 64 億美元，2019 年 12 月 31 日為 58 億美元。第四季度現金的增加反映了運營現金、庫存減少和整體營運資本和股票練習。我們在本季度以每股 661.10 美元的平均價格回購了 3400 萬美元的股票。

And with that, I'd like to turn it over to Philip, who will go over our procedure performance.

有了這個，我想把它交給菲利普，他將檢查我們的程序性能。

Thank you, Marshall. Our overall fourth quarter procedure growth was 6% compared to 19% growth during the fourth quarter of 2019 and 7% growth last quarter. Our Q4 procedure growth was driven by 5% growth in the U.S. and 11% growth OUS. Resurgences of COVID in the U.S. and Europe impacted our growth rates in the quarter, and we saw procedure growth rates decline as the quarter progressed, particularly late in the quarter.

謝謝你，馬歇爾。我們第四季度的整體程序增長率為 6%，而 2019 年第四季度的增長率為 19%，上一季度的增長率為 7%。我們的第四季度程序增長受到美國 5% 增長和 OUS 增長 11% 的推動。美國和歐洲新冠疫情的複甦影響了我們本季度的增長率，隨著季度的進展，我們看到程序增長率下降，尤其是在本季度末。

With respect to key contributors to growth, overall procedures in China and bariatrics in the U.S. were the largest drivers of procedure growth in Q4. In the U.S., within General Surgery, bariatric, cole and hernia were the largest contributors to procedure growth within the quarter. Bariatrics may be benefiting from certain patients prioritizing weight loss as obesity is a significant COVID risk factor. In addition, we continue to receive positive reviews of our short-form 60 stapler, which provides surgeons an optimized robotic toolset and feedback for bariatric procedures.

關於增長的主要貢獻者，中國的整體手術和美國的減肥是第四季度手術增長的最大驅動力。在美國，在普通外科中，減肥、科爾和疝是本季度手術增長的最大貢獻者。由於肥胖是一個重要的 COVID 風險因素，因此某些優先減肥的患者可能會受益於減肥治療。此外，我們繼續收到對我們的短型 60 吻合器的積極評價，它為外科醫生提供了優化的機器人工具集和減肥手術的反饋。

In China, procedure growth accelerated as new systems installed under the quota began to provide additional capacity for incremental growth. Q4 China procedures had broad-based growth in urology, thoracic, general surgery and gynecology.

在中國，隨著配額下安裝的新系統開始為增量增長提供額外容量，程序增長加速。 Q4 中國手術在泌尿外科、胸外科、普外科和婦科領域廣泛增長。

With respect to our more mature procedure categories in the U.S., Q4 gynecology procedure growth was up, reflecting growth in cancer procedures, partially offset by declines in benign procedures. On a worldwide basis, dVP procedures in the fourth quarter declined year-over-year and had similar trends as we described last quarter. COVID is impacting the diagnostic and patient pipeline related to dVP.

關於我們在美國更成熟的手術類別，第四季度婦科手術增長上升，反映了癌症手術的增長，部分被良性手術的下降所抵消。在全球範圍內，第四季度的 dVP 程序同比下降，並且與我們上一季度所述的趨勢相似。 COVID 正在影響與 dVP 相關的診斷和患者管道。

Now turning to the clinical side of our business. Each quarter on these calls, we highlight certain recently published studies that we deem to be notable. However, to gain a more complete understanding of the body of evidence, we encourage all stakeholders to thoroughly review the extensive detail of scientific studies that have been published over the years.

現在轉向我們業務的臨床方面。在這些電話會議的每個季度，我們都會重點介紹我們認為值得注意的某些最近發表的研究。但是，為了更全面地了解證據主體，我們鼓勵所有利益相關者徹底審查多年來發表的科學研究的廣泛細節。

Dr. Clark A. Wilson and Jihad Kaouk from the Cleveland Clinic and colleagues in a paper published in neurology described their experience evaluating robotic-assisted radical prostatectomy with da Vinci SP through an extraperitoneal approach and enhanced recovery protocol for same-day surgery. 60 subjects with organ-confined disease underwent an SP procedure with no patients requiring conversion to another approach.

克利夫蘭診所的 Clark A. Wilson 和 Jihad Kaouk 博士及其同事在神經病學上發表的一篇論文中描述了他們通過腹膜外方法和增強的當日手術恢復方案評估機器人輔助的達芬奇 SP 根治性前列腺切除術的經驗。 60 名患有器官局限疾病的受試者接受了 SP 手術，沒有患者需要轉換為另一種方法。

Median length of stay for all patients was 4.2 hours. 75% of all patients enrolled were discharged on the day of surgery and 96% of patients discharged within 24 hours, when excluding those either with surgery after 6:00 p.m or with preplanned admissions due to patient preference or significant comorbidities.

所有患者的中位住院時間為 4.2 小時。 75% 的入組患者在手術當天出院，96% 的患者在 24 小時內出院，排除下午 6:00 後接受手術或因患者偏好或嚴重合併症而預先計劃入院的患者。

The authors concluded a robotic-assisted radical prostatectomy with the da Vinci SP system and extraperitoneal approach can be performed safely and reproducibly as the same-day surgery. This publication adds to the number of early studies around the emerging SP technology, demonstrating encouraging results within robotic-assisted radical prostatectomy as a same-day surgery and acceptable, very operative, functional and short-term oncological outcomes in the hands of experienced surgeons for the appropriate patients. We look forward to the growth of the body of evidence around da Vinci SP.

作者得出結論，使用 da Vinci SP 系統和腹膜外方法可以安全、可重複地進行機器人輔助根治性前列腺切除術，就像當天手術一樣。該出版物增加了圍繞新興 SP 技術的早期研究數量，展示了機器人輔助根治性前列腺切除術作為當日手術的令人鼓舞的結果，以及在經驗豐富的外科醫生手中可接受的、非常可操作、功能性和短期的腫瘤學結果合適的患者。我們期待圍繞 da Vinci SP 的大量證據的增長。

Lastly, we'd like to highlight that our second annual sustainability report will be available after the call on our Investor Relations website.

最後，我們要強調的是，我們的第二份年度可持續發展報告將在我們的投資者關係網站電話會議後提供。

That concludes our prepared comments. We will now open the call to your questions.

我們準備好的評論到此結束。我們現在將打開您的問題的電話。

(Operator Instructions) First, we go to the line of Amit Hazan with Goldman Sachs.

（操作員說明）首先，我們與高盛一起前往 Amit Hazan。

I thought maybe I'd first go to your comments, in general, on hospital capital spending and maybe try to reconcile some of them. I think if you go back to last week, you cited hospitals with 7-plus systems were up strongly. And here, you're still citing lower utilization as the key headwind.

我想也許我會首先參考您對醫院資本支出的一般評論，然後嘗試調和其中的一些。我想如果你回到上週，你提到擁有 7 個以上系統的醫院都在強勁增長。在這裡，您仍然將較低的利用率作為主要不利因素。

And so I'm just wondering, are you otherwise seeing a skewing towards newer customers And just trying to get my hands around, I have to imagine it's complicated and hospital systems are different, but how much more color you can provide around kind of some of these different data points that you've provided?

所以我只是想知道，你是否看到了向新客戶傾斜的情況？只是試圖讓我動手，我不得不想像它很複雜，醫院系統也不同，但是你可以提供多少顏色您提供了哪些不同的數據點？

Yes. I think that -- go ahead.

是的。我認為——繼續。

Why don't I jump in, Marshall, and then I'll kick it back to you. Amit, thanks for the question. We were talking about earlier in the month here. We think there's some budget flushing that happened at the end of 2020.

馬歇爾，我為什麼不跳進去，然後我會把它踢回給你。阿米特，謝謝你的問題。我們在本月早些時候在這裡討論過。我們認為 2020 年底發生了一些預算沖水。

How strong that will be into 2021? Did they pull forward spending that would otherwise normally have been in '21? Hard to say.

到 2021 年會有多強？他們是否提前了原本通常會在 21 年出現的支出？很難說。

Having said that, if you look at where we were winning relative to other priorities, even if there is some budget pull forward, large customers were -- that already had robotics programs were expressing confidence with us, which we think is a positive.

話雖如此，如果你看看我們相對於其他優先事項的獲勝情況，即使有一些預算提前，大客戶 - 已經有機器人項目的大客戶對我們表達了信心，我們認為這是積極的。

The caution we're sending you now in this call is just that, over time, there'll be an equilibration, which is there is some excess capacity in the field because COVID is suppressing procedures.

我們現在在這次電話會議中向您發出的警告是，隨著時間的推移，將會出現一種平衡，即由於 COVID 正在抑製程序，該領域存在一些產能過剩。

And at some point, COVID will lift and that capacity will be absorbed. Some folks will invest ahead, getting ready and being able to work on backlog and others will be conservative and wait till they consume that capacity. Forecasting that is hard. And so that's how we're trying to help you navigate through this.

並且在某個時候，COVID 將解除，而這種能力將被吸收。有些人會提前投資，做好準備並能夠處理積壓的工作，而另一些人會保守，等到他們消耗掉這些容量。很難預測。這就是我們試圖幫助您度過難關的方式。

But Marshall, please clean up anything that you need to do in that answer.

但是馬歇爾，請清理您在該答案中需要做的任何事情。

No, you hit it perfectly.

不，你完美地擊中了它。

Okay. And as my follow-up, and separate on data and digital engagements to date. Again, kind of going off of a comment you made last week just hospital analytics and you talked about the 350 hospitals, 690 engagements. I'm just wondering how much more color you can give on that in terms of how much of that is that programmatic variety that you talked about that won't necessarily be monetized versus something that could either improve outcomes or reduce costs and potentially be monetized. Just any color around those early engagements would be helpful.

好的。作為我的後續行動，迄今為止的數據和數字參與是分開的。再一次，有點偏離你上週發表的關於醫院分析的評論，你談到了 350 家醫院，690 次參與。我只是想知道，你談到的程序化品種中有多少不一定會被貨幣化，而不是那些可以改善結果或降低成本並可能被貨幣化的東西，你還能提供多少色彩.這些早期參與的任何顏色都會有所幫助。

Yes. Thanks for the question. When we're talking about what we shared with you in the talk at JPMorgan, most of that is programmatic analysis. And it's not so much something that we think is going to be revenue-generating directly. We think that it illuminates the value of our ecosystem and strong da Vinci programs, and that is a benefit to us.

是的。謝謝你的問題。當我們談論我們在摩根大通的演講中與您分享的內容時，其中大部分是程序分析。我們認為這並不是直接產生收入的東西。我們認為它闡明了我們的生態系統和強大的達芬奇計劃的價值，這對我們有利。

It increases the stick rate. It allows people to see in a verifiable way within their own data sets, the value they're bringing. It gives them action plans to find opportunity for standardization and other kinds of efficiency improvements, so it's of high value to the customer and high value to us.

它增加了粘滯率。它允許人們在他們自己的數據集中以可驗證的方式看到他們帶來的價值。它為他們提供了行動計劃，為標準化和其他類型的效率改進尋找機會，因此它對客戶和我們都具有很高的價值。

Some of the other things that we've shared with you, for example, Iris, those things are something that we'll collect revenue for. They probably won't become huge revenue arms in and of themselves, but they bring value on a per-case basis, and it's something that we can talk to the customer about in terms of value creation there. They also strengthen the ecosystem.

我們與您分享的其他一些東西，例如 Iris，這些東西是我們將為其收取收入的東西。它們本身可能不會成為巨大的收入武器，但它們會在每個案例的基礎上帶來價值，這是我們可以在那裡與客戶討論的價值創造問題。它們還加強了生態系統。

So I think for shareholders who are asking the question, "Hey, when does informatics and machine learning create a revenue arm of its own?" I'm not sure that's the right question. I think that analytics and informatics power the ecosystem as a whole. We're pretty agnostic as to how we get paid for that. If we get paid for that through increased utilization, wonderful. That works great. We look at the cost to develop those programs and kind of overall their contribution to our financial health. But we don't have to charge for them individually if that's not how a customer wants to pay for it.

所以我認為對於那些提出問題的股東來說，“嘿，信息學和機器學習什麼時候會創造出自己的收入部門？”我不確定這是正確的問題。我認為分析和信息學為整個生態系統提供動力。對於我們如何獲得報酬，我們非常不可知論。如果我們通過提高利用率來獲得報酬，那就太好了。這很好用。我們著眼於開發這些計劃的成本以及它們對我們財務健康的總體貢獻。但是，如果客戶不想這樣付款，我們就不必單獨收費。

Let me turn it to you, Marshall, and any color you want to add.

讓我把它交給你，馬歇爾，以及你想添加的任何顏色。

No, I think that's right. I think that we look at it as the opportunity to increase the ecosystem and to expand our base and/or accelerate adoption.

不，我認為這是對的。我認為我們將其視為增加生態系統並擴大我們的基礎和/或加速採用的機會。

Next, we have the line of David Lewis of Morgan Stanley.

接下來，我們有摩根士丹利的大衛劉易斯的產品線。

Marshall, I appreciate we don't have guidance and I appreciate your commentary on spending levels for '21, but as I'm sure you appreciate without revenue figures, those are kind of hard numbers to put in context. So I was wondering if you could help us out a little bit more. I mean is the right messaging here that OpEx growth in '21 is going to go faster than whatever the sales growth rate is?

馬歇爾，我很欣賞我們沒有指導，我很欣賞你對 21 年支出水平的評論，但我相信你在沒有收入數據的情況下會欣賞，這些數字很難放在上下文中。所以我想知道你是否可以幫助我們更多一點。我的意思是，21 年的 OpEx 增長將比銷售增長率更快，這是正確的信息嗎？

Or ask the -- kind of same question a different way. I mean SG&A for the last several years has grown in line with revenue and R&D has grown kind of 2x revenue growth rates. Are those the type of -- any of those parameters, you would kind of give us any visibility and to be super helpful. And then I've got a couple of follow-ups.

或者用不同的方式問——同樣的問題。我的意思是，過去幾年的 SG&A 與收入同步增長，而研發的收入增長率達到了 2 倍。那些參數的類型 - 任何這些參數，你都會給我們任何可見性並且非常有幫助。然後我有幾個跟進。

It's a good question, and I am empathetic to the fact that we aren't giving you revenue guidance and so it's hard to put those numbers into context. However, it really does come down to that the impacts of COVID are really pretty unpredictable. And so if COVID wanes quickly, then I think the spend we're talking about might match up better with a revenue increase.

這是一個很好的問題，我對我們沒有為您提供收入指導這一事實表示同情，因此很難將這些數字置於上下文中。但是，確實可以歸結為COVID的影響確實非常不可預測。因此，如果 COVID 迅速消退，那麼我認為我們正在談論的支出可能會更好地與收入增長相匹配。

But I got to tell you, the point of my -- the reason I pointed this all out in terms of the increases in expenses that we were able -- this year, we saw a long period where COVID impacted us. And we -- some of the variable expenses I outlined came in pretty low relative to what they historically had been. And those will increase as COVID goes away.

但我必須告訴你，我的觀點——我指出這一切的原因是我們能夠增加的開支——今年，我們看到了 COVID 影響我們的很長一段時間。而且我們 - 我概述的一些可變費用相對於它們的歷史水平相當低。隨著COVID的消失，這些將增加。

But in addition to that, there are other expenses that we will continue to spend. The increase -- there will be increases regardless of what happens to COVID. I think we want to continue to invest in the R&D areas that I mentioned. And we want to -- because we see that there's a real opportunity to continue to expand our marketplace and to expand penetration in the long term. And so we're going to increase those costs. I know I haven't given you what you're looking for, but it's just a very difficult environment to predict revenue and procedures at this point.

但除此之外，我們還將繼續花費其他費用。增加——無論 COVID 發生什麼情況，都會增加。我認為我們希望繼續投資於我提到的研發領域。我們想要 - 因為我們看到有一個真正的機會來繼續擴大我們的市場並擴大長期滲透率。因此，我們將增加這些成本。我知道我沒有給你你想要的東西，但在這一點上預測收入和程序只是一個非常困難的環境。

Okay. And then just maybe 2 quick follow-ups. One easier to answer than the other. Just in terms of volumes. Obviously, fourth quarter was more similar to third quarter. And generally speaking, the message from most corporates last week was that first quarter is going to be at fourth quarter, if not, frankly, a little worse. I just wonder if you could sort of comment on sort of what you're seeing from the procedure environment here in the first quarter?

好的。然後可能只是 2 次快速跟進。一個比另一個更容易回答。就數量而言。顯然，第四季度與第三季度更為相似。一般而言，上周大多數公司發出的信息是，第一季度將是第四季度，如果不是，坦率地說，情況會更糟一些。我只是想知道您是否可以對您從第一季度的程序環境中看到的內容髮表評論？

And then just secondarily, on the extended use program, obviously, we saw kind of a bolus on revenue per procedure this particular quarter as hospitals didn't change inventory patterns. Are you seeing any evidence? I know it's hard in COVID that it's driving higher demand, the extended use program driving higher demand. And when would you expect those revenue per procedure numbers to begin to reverse? Is that as early as the first quarter or probably more likely middle part of the year? Sorry for both questions.

其次，在擴展使用計劃中，很明顯，由於醫院沒有改變庫存模式，我們在這個特定季度看到了每次手術的收入有所增加。你有沒有看到任何證據？我知道在 COVID 中很難推動更高的需求，擴展使用計劃推動更高的需求。您預計每個程序的收入何時開始逆轉？最早是在第一季度還是更可能在今年年中？很抱歉這兩個問題。

Yes. So your -- the first part of your question was...

是的。所以你的 - 你問題的第一部分是......

Q1 volume update.

Q1 卷更新。

Yes. Q1 volume. I made the comment that as we went through the quarter, the resurgence became more acute and it had a greater impact on procedures. And so I gave you the California example of where you go from growth in October to reduction in December. That should be an indication of the level of sort of impact they can have.

是的。第一季度成交量。我發表評論說，隨著我們度過這個季度，復甦變得更加嚴重，並且對程序產生了更大的影響。所以我給你舉了加利福尼亞的例子，說明你從 10 月份的增長到 12 月份的減少。這應該表明他們可以產生的影響程度。

And then I may -- I also made the comment that we saw the trends at the end of the quarter continue into January. So I think you said that other companies are saying that Q1 could be worse, it could be. But again, we're not going to try to predict exactly where it's going to come out, given the uncertainties around it. But it's clear coming into the quarter, it was at the bottom end of what was going on in Q4.

然後我可能 - 我還發表評論說，我們看到本季度末的趨勢持續到 1 月份。所以我認為你說其他公司說第一季度可能會更糟，它可能會。但同樣，考慮到周圍的不確定性，我們不會試圖準確預測它會在哪裡出現。但很明顯，進入第四季度，它處於第四季度的底端。

As far as extended use instruments go, we launched it in the U.S. in -- at the beginning of the quarter and in Europe in the middle of the quarter, about 3/4 of our customers are now acquiring extended use instruments. They're starting to be used on procedures. It's really hard for us to predict exactly when we'll start to see the benefits of those extended use instruments in terms of elasticity and -- price elasticity, and it's certainly going to be confounded by COVID.

就延長使用儀器而言，我們於本季度初在美國和本季度中期在歐洲推出了它，我們大約 3/4 的客戶現在正在購買延長使用儀器。它們開始用於程序。我們真的很難準確預測何時會開始看到這些擴展使用工具在彈性和價格彈性方面的好處，而且它肯定會被 COVID 混淆。

So I think it will take time. I think it's going to take a while before we start to see that. Sometimes you have to point out the benefits to the hospital. You have to sell it a little bit. And I just think we'll be patient about it.

所以我認為這需要時間。我認為我們需要一段時間才能開始看到這一點。有時您必須指出對醫院的好處。你必須賣一點點。我只是認為我們會對此保持耐心。

Next, we have the line of Bob Hopkins, Bank of America.

接下來，我們有美國銀行 Bob Hopkins 的產品線。

Gary, I wanted to get your opinion on 2 geographies, if okay. First, on the U.S. Just curious, do you think that perhaps by the second half of this year, there's a chance based on everything you're seeing that we could be close to a normal level of surgical procedure volumes in the U.S. or given what you're seeing on the diagnostic side and the slow vaccine rollout that, that's more likely to be a 2022 event? And then I'd also love to get your opinion on China and the durability of the phenomenal growth you appear to be having here of late?

加里，如果可以的話，我想听聽你對兩個地區的看法。首先，關於美國 只是好奇，你認為也許到今年下半年，根據你所看到的一切，我們有可能接近美國的外科手術量的正常水平，或者考慮到什麼您在診斷方面看到了疫苗的緩慢推出，這更有可能是 2022 年的事件？然後我也很想听聽你對中國的看法，以及你最近在這裡所經歷的驚人增長的持久性？

Bob, on the first one, the U.S., I won't predict for you, but let's talk about the puts and the takes, the things that are going to be the push/pull about it. Clearly, hospitals want to get back to treating patients who are non-COVID patients. There's a demand and the desire to do that.

鮑勃，關於第一個，美國，我不會為你預測，但讓我們談談看跌期權，以及將成為推/拉的事情。顯然，醫院希望重新開始治療非 COVID 患者。有這樣做的需求和願望。

It takes a couple of things. One is that resources get freed up from treating COVID patients to allow them to treat other things, and some of that is ICU resources and a lot of it is staff. So as COVID surges go, so does access to that set of resources. You're tracking and analysis is as good as ours in terms of looking at how well the vaccine is going to go out and what the COVID numbers might be. So I think that's a large part of it.

這需要幾件事。一是從治療 COVID 患者中騰出資源，讓他們可以治療其他事情，其中一些是 ICU 資源，其中很多是工作人員。因此，隨著 COVID 的激增，對這組資源的訪問也隨之而來。在查看疫苗的效果如何以及 COVID 數字可能是多少方面，您的跟踪和分析與我們的一樣好。所以我認為這是很大一部分。

In terms of the diagnostic pipelines, kind of the same thing. I think everybody wants to get patients back in to get diagnosed. There's -- we think a backlog that's been building for surgical patients as the surge happens. And then you have this longer backlog of folks who have been forgoing normal checkups, whether it's colonoscopies or PSA screening or what have you, that will start coming back in. And of course, disease doesn't take a holiday. And as a result, those things will be more advanced when they're caught.

就診斷管道而言，類似的事情。我認為每個人都希望讓患者重新接受診斷。有 - 我們認為隨著激增的發生，外科患者正在積壓。然後你有更多的積壓的人，他們已經放棄了正常的檢查，無論是結腸鏡檢查還是 PSA 篩查或者你有什麼，都會開始回來。當然，疾病不會休假。結果，那些東西被抓到的時候會更先進。

We've seen this before. We've been in this movie when we saw changes to PSA testing recommendations. That will again create a backlog, but it will take longer for it to realize and longer for it to process through. I don't think it's going to drive substantive share shifts between treatment modalities. I think it's going to be hard on patients as they go through that. And that will provide a headwind for us in -- certainly, in 2021 and then tailwinds thereafter as those folks are diagnosed and come back into the pipe. So that's kind of where I see the U.S.

我們以前見過這種情況。當我們看到 PSA 測試建議的變化時，我們一直在看這部電影。這將再次產生積壓，但它需要更長的時間才能實現，並且需要更長的時間才能完成。我認為這不會推動治療方式之間的實質性份額轉移。我認為這對患者來說會很艱難。這將為我們提供逆風——當然，在 2021 年，然後是順風，因為這些人被診斷出來並重新進入管道。所以這就是我看到美國的地方

Moving to China. Long term, we're quite excited. Pretty clearly, Chinese patients are interested in high quality care. Chinese surgeons are quite interested in robotics and in da Vinci, and our partnership with Fosun and the joint venture is going well for us. So in the near term, that feels great. And I think there's a lot of strong underlying interest.

搬到中國。從長遠來看，我們很興奮。很明顯，中國患者對高質量的護理很感興趣。中國外科醫生對機器人和達芬奇非常感興趣，我們與復星和合資企業的合作對我們來說進展順利。所以在短期內，感覺很棒。我認為有很多強烈的潛在興趣。

As we've talked about before, the medical marketplace in China is complicated. Right now, systems are under a quota, centrally managed quota. We see changes occurring in the Chinese regulatory environment over time as the FDA implements new policies and processes and we see that there are Chinese companies that are interested in this opportunity and are pushing hard to field competitive systems.

正如我們之前談到的，中國的醫療市場很複雜。目前，系統處於配額之下，集中管理配額。隨著 FDA 實施新的政策和流程，隨著時間的推移，我們看到中國監管環境正在發生變化，我們看到有中國公司對這一機會感興趣，並正在努力推動競爭體系的發展。

So we are committed long-term to China. I think it's going to be a strong demand market and a bouncy, sometimes turbulent marketplace due to policy changes and some of the central controls that are in place. We'll keep you updated as we get more clarity there.

所以我們長期致力於中國。我認為這將是一個強勁的需求市場和一個充滿活力、有時甚至是動蕩的市場，這是由於政策變化和一些中央控制措施到位。隨著我們在那裡變得更加清晰，我們會及時通知您。

Next, we have the line of Larry Biegelsen, Wells Fargo.

接下來，我們有富國銀行的拉里·比格爾森 (Larry Biegelsen) 的產品線。

I'll just ask one multipart question on Ion. I'm just curious to know kind of the -- what comes next year? You talked about the PRECISE data completing enrollment, I think, in the second quarter. Should we assume that we see that data in 2022? Is there any update on Ion in China?

我只會問一個關於 Ion 的多部分問題。我只是想知道——明年會發生什麼？我認為，您談到了第二季度完成註冊的 PRECISE 數據。我們是否應該假設我們會在 2022 年看到這些數據？ Ion在中國有更新嗎？

And then your competition has talked about indication expansion beyond lung bronchoscopy. Any color you're willing to share there?

然後你的競爭對手談到了肺支氣管鏡檢查以外的適應症擴展。你願意在那里分享任何顏色嗎？

And just lastly, adding a therapeutic capability to Ion. So basically, the road map here on Ion, what can we expect maybe going forward here?

最後，為 Ion 添加治療能力。所以基本上，關於 Ion 的路線圖，我們可以期待什麼？

All right. Thanks, Larry. Philip, I'm going to turn to you on the PRECISE trial timing, and then I'll take it from there.

好的。謝謝，拉里。菲利普，我將向你諮詢 PRECISE 試用時間，然後我會從那裡開始。

Yes. We -- with respect to when you might hear some data, it is a fair assumption to expect to hear something in 2022. We haven't been more specific beyond that, Larry.

是的。我們——關於你何時可能會聽到一些數據，這是一個公平的假設，期望在 2022 年聽到一些數據。除此之外，我們沒有更具體的，拉里。

With regard to future indications, right now, where we're at with Ion, we are -- our commercial teams and our manufacturing operations teams are tightly focused on supplying and performing in the diagnostic bronchoscopy market, our first indication. Clearly, Ion is a platform technology, and we're excited about it.

關於未來的適應症，現在，我們在 Ion 的位置，我們的商業團隊和我們的製造運營團隊密切關注診斷支氣管鏡市場的供應和執行，這是我們的第一個適應症。顯然，Ion 是一種平台技術，我們對此感到興奮。

That said, I'd remind everybody, we are in early innings, all of us. The entire field is in early innings with regard to bronchoscopy. Our clinical results there are outstanding. I think that they are market-leading relative to competitors, any of the competitors. And we want to fulfill that market. We want to satisfy those customers, that means satisfying them in terms of quality and demand and shipments and so on. We think there are longer-term applications beyond bronchoscopy and beyond diagnostics, and we're working on those. We are working on ablation technologies and some other things.

也就是說，我要提醒大家，我們都處於早期階段。整個領域在支氣管鏡檢查方面處於早期階段。我們的臨床結果在那裡非常出色。我認為相對於競爭對手，任何競爭對手，它們都是市場領先的。我們希望滿足這個市場。我們希望滿足這些客戶，這意味著在質量、需求和出貨量等方面滿足他們。我們認為除了支氣管鏡檢查和診斷之外還有更長期的應用，我們正在研究這些應用。我們正在研究消融技術和其他一些東西。

We're not ready to speak publicly about where we might go next for a couple of reasons: one is, we're still in the very earliest innings about making bronchoscopy a reality; and two, for competitive reasons, we're not ready yet to describe what we intend to do next.

我們還沒有準備好公開談論下一步的發展方向，原因有兩個：一個是，我們仍處於使支氣管鏡檢查成為現實的最早階段；第二，出於競爭原因，我們還沒有準備好描述我們接下來打算做什麼。

And China, Gary?

還有中國，加里？

On the China front, we, of course, have the joint venture with Fosun. We are working through pathways for Ion in China. We think there's a market there. I would advise folks that the Chinese regulatory system and CFDA handles Gen 1 products pretty differently than FDA does in the U.S. And as a result, you want to see a little greater maturity in your product line before you go broadly there. So we're working through that with our JV and also with the Chinese regulators. When we have some time lines for you, we will describe them, but we remain active and interested.

在中國方面，我們當然有與復星的合資企業。我們正在為 Ion 在中國開闢道路。我們認為那裡有市場。我會建議人們，中國的監管體系和 CFDA 處理 Gen 1 產品的方式與 FDA 在美國的處理方式截然不同。因此，您希望在您的產品線更加成熟之前，再廣泛涉足那裡。因此，我們正在與我們的合資企業以及中國監管機構合作解決這個問題。當我們為您提供一些時間線時，我們將對其進行描述，但我們仍然保持活躍和感興趣。

Next, we have the line of Tycho Peterson, JPMorgan.

接下來，我們有摩根大通的 Tycho Peterson 的產品線。

Gary, you mentioned no kind of shift in treatment modalities. So I assume the deceleration doesn't imply any kind of share loss to laparoscopic. But as we think about coming out of the pandemic, the other side of it is you highlight a remote technology for monitoring, proctoring and analysis. Are there structural changes here, you think, coming out of the pandemic that could drive faster adoption of robotics?

加里，你沒有提到治療方式的任何轉變。所以我認為減速並不意味著腹腔鏡的份額損失。但是，當我們考慮從大流行中走出來時，另一面是您強調了一種用於監控、監督和分析的遠程技術。您認為，從大流行中出現的結構性變化是否可以推動機器人技術的更快採用？

I believe so. Now this is -- the right answer is we'll see. Time will tell. But there are some encouraging anecdotes, and they're anecdotes. One is, I think folks are realizing that a lot can get done without jumping on planes and that's true for surgeons. And one of the things that our teams have done beautifully this year is to more fully digitize and regionalize training. That has been great. So forward deployment of training and greater use of digital tools, that will continue. And I think the acceptance of that is increasing. It's also accelerated remote proctoring, as you said. So I think that has been a positive for us and something that we had, thankfully, made some investments prior to the pandemic.

我相信是這樣。現在這是 - 正確答案是我們拭目以待。時間會證明一切。但是有一些令人鼓舞的軼事，它們是軼事。一個是，我認為人們已經意識到，很多事情都可以在不跳上飛機的情況下完成，外科醫生也是如此。今年我們的團隊做得很好的一件事就是更全面地數字化和區域化培訓。那太棒了。因此，向前部署培訓和更多地使用數字工具，這將繼續下去。我認為人們對此的接受度正在增加。正如你所說，它還加速了遠程監考。因此，我認為這對我們來說是積極的，謝天謝地，我們在大流行之前進行了一些投資。

The second part is, I think, that people are seeing changes in resource consumption, days in the hospital, ICU time, patient comforted being housed in hospitals in the pandemic has declined. And I think that will be durable. I think even after COVID rates start to drop, I think folks thinking that sitting around a hospital isn't a great idea. And using ICU resources when you don't have to isn't a great idea.

第二部分是，我認為，人們看到資源消耗、住院天數、重症監護室時間、在大流行中被安置在醫院的患者感到欣慰的變化有所減少。我認為這將是持久的。我認為即使在 COVID 率開始下降之後，我認為人們認為坐在醫院附近並不是一個好主意。而在非必要時使用 ICU 資源並不是一個好主意。

And I -- already, I think we see that folks are saying, "Hey, really high-quality minimally invasive surgery done well." And by the way, having the analytics to back that up is going to be appreciated and maybe an accelerant. So I am cautiously optimistic that some of the trends we're seeing in terms of what recovery might be are going to be real positive for Intuitive.

而且我 - 已經，我想我們看到人們在說，“嘿，真的高質量的微創手術做得很好。”順便說一句，擁有分析來支持這一點將受到讚賞，並且可能是一種促進劑。因此，我謹慎樂觀地認為，我們在復蘇方面看到的一些趨勢將對 Intuitive 產生真正的積極影響。

Another thing you highlighted at the conference was the regulatory requirements and time lines for the industry keep increasing. I know that's something you've been talking about for a while. But as we think about the road map here for SP, the IDT -- IDE trial for colorectal, have the time lines gotten pushed out further in your view given the regulatory burden? Or it's just kind of in line with what you've been talking about for a while?

您在會議上強調的另一件事是該行業的監管要求和時間表不斷增加。我知道這是你一直在談論的事情。但是當我們考慮 SP 的路線圖時，IDT - 結直腸的 IDE 試驗，考慮到監管負擔，您認為時間線是否被進一步推延？或者它只是與你一直在談論的內容一致？

Yes. I think we're starting to see the contours of the regulation side in the U.S. stabilize. So it's stabilizing at a requirement level that's greater than it was in year's past, but I don't think it's continuously moving. That's been good.

是的。我認為我們開始看到美國監管方面的輪廓趨於穩定。因此，它穩定在比去年更高的需求水平，但我認為它不會持續變化。那已經很好了。

I think the thing that's challenged some time lines for us and others is COVID. If your clinical trial sites are having to manage COVID as well as whatever your clinical trial is, that can put pressure on you. That's kind of a near-term thing.

我認為對我們和其他人來說，挑戰某些時間線的事情是 COVID。如果您的臨床試驗中心必須管理 COVID 以及您的臨床試驗，這可能會給您帶來壓力。這是近期的事情。

I think longer term, the question of what does this do if clinical trial requirements and general data requirements in the U.S. and Europe for computer-aided systems and robotics have become greater, what does that imply? And it probably implies a couple of things. One is that systems in the market are likely to stay in the market a little longer because it's just extended time lines for innovation. I think the other thing is that it probably resequences when you see different products where in the world because some health care systems, Korea being notable, are allowing innovative products into their systems a little more quickly and other ones are becoming a little less so.

我認為從長遠來看，如果美國和歐洲對計算機輔助系統和機器人技術的臨床試驗要求和一般數據要求變得更大，這會做什麼，這意味著什麼？這可能意味著幾件事。一是市場上的系統可能會在市場上停留更長時間，因為它只是延長了創新的時間線。我認為另一件事是，當你在世界上看到不同的產品時，它可能會重新排序，因為一些醫療保健系統，尤其是韓國，允許創新產品更快地進入他們的系統，而其他的則變得不那麼快。

So for a company like us, you'll see increased investment in head count and in resources for clinical and regulatory staff, and you'll see a reordering of where we go with new innovations over time. You'll probably see for the industry, platforms sit a little longer, that probably benefits incumbents a little more than it does insurgents.

因此，對於像我們這樣的公司，您會看到對員工人數和臨床和監管人員資源的投資增加，並且隨著時間的推移，您會看到我們在新創新方面的重新排序。你可能會看到，對於這個行業來說，平台的存在時間會更長一些，這可能對現有企業的好處多於對叛亂者的好處。

Great. And then one last one on the extended use rollout. You did Europe recently, U.S. last quarter. Is there a next step to the process? Are you going to do it in Asia? And any reason the elasticity would be different in any of the geographies in your view?

偉大的。然後是擴展使用推出的最後一個。你最近在歐洲，上個季度在美國。這個過程有下一步嗎？你打算在亞洲做嗎？在您看來，任何地區的彈性會有所不同的任何原因？

Marshall, why don't you take that first?

馬歇爾，你為什麼不先拿那個？

Sure. The rollout into other parts of the world will depend on the regulatory time lines. As you could imagine, in China, it will take a long time. In some of the other markets, it might be a little bit quicker. I don't have a complete road map of every country. But yes, Asia-Pac is absolutely on our mind, and we'd like to get them out to our direct markets in Asia as soon as possible.

當然。推廣到世界其他地區將取決於監管時間表。可以想像，在中國，這需要很長時間。在其他一些市場，它可能會快一點。我沒有每個國家的完整路線圖。但是，是的，我們絕對在意亞太地區，我們希望盡快將它們推向我們在亞洲的直接市場。

As far as the impact on elasticity, we did 2 things in the United States, if you recall. We modified the -- we obviously launched extended use instruments, which lower the cost of care for hospitals. But we also, simultaneous with that, lowered the price of a few select instruments that are used typically in lower benign -- lower acuity procedure -- or benign lower acuity procedures like cholecystectomy, benign hysterectomies and inguinal hernias. And then in totality, then the use that -- if you look at an instrument, set that might be used in cholecystectomies, then the cost is competitive with other minimally invasive approaches.

至於對彈性的影響，如果你還記得的話，我們在美國做了兩件事。我們修改了——我們顯然推出了延長使用的儀器，這降低了醫院的護理成本。但與此同時，我們還降低了一些通常用於低度良性（低敏度手術）或良性低敏度手術（如膽囊切除術、良性子宮切除術和腹股溝疝）的精選器械的價格。然後總體而言，然後是使用 - 如果您查看可能用於膽囊切除術的儀器，設備，那麼成本與其他微創方法相比具有競爭力。

In each country, we have modified the pricing differently, and we're targeting those procedures that are pressured by reimbursement. So you can't kind of peanut butter spread the comment of what elasticity will do in the United States, will happen in the other countries. But we are targeting specified procedures in each of those countries where reimbursement is stressed, and we believe we provide value. And we'll see. We believe that we'll create some elasticity in each country. It will just vary in terms of magnitude.

在每個國家/地區，我們都對定價進行了不同的修改，我們的目標是那些受到報銷壓力的程序。所以你不能像花生醬那樣散佈關於彈性在美國會發生什麼，在其他國家會發生什麼的評論。但我們針對每個強調報銷的國家的特定程序，我們相信我們提供價值。我們拭目以待。我們相信我們會在每個國家創造一些彈性。它只會在大小上有所不同。

Okay, next we have the line of Richard Newitter of SVB Leerink.

好的，接下來我們有 SVB Leerink 的 Richard Newitter 的產品線。

If I could just start off on the competitive landscape. Gary, any comments you could offer on -- internationally, any competitors that are on the market? And what you're seeing out there relative to kind of what you would have expected? And within the U.S., just in light of some updates from mainly competitor, J&J recently, this fall, provided an update on the feature set. And any thoughts you would care to offer on where they're going to be trying to compete, particularly on kind of ex the robotic arms, et cetera?

如果我能從競爭格局開始。加里，您可以就國際市場上的任何競爭對手提供任何意見嗎？你所看到的相對於你所期望的那種？在美國，鑑於主要競爭對手 J&J 最近在今年秋天提供了一些更新，提供了功能集的更新。對於他們將要在哪裡競爭，特別是在機械臂等方面，你有什麼想法嗎？

Sure. Just on the -- just speaking to the international side, the first thing I'd remind everybody is it's not really a robot-versus-robot question for customers. It's really a robotically-enabled ecosystem that drives outcomes versus a robotically-enabled ecosystem that drives different outcomes. That is -- it's programmatic versus programmatic.

當然。就 - 就國際方面而言，我要提醒大家的第一件事是，對於客戶來說，這並不是一個真正的機器人與機器人的問題。它實際上是一個驅動結果的機器人生態系統，而不是驅動不同結果的機器人生態系統。那就是 - 它是程序化與程序化的。

So in each of these, when they come out, you kind of look at it and say, "Okay, what's the robot capable of? Do they have instruments any accessories, the imaging systems, the advanced tools that are required, some of those software and analytic capabilities, training capabilities and so on?" And you see a pretty different skill set and capability out of each of these ecosystems. And that's true as well for some of the bigger competitors that are domestic. So that's how we think about it. And I think that's how customers, by and large, will think about it. There will always be some customers who are interested in trialing and seeing what's capable out of something new, so I'd expect that.

所以在每一個中，當它們出來時，你會看著它說，“好吧，機器人有什麼能力？他們有儀器嗎？任何配件，成像系統，需要的高級工具，其中一些軟件和分析能力、培訓能力等等？”你會看到這些生態系統中的每一個都具有完全不同的技能和能力。對於一些國內較大的競爭對手來說也是如此。所以我們就是這麼想的。我認為這就是客戶總體上會考慮的方式。總會有一些客戶有興趣試用並了解新事物的能力，所以我希望如此。

Nothing architecturally that I've seen of any of them, including the most recent announcements, has surprised me. I think we've seen a lot of these ideas. We've trialed personally a lot of them inside the company. And so I think time will tell.

我所見過的任何一種架構，包括最近的公告，都沒有讓我感到驚訝。我想我們已經看到了很多這樣的想法。我們已經在公司內部親自試用了很多。所以我認為時間會證明一切。

We have made the trade-offs we've made for a reason based on evaluation, building product and kind of scientific method. And I think that customers will evaluate those trade-offs over time.

基於評估、構建產品和科學方法的種類，我們做出了權衡。我認為客戶會隨著時間的推移評估這些權衡。

We've also seen the idea that some of the bigger players want to bundle, that they're going to put all these things together, maybe lower the price of capital and try to throw some other things in and see if they can entice folks. And I think the way I'd ask customers and shareholders to think about it is bundling makes sense if the underlying products are commodities, if everybody is selling 2 ply toilet paper and one brand is not that different than the other, it's all fine. But that's not where we are.

我們也看到了一些更大的玩家想要捆綁的想法，他們會將所有這些東西放在一起，也許會降低資本價格並嘗試投入一些其他東西，看看他們是否能吸引人們.而且我認為我要求客戶和股東考慮捆綁的方式是有意義的，如果基礎產品是商品，如果每個人都在銷售 2 層衛生紙並且一個品牌與另一個品牌沒有什麼不同，那一切都很好。但這不是我們所在的地方。

Robotic systems and the instrumentation and the imaging systems are not commoditized. And as a result, there'll be strong differences in how they're used and what the outcomes are. And in that regard, I think that's what we'll point our customers to and our sales force to understand as these different things come out.

機器人系統、儀器和成像系統沒有商品化。因此，它們的使用方式和結果將存在很大差異。在這方面，我認為隨著這些不同的事情的出現，我們將向我們的客戶和我們的銷售人員指出這一點。

Got it. And if I could just have one more follow-up on the capital environment and the discussions that you're having. As you talk to the institutions as they think of their 2021 budgets, I'm curious, one, are they kind of thinking of a 2-year budgeting process? Or is it any different than the way they've approached their budgeting in the past in the wake of COVID?

知道了。如果我能對資本環境和你們正在進行的討論再進行一次跟進。當您與各機構討論 2021 年預算時，我很好奇，他們是否在考慮 2 年預算流程？或者這與他們過去在 COVID 之後處理預算的方式有什麼不同？

And then maybe two, is the -- what signs are they saying they're going to look for to kind of get back to you to have confidence to go and make the purchase with the uncertainty that still exists?

然後可能是兩個，他們說他們會尋找什麼跡象來讓你有信心在仍然存在的不確定性的情況下進行購買？

Marshall, why don't you kick off that answer, and I'll add a little when you're done.

Marshall，你為什麼不開始這個答案，當你完成後我會補充一點。

Yes. I think the first part of your question, what are they doing from a budget perspective? I don't have enough insight to be able to answer the question well. I -- we said that we believe that they'll go through a reset, of course, for 2021. I don't know if they'll have the same level of spending they did. We believe that there is financial pressure on the hospitals -- on a number of the hospitals as a result of COVID. So we -- there's the possibility that 2021 budgets will be less -- will be smaller than they were in 2020, but I don't have great insight to that.

是的。我認為您問題的第一部分，從預算的角度來看，他們在做什麼？我沒有足夠的洞察力來很好地回答這個問題。我——我們說過我們相信他們會經歷一次重置，當然，在 2021 年。我不知道他們是否會有與他們相同的支出水平。我們認為，由於 COVID，醫院面臨財務壓力——許多醫院面臨財務壓力。因此，我們 - 2021 年的預算可能會更少 - 將比 2020 年少，但我對此沒有很好的洞察力。

Yes. I think the thing I would point to that, I think, is kind of a economics question for everybody is just going to be something to look at is they will make their estimates as to how fast folks will return and whether they want to accelerate so that they have capacity available for dealing with the backlog. I think that will differ by hospital groups. So some folks will have the capital capacity to lean in and see this as an opportunity to deepen their exposure or their presence in market. Others will feel conservative, and we'll want to wait and see, so I do not think it's going to be a one size fits all in terms of how they do their financial planning.

是的。我認為我要指出的一點是，對於每個人來說都是一個經濟學問題他們有能力處理積壓。我認為這將因醫院集團而異。因此，一些人將有資本能力傾斜，並將其視為加深他們的曝光率或在市場上的存在的機會。其他人會感到保守，我們會拭目以待，所以我認為就他們如何進行財務規劃而言，這不會是一刀切。

That was our last question. So I'll conclude from here. In closing, we continue to believe there is a substantial and durable opportunity to fundamentally improve surgery and acute interventions. Our teams continue to work closely with hospitals, physicians and care teams in pursuit of what our customers have termed the quadruple aim: better and more predictable patient outcomes; better experiences for patients; better experiences for their care teams; and ultimately, a lower total cost of care. We believe value creation in surgery and acute care is foundationally human. It flows from respect for and understanding of patients in care teams, their needs and their environment.

那是我們的最後一個問題。所以我將從這裡總結。最後，我們仍然相信存在從根本上改善手術和急性干預的實質性和持久的機會。我們的團隊繼續與醫院、醫生和護理團隊密切合作，以追求我們的客戶所說的四重目標：更好、更可預測的患者結果；為患者提供更好的體驗；為他們的護理團隊提供更好的體驗；並最終降低總護理成本。我們相信，手術和急症護理的價值創造從根本上說是人性化的。它源於對護理團隊中患者、他們的需求和環境的尊重和理解。

Thank you for your support on this extraordinary journey. We look forward to talking to you again in 3 months.

感謝您對這次非凡旅程的支持。我們期待在 3 個月後再次與您交談。

And ladies and gentlemen, that does conclude the presentation for this afternoon. Again, we thank you very much for all of your participation and for using our teleconferencing services. You may now disconnect.

女士們，先生們，今天下午的演講到此結束。再次，我們非常感謝您的參與和使用我們的電話會議服務。您現在可以斷開連接。