NuVasive (NUVA) Q1 2018 Results - Earnings Call Transcript

NuVasive, Inc. (NASDAQ:NUVA) Q1 2018 Earnings Call May 1, 2018 4:30 PM ET

Executives

Carol A. Cox - NuVasive, Inc.

Gregory T. Lucier - NuVasive, Inc.

Rajesh Asarpota - NuVasive, Inc.

Harry Skip Kiil - NuVasive, Inc.

Analysts

Matt O'Brien - Piper Jaffray & Co.

Joshua Jennings - Cowen and Company, LLC

Kaila P. Krum - William Blair & Co. LLC

Robbie J. Marcus - JPMorgan Securities LLC

Mike Matson - Needham & Co. LLC

Joanne Karen Wuensch - BMO Capital Markets (United States)

Richard Newitter - Leerink Partners LLC

Isaac Ro - Goldman Sachs & Co. LLC

Kyle William Rose - Canaccord Genuity, Inc.

Operator

Ladies and gentlemen, greetings and welcome to the NuVasive, Inc. First Quarter 2018 Conference Call. At this time, all participants are in a listen-only mode. A brief question-and-answer session will follow the formal presentation. As a reminder, this conference is being recorded.

I would now like to turn the conference over to your host, Carol Cox, Executive Vice President, External Affairs. Thank you. You may begin.

Carol A. Cox - NuVasive, Inc.

Great. Thank you, Adam, and welcome everyone to NuVasive's first quarter 2018 earnings call. The company's earnings release, which we issued earlier this afternoon, is posted on our website, as is an investor presentation, both of which have been filed on Form 8-K with the Securities and Exchange Commission. We've also posted supplemental financial information on the IR website to accompany our discussion. On today's call, we will be covering information that is included in the investor presentation and I encourage you to access these materials so that you may also follow along.

Before we begin, I would like to remind you that in the discussions today, we may include forward-looking statements, which are based on current expectations and involve risks and uncertainties, assumptions and other factors which, if they do not materialize or prove to be correct, could cause NuVasive's results to differ materially from those expressed or implied by such forward-looking statements.

Additional risks and uncertainties that may affect future results are described in NuVasive's news release and periodic filings with the Securities and Exchange Commission. We assume no obligation to update any forward-looking statements or information, which speak as of their respective dates.

This call will also include a discussion of several financial measures that are not calculated in accordance with generally accepted accounting principles or GAAP. We generally refer to these as non-GAAP financial measures. These measures include our cost of goods sold, gross margin, sales, marketing and administrative expenses, research and development expenses, operating margin, non-GAAP earnings per share, free cash flow and EBITDA. Reconciliations to the most directly comparable GAAP financial measures may be found in today's news release and the Supplementary Financial Information, which all are accessible from the Investor Relations section of the NuVasive website.

Joining our today's call are Greg Lucier, our Chairman and Chief Executive Officer; and Raj Asarpota, our Chief Financial Officer.

With that, I'll turn the call over to Greg.

Gregory T. Lucier - NuVasive, Inc.

Thank you, Carol. Earlier this afternoon, we reported first quarter 2018 revenue results of approximately $261 million, representing year-over-year growth of about 5% on a reported basis, and in line with the guidance range we provided you in February. Results were driven primarily by strong International growth of approximately 20% on a constant currency basis, U.S. hardware case volume growth of 5%, and a sequential improvement in the biologics business. As we anticipated at the start of 2018, these results are against the backdrop of a stable but flat U.S. spine market today.

Now, let me elaborate on the first quarter U.S. revenue results. U.S. core hardware revenue increased 1% driven by a strong case volume growth, partially offset by pricing headwinds of 2% and product mix of 2%. In particular, we saw solid contributions from the XLIF and TLIF franchises, and continued penetration of our RELINE posterior fixation system. Raj will get into more detail on the mix we saw in U.S. Spinal Hardware in a moment.

However overall, we are pleased with how the quarter came together in this area. New product introductions from late last year are taking hold in the market, helping us validate the continued investments in R&D, or addressing the needs of surgeon customers. In particular, our TLX expandable cage, RELINE Small Stature, XLIF Modulus and COHERE, the porous PEEK implant we acquired through the Vertera acquisition last year contributed to our growth.

We are seeing good early adoption of our Lateral Single-Position Surgery platform along with the surgeon training program for this procedure being very well received followed by adoption pull-through after the training. We also continued to gain share on our NuVasive Specialized Orthopedics portfolio, including our PRECICE technology for limb lengthening as well as RELINE Trauma product pull-through and advancing new users in the adolescent idiopathic space.

In the Surgical Support business, revenue was essentially flat year-over-year as we expected declines in the biologics business were offset by growth in our NuVasive Clinical Services business, which includes contributions from SafePassage as of mid January 2018 when the acquisition closed, and sales of our LessRay technology platform for radiation reduction.

As I mentioned, our biologics business performed better than expected, down 10% versus the hardest comparison quarter we will see this year, and better than the results we had guided to. I'm cautiously optimistic we are starting to see renewed traction with surgeons and healthcare systems as we implement new strategies to regain share and increase volume. While not a full recovery, I'm confident we have the right team in place working strategically with a sense of urgency to drive sustainable improvement in this area.

Turning to the services business, during the quarter, NCS results were impacted by lower U.S. case volumes related to our focus on the integration of SafePassage and a strategic decision to exit certain accounts that didn't meet our profitability target. As you know, an integral part of our ongoing strategy in the services business is an active and robust business development process. While we are seeing success with this strategy, the timing of lost accounts this quarter did not weigh (05:50) the new business coming in from the legacy service business which we expect to ramp up for the balance of the year.

The fundamentals of the service business remain intact though. We are still seeing solid adoption of our M5 units, which delivers revenues through the pull through of our disposables products and spinal hardware technologies. Moreover, given this business does not require the same level of capital as our core business, but it's just as profitable, we like its mix in our portfolio. Now, we just have to get the revenue growth to where it matches the rest of our business and our expectations.

Turning to International results for Q1, revenue increased 28% on a reported basis, up 20% on a constant currency basis. This is in line with our forecast and driven by strength across all geographies. This consistently strong performance from our International business is the result of an intense focus over the last few years in developing the infrastructure, hiring strong regional management teams, and consistently executing a strategy of leading with our lateral offering, and expanding the surgeon relationship from there. With this momentum, we remain confident in our ability to take share across key international markets from the roughly 4.5% share we hold today to doubling that over the next few years. Raj will share more detail in how each region performed in his remarks.

Profitability, as you know, margin expansion is a key element in our effort to deliver value creation for our shareholders. While we have made considerable progress in reducing our operating expenses, our strategy to radically improve gross margins through self-manufacturing continues to lag our expectations due to a delay in hitting factory absorption rate targets.

Now I'm going to be the first one to admit, we set out to tackle this project in an aggressive way, but I knew when I came on as CEO three years ago, we had to completely reimagine, how we manufacture our technology in order to handle price pressures that have become an inevitable element of the healthcare industry.

The foundation of that thesis is still very sound. On a per unit basis in our Ohio plant, we are efficiently and effectively driving unit costs down. The hurdle in our results is a total throughput of the Ohio plant in relation to fixed costs. As we are unable to ramp up the production output to the levels we need, we ultimately are not getting the gross margins we require, and so our challenge ahead of us is to get this right, get the output higher and ultimately drive the gross margins to the benefits that we projected when we built this plant. Now, it's time to deliver and we will do so in the second half of 2018.

Innovation remains at the heart of what NuVasive does best and we continue to lead the industry by delivering the technologies and innovations that surgeons want and need. Our commercial launch plans for 2018 include more than a dozen new product introductions spanning from implant systems to the introduction of our Surgical Intelligence platform, as well as the next generation MAGEC rods for early-onset scoliosis. These technologies will help us meet our commitment to enable a complete procedure, enhancing the entire surgical experience and expanding current offerings in key markets.

This past quarter, we made solid headway in our efforts in key areas that when combined differentiates and place NuVasive in a strong position to compete for both the clinical and economic perspective and will support the growth in 2018 and beyond. These areas include further adoptions of minimally invasive lateral surgery, like I mentioned, the buildup of our Surgical Intelligence platform, and a service organization that we believe will deliver a highly competitive integrated offering over time.

As an example, at the recent American Association of Neurological Surgeons Scientific meeting, we hosted a hands-on workshop with several top surgeons featuring the latest advances in Lateral Single-Position Surgery, technology to reduce the OR radiation and developments in 3D-printed implants. This forum demonstrated our commitment to safer, faster and smarter surgery. We believe strongly in the merit of the Lateral Single-Position Surgery platform and the response from the early adopters have been nothing but positive. Reducing the number of times the patient has to be repositioned during surgery improves the OR efficiency and surgeons are seeing this as a true benefit to both patients and their practices.

In addition, from an internal R&D standpoint this past quarter, we have continued to make good headway on how we will redefine the experience for surgeon partners and patients with our Surgical Intelligence platform, spine's only integrated surgical platform, connecting technology and tools to align the right patient with the right surgery for the right outcome.

As I mentioned on last quarter's call, we plan to unveil the Surgical Intelligence platform in September at NASS, which will be a connected system, and phased in to bring together radiation reduction, monitoring, planning, imaging, 2D and 3D navigation, automation and insights to help deliver an optimized OR and quality patient outcomes. It is a significant step in our evolution from a product-focus company to a systems-based company, focused on delivering end-to-end solutions that not only enable predictable, clinical and economic outcomes, but also pull-through the implants and create stickiness in the market.

So in closing, our International business continues to execute on all cylinders and delivers results well above the market growth. Last year's new technology introductions continue to ramp up and I'm encouraged by the progress of our biologics team. We have more work to do with our internal manufacturing capabilities in West Carrollton to achieve the desired impact on our income statement, not only getting us to the 20% operating margins, but even higher. Those benefits will start to flow in the second half of 2018.

As for the market, it has not materially changed since the second half of 2017, but with that being said, we continue to be a share taker and applying additional focus on new product introductions and increased rigor on day-to-day execution by our sales leaders.

Now, let me turn it over to Raj for his comments. Thank you.

Rajesh Asarpota - NuVasive, Inc.

Thanks Greg, and good afternoon, everyone. Before we get started with the financials, let me remind you that many of the financial measures covered in today's call are on a non-GAAP basis unless noted otherwise. Please refer to today's earnings news release as well as the supplemental financial information on nuvasive.com for further information regarding our non-GAAP reconciliations.

For the first quarter 2018, we reported revenue of $261 million, which reflects approximately 5% reported growth performance year-over-year and 3% growth performance on a constant currency basis. Excluding the impact of our SafePassage acquisition, which closed in mid-January 2018, revenue grew approximately 2% on an organic basis, excluding the impact of currency.

Our results were primarily driven by strong International growth of 20% on a constant currency basis and essentially flat revenue performance in the U.S. where case volume growth in our core hardware business and the impact of new product introductions was offset by the expected decline in the biologics business, and weaker case volume in our legacy NuVasive Clinical Services business.

Our U.S. Spinal Hardware revenue was $141.5 million for the first quarter, which represents approximately 1% growth over the prior year revenue of $140.6 million. The primary drivers of this performance were growth in case volume of approximately 5% contribution from product launches like XLIF Modulus, TLX, RELINE Small Stature, and COHERE, and continued growth in our RELINE posterior fixation systems. Offsetting these gains was pricing pressure of approximately 2% and some mix challenges primarily in the area of cervical and centered around the timing of new product introductions that we expect to see in the back half of 2018. Additionally, we are pleased with our ongoing efforts to convert new surgeons to NuVasive, which was strong in the first quarter of 2018 and will contribute to growth throughout the year.

Revenue from U.S. Surgical Support performed at $69.6 million for the first quarter, which was flat compared to the same period in prior year. Revenue growth of $4.5 million from our acquisition of SafePassage was offset by lower U.S. case volume experienced within our current existing services business and the expected weakness in our biologics product line.

Early in the first quarter, we acquired SafePassage, which is a fast growing market leader in the services business and demonstrates the kind of growth we see available in the services space. As we on-boarded the business, our focus on integration was a contributing factor that led to weaker case volumes in our existing U.S. services business. As a management team, we are balancing, maintaining a key focus on attending to the existing customer base and in some cases expanding our footprint concurrently, while moving thoughtfully through the integration process.

Another driver in the service business revenue results was a select group of strategically identified accounts that we chose to exit as the profitability in those accounts did not meet our internal threshold for margin. In turn, we're utilizing our resources to go deeper into existing accounts and to be more aggressive in winning new accounts for the balance of the year.

In our biologics business, we have seen positive momentum from the back half of 2017, moving into the first quarter of 2018, and expect to see this momentum stem losses going forward. As Greg mentioned, under new leadership for this business, we have adjusted efforts to be more competitive and recapture seven lost accounts with offerings across the entire portfolio. This re-engagement combined with sales force-wide retraining on biologics at our global sales meeting earlier this year have yielded positive results for the franchise.

As it pertains to LessRay, we continue to see growing interest in the platform. We are slightly behind our revenue targets, which we believe is more of a timing issue as we drive to convert trials to firm partnership commitments as the year progresses.

Our International revenue was $49.5 million, growing approximately 28% on a reported basis and 20% on a constant currency basis. This marks the sixth consecutive quarter with at least 20% growth rate and we are very pleased to see the strong performance spread across all key regions.

On a constant currency basis, EMEA grew 21% year-over-year driven by solid performances across Western Europe and growth in key emerging markets like South Africa and Saudi Arabia. In the UK, we experienced difficult market conditions due to limited bed availability as hospital beds were re-allocated away from elective procedures resulting from the unusually bad flu season. This was seen as a temporal dynamic for the quarter and we expect the UK business to improve in the second quarter.

On a constant currency basis, Asia Pac grew 23%, primarily driven by strong results in Japan, following the re-introduction of XLIF into that market in the first quarter of 2017 and continued market share gains in the region. On a constant currency basis, Latin America grew 6% and delivered its sixth consecutive quarter of growth driven by strong performance in Brazil, where the business has more than doubled over prior year. The revenue in Puerto Rico has still been challenged by the lingering infrastructure impact of the hurricane. That said, we are very pleased that the strength in Brazil has offset much of that softness and continues to deliver strong growth.

Profitability. Moving to profitability, our non-GAAP gross margin for the first quarter was 71.8%, a decline of 350 basis points below prior year of 75.3%. We experienced a higher than expected decline in gross margin and what ultimately led to operating margin erosion in the quarter as a result of slower production throughput at our West Carrollton facility.

Approximately 120 basis points of the decline was attributable to that facility and the primary driver of the year-over-year decline. As it pertains to West Carrollton, we have been disappointed with the level of production throughput performance in the first quarter after fully migrating from our facility in Fairborn at the end of 2017. What we found once volumes had ramped up early in the quarter, the back end of the manufacturing process had bottlenecks which impacted total output and therefore absorption rates. We have since worked to fix these issues and normalize the plant ramp up.

In the second quarter, we have experienced increased throughput from the first quarter level and that acceleration will continue through the year. Our efforts around in-sourcing manufacturing and the significant contribution it will make to our margin improvement thesis remains intact, and while we are a bit behind on our progress, we believe getting this right represents a tremendous margin opportunity for the future. When we get to full capacity, the manufacturing plant will deliver 400 basis points of improved profitability, while allowing us to control our source of inventory. We will continue to focus on ensuring our investments in the factory will deliver the supply chain benefits through the balance of the year and beyond.

Other drivers of gross margin variance in the quarter included 70 basis points decline resulting from the acquisition of SafePassage, which as a reminder is offset in operating margin. Our mix of revenue related to the operating plan yielded approximately 70 basis points of decline as a result of being heavily weighted towards International revenue which have lower margins. And lastly, pricing pressure on revenue generated around 30 basis points of decline over prior year.

Non-GAAP SM&A expenses as a percent of revenue decreased 240 basis points from prior year to 54% in the first quarter or $140.7 million. With the growth in our International business, we are continuing to leverage our expanding scale that fixed overhead cost. Domestically, we have seen the benefit of productivity and efficient cost containment.

We continue to manage our operating expenses in a very disciplined manner. Non-GAAP research and development, or R&D, expenses totaled approximately $14.5 million in the first quarter or 5.6% of revenue, which was an increase of 60 basis points compared to the first quarter in 2017. As we have declared in the past, our increased R&D spend reflects continued commitment to supporting internal R&D efforts and investing in strategic assets that we acquired to drive innovation. A clear demonstration of that is apparent through our investments in Surgical Intelligence and Advanced Materials platforms. We believe both recent and upcoming product launches related to these platforms will drive material results.

First quarter non-GAAP operating profit margin was 12.3%, down 170 basis points compared to 14% we have reported in the first quarter of 2017. For the quarter, the primary issue impacting our profitability was related to our manufacturing facility. We saw gross margin pressures from the slower production throughput at West Carrollton, which flowed through to the operating margin line.

Year-over-year, we made progress in reducing our operating spend as a percentage of revenue with operating expenses down 180 basis points over prior year, but not enough to offset the headwinds created by our gross margin challenge. While we are disappointed in our operating margin performance in Q1, we remain committed to delivering 100 basis points of expansion for the year. We will continue to invest in the business with a prudent and balanced approach, while driving for both gross margin and operating margin improvements to deliver increased profitability in future periods.

Moving further down the P&L, interest and other expense net on the non-GAAP basis was $5.9 million in the first quarter, up from $5.1 million in the same period last year. This increase was primarily a result of certain equity investments we made in 2017.

Now turning to tax, our non-GAAP tax expense in the quarter was $5.9 million, resulting in a non-GAAP effective tax rate of 22.5% which, we're very pleased to say, is an improvement of more than 1,200 basis points from the prior year. This significantly lower rate is a combination of the newly enacted tax reform in the United States of which NuVasive is a large benefactor, as well as the continued shift to international profitability, which helps reduce the overall tax rate. As you may recall, years ago we had set up our tax structure to benefit from a shift to more International revenue and we continued to see benefits associated with those efforts.

First quarter non-GAAP net income was $20.2 million or earnings per share of $0.39, compared to non-GAAP net income of $19.7 million or earnings per share of $0.37 in the same period last year, an increase of $0.02 or 5% over prior year. This performance was below our expectations stemming from the margin challenge I previously discussed. We expect to grow non-GAAP EPS in the double digits over time and look to get back into the growth trajectory on operating margin as well.

Turning to our GAAP results, GAAP net loss for the first quarter of 2018 was $27.1 million or $0.53 per share compared to net income of $12.4 million or $0.22 per share in the same period last year. Please refer to our earnings press release or the supplemental financial information file posted on nuvasive.com for further information related to our GAAP versus non-GAAP adjustments.

Adjusted EBITDA margin, which excludes the impact of non-cash stock-based compensation and other non-GAAP adjustments was 21.1% for the first quarter 2018, compared to 23.9% in the same period last year. This decrease was largely in line with the decrease in operating margin in the year combined with some favorability in the share-based compensation in the current year.

Finally, free cash flow for the quarter was a positive $7 million compared to a negative $6 million in the same period in 2017. The increase over prior year was driven primarily by working capital improvements. During the quarter, we recorded an accrual for litigation liability of approximately $29 million related to a previously disclosed lawsuit with a former sales agent. It is important to know that this is an accrual only and our appeal of the judgment is still pending. More information can be found in our SEC filings.

For the quarter, we're also announcing a tax ruling with the Tennessee state government, which entails the consideration for NuVasive to be viewed as a locally-based entity no longer subject to property, sales, and use taxes specific to the state. With our primary distribution facility based in Memphis, we expect this will yield in excess of $100 million in tax savings over the next 15 years.

As it pertains to the cost of this structure, we have recorded a non-recurring, success-based specialized tax consulting fee for $6.1 million in our financials during the quarter. We are pleased about the savings this ruling brings over the upcoming years in delivering enormous value back to our shareholders.

Now turning to the topic of guidance, based on our first quarter results and our outlook for the remainder of the year, we are reiterating full-year revenue guidance for 2018 to be in the range of $1.095 billion to $1.105 billion. We have updated exchange rate assumptions and expect currency to have a positive impact in 2018 of approximately $10 million, which is up $5 million from our prior assumptions. While this is a modest improvement in potential contribution from currency, it is too early in the year to update revenue expectations based on currency alone.

As a result of the profitability challenge in our manufacturing facility, we are adjusting down our gross margin guidance from 74% to 73.5% for the year and recovering that profitability erosion through effective operating expense leverage. We are reiterating our operating margin goal and guidance for the year at 17.6%. Our work will be singularly focused on accelerating the output from our manufacturing facility and optimizing our operating cost structure through the initiatives that have been in place to achieve our internal path to 25% operating margin plan.

In closing, we're encouraged by the achievement of our revenue guidance for the first quarter driven by momentum in our International business, growth in our hardware case volume and better-than-expected performance in our biologics portfolio. As we look ahead to the balance of the year, we remain confident and committed to continuing on delivering both our revenue plan and operating margin target of 100 basis points improvement for the year.

Thank you. And with that, we'll open the call for Q&A.

Question-and-Answer Session

Operator

Thank you. Ladies and gentlemen, we will now be conducting our question-and-answer session. Our first question comes from the line of Matthew O'Brien from Piper Jaffray. Please go ahead.

Matt O'Brien - Piper Jaffray & Co.

Thanks for taking the questions. I'm going to break the rules and ask two here together. But would love to hear a little bit more on the mix commentary that you had on the U.S. hardware business. Is that specifically reimbursed? Are payers telling you to move from lower profile cervical products to the more traditional plates and screws, which have a lower margin and that's where that mix impact comes from? Because, as I look at that, if you exclude that I think you're still taking your U.S. hardware outlook up a little bit and I'm not sure if you had anticipated that kind of mix headwind, so you're actually taking it up a little bit higher than maybe that you've been expecting or we've been expecting?

Rajesh Asarpota - NuVasive, Inc.

Yeah.

Matt O'Brien - Piper Jaffray & Co.

And then the second question is on the U.S. Surgical Support business. You took that down in your guidance. Is that entirely because of exiting those accounts? And is that the entire reason for the modest organic reduction to the sales outlook for the business?

Rajesh Asarpota - NuVasive, Inc.

Matt, so let me start with your first question here on mix, and I think you made a good observation. Really it's nothing to do with reimbursement. What I'm seeing and what we're seeing here is really a mix as a result of timing on some product launches, which we expect to see as a result of continued ramp in the NPI that we launched at the end of 2017. And as – so we had a bit of a gap in the first quarter as our cervical NPI comes in the second half of the year. So that's the mix issue we were struggling with this quarter. But again, as we release – we bring new products in online with the second half, we expect to recover that. So it's really a question of making sure that we have the right product mix primarily as it relates to the cervical piece of the business – part of the business.

Matt O'Brien - Piper Jaffray & Co.

Okay. And the U.S. Surgical business?

Rajesh Asarpota - NuVasive, Inc.

I'm sorry, can you repeat the question on the Surgical business.

Matt O'Brien - Piper Jaffray & Co.

Sure. Your organic guidance for the year came down I think 30 basis points to 40 basis points. And I think that's entirely because of the U.S. Surgical business. The outlook there is down I think 200 basis points. Is that entirely from the accounts you're expecting to exit and was that something you had anticipated when you were guiding for the year?

Rajesh Asarpota - NuVasive, Inc.

No. We're not taking our guidance down. So I'm not sure I'm connecting with your question here, Matt.

Matt O'Brien - Piper Jaffray & Co.

Okay. Thank you.

Rajesh Asarpota - NuVasive, Inc.

Okay.

Operator

Thank you. Our next question comes from the line of Josh Jennings from Cowen and Company. Please go ahead.

Joshua Jennings - Cowen and Company, LLC

Hi, good afternoon. Thanks for taking the questions. I was hoping to focus on the U.S. Spinal Hardware business. Thanks for the metrics on case volumes and the 5% and the mix and pricing commentary. But I was hoping to get some color on the NuVasive revenue per case. If we could think about that sequentially and whether there's any improvement there and then whether or not we should be thinking about improvement in NuVasive revenue per case going forward this year with the new product introductions, particularly the interbody spacer segment and with some of the biologics improvement.

Rajesh Asarpota - NuVasive, Inc.

So we are seeing a slight uptick in the per case volume like per case revenue growth. So as we look at versus prior year, we are seeing some revenue lift from improved procedure revenue per case.

Joshua Jennings - Cowen and Company, LLC

Okay. Thanks. And then just a follow up on the U.S. Spinal Hardware business. There had been some concerns about sales repatriation and potential surgeon defection. And I was just hoping to get – to check the box about did you see any outside sales repatriation in 1Q or any surgeon defections? And what are the plans for sales rep adds? And were you net adders of new surgeon customers in the quarter? Thanks for taking the questions.

Gregory T. Lucier - NuVasive, Inc.

Yeah, you bet. This is Greg. Just to further add some color on the last question. The dollar per procedure continues to notch up slightly, but if you maybe take your question and go to the medium term, I think there's an opportunity for it to go nicely up, just as we continue to mix more towards deformity and we continue to put more electronic systems into the operating room. So the overall dollar per procedure will begin and flow upwards over the next couple years.

In terms of attrition of sales reps, actually our sales rep attrition is at its lowest rate since I've gotten here. I think the sales force is very stable. So that's good. And then surgeon attrition really not anything different than what we've had in the past, so pretty standard in terms of the quarter.

Operator

Thank you. Our next question comes from the line of Kaila Krum from William Blair. Please go ahead.

Kaila P. Krum - William Blair & Co. LLC

Great. Hey, guys. Thanks for taking our questions. So first on biologics, second on the Surgical Intelligence platform. So first on biologics, and you mentioned you are seeing sequential improvements there. Can you talk about specifically what you are seeing? Because I think you're still expecting about 6% growth in the Surgical Support business for the full year. So that is a reasonably sizable acceleration from this quarter's levels. So, again, just any color about what gives you confidence in that improvement, and what's implied as it relates to biologics within there would be helpful?

Gregory T. Lucier - NuVasive, Inc.

Yeah. I got you. So the biologics business, as we said in the prepared remarks, performed better than expected. We think we're at a trough at the low point of the growth rates or negative growth rate. And if you just track the retraction in that business over the last couple of quarters, you would see that the deceleration is now slowing and the goal here is to get to positive growth over the next couple of quarters. So we're, as I said, encouraged by what took place in the first quarter and onward and upward for the balance of the year there. Your second question was outside of biologics and pertains to Surgical Support. Is that right?

Kaila P. Krum - William Blair & Co. LLC

Yeah. Just as it relates to the initial launch of the platform, I know you've been a little elusive about your efforts there. And you've said that you'd give us more color out at NASS. But just perhaps if you could walk through sort of what you viewed perhaps to be some of the shortfalls of existing robotics technology today that perhaps your system could address. And then do you think you'll have more of an edge breaking into the ASC segments of the market versus the OR? Thanks.

Gregory T. Lucier - NuVasive, Inc.

You bet. So as we have been consistent in our opinion, in the world of healthcare, the last thing the OR needs in the world of spine is the addition of $1 million piece of hardware that basically only does one thing and that is help place pedicle screws. And when you actually look what's needed in the operating room, we think it's more sophisticated navigation, radiation reduction, and what we would just call smart automation. And smart automation is the right tasks at the right economics.

At NASS we're going to launch our platform that will embody all of those elements in a way that's very economical. And so it takes a little bit of a steady hand to get through the kind of enthusiasm that people have for "robotics" right now because it's a shiny new object, but I think we're focused here on the right solution that we'll launch at NASS.

And your point is right that most of the growth of spine procedures will happen outside of hospitals and that's where the economics are going to be really important. And I think you're seeing that we're designing systems for where surgery has to be a couple of years from now, not where it is today and that's what we'll talk more about at NASS.

Kaila P. Krum - William Blair & Co. LLC

All right. Thanks, guys.

Operator

Thank you. Our next question comes from the line of Robbie Marcus from JPMorgan. Please go ahead.

Robbie J. Marcus - JPMorgan Securities LLC

Great. Thanks for taking the question. I was hoping – you gave some good color that you thought NuVasive volumes were 5% in the U.S. in the quarter. We've gotten different data points from some of your competitors that it seems like the market in general, both in the U.S. and globally, remained flat in the first quarter. So it'd be great to get your take on where you think the market is – was in the first quarter and where you think it's stabilizing in the second quarter? Thanks.

Gregory T. Lucier - NuVasive, Inc.

You bet. So internationally, we saw consistent demand that we've seen in the last few years, and as you can see, we continue to execute against those customer demands at a very robust pace, 20% constant currency growth. And as Raj guided, we don't see any reason why we won't continue to do that for the balance of the year.

In the first quarter in the U.S., case volumes were 5%, price deflation was 2%, and our particular mix issue in the first quarter also gave us about 2% headwind. As Raj also said, we don't see that mix issue repeating itself in subsequent quarters. So, knock on wood, we'll actually see higher hardware growth rates from NuVasive in the U.S., which means we are definitely taking share.

So that's what we would tell you is our view of the world is that the international markets remain about the same. The U.S. market is flat but stable, not getting worse, not getting better, but we're executing better, and we think we'll show that even in the next couple of quarters and a better extent in the U.S.

Robbie J. Marcus - JPMorgan Securities LLC

Okay. So if I look at your guidance for U.S. Spinal Hardware and its 2.6% to 2.4% growth, should I interpret that as something around 5% volume growth offset by 3% to 4% price?

Gregory T. Lucier - NuVasive, Inc.

No. I think you should presume 5% case volume growth, 2%-ish is (40:26) price, and then you've got our guidance.

Robbie J. Marcus - JPMorgan Securities LLC

Okay. There's still a little bit of a delta there. Is there anything specific to point to?

Gregory T. Lucier - NuVasive, Inc.

I'm going to let you do the final math. Our guidance is our guidance.

Robbie J. Marcus - JPMorgan Securities LLC

Okay. And just one quick follow-up on SG&A. You lowered that to offset the lower gross margin. Where exactly do you think you'll be able to pull back on SG&A? Thanks.

Rajesh Asarpota - NuVasive, Inc.

Look, we have – if you look at our operating expense budget for the year, it's over $600 million, and to find like less than 1% here, which was the mix on our operating profits, we think we easily get that by just a little bit of belt tightening. We have the back office efficiencies and spend elsewhere in the business that's discretionary that we can pull back on. So clawing back that $4 million to $5 million is no big deal.

Robbie J. Marcus - JPMorgan Securities LLC

Now the other thing I want to emphasize, although we didn't get a question on it yet, is our Ohio manufacturing plant. I do want to make sure the investor understands what we believe will happen. So those of you that have visited this plant, this is the most advanced spine manufacturing plant on the planet. It's highly automated. It's all digital. It's big.

And our issue isn't that the unit costs aren't going to be competitive. They are. We can make parts now 20% to 25% lower than anything possible on the outside. Our issue now is getting all of the throughput out of the plant to absorb the fixed cost. We will be there in the second half of the year. And when you look at margins, it will have a demonstrable impact on the gross margins, which will flow to the operating margins.

Robbie J. Marcus - JPMorgan Securities LLC

Thanks a lot.

Operator

Thank you. Our next question comes from the line of Mike Matson from Needham & Co. Please go ahead.

Mike Matson - Needham & Co. LLC

Hi. Thanks for taking my questions. I guess, first, just wanted to ask about LessRay. I think you commented it was running below your expectations. So you mentioned the shiny new object of robotics. Is this just kind of losing out just to robotics at this point?

Rajesh Asarpota - NuVasive, Inc.

Look, the LessRay product is selling. We're not going to break out the numbers. We like its traction in the marketplace. We like how we're unfolding the story that this is the entryway to our Surgical Intelligence platform, and it will be a nice net positive for the 2018 results. And I would just contrast to a robot. It's far less expensive, and it gets to one of the top items when surgeons are really reflective of what they want, and what they want for sure is radiation reduction if they're going to do minimally invasive surgery.

Mike Matson - Needham & Co. LLC

Okay, thanks. And then just on the margins, what sort of trajectory should we expect there? I mean is it going to be more of a ramp over the next few quarters? Or is it going to be more of a step change in the second half of the year in terms of, I guess, gross margins you said there was a manufacturing costs and (44:00) everything? Thanks.

Rajesh Asarpota - NuVasive, Inc.

Yeah. So let's talk about gross margins and primarily focus on the NML contribution. So we had talked about 130 basis points for the year. And like we mentioned in our prepared remarks, we were down in the first quarter. So as we look towards the balance of the year, nothing's changed in terms of the trajectory there. So we see an increased accretion in the back half of the year. While we won't be able to claw back everything that we missed in the first quarter, we still expect to deliver an 80-plus basis points of improvement on that line. So what you're going to see in Q2 is pretty much a bit of neutral factor and then significantly accretive in Q3 and Q4.

Mike Matson - Needham & Co. LLC

Thank you.

Operator

Thank you. Our next question comes from the line of Joanne Wuensch from BMO. Please go ahead.

Joanne Karen Wuensch - BMO Capital Markets (United States)

Hi, can you hear me okay?

Gregory T. Lucier - NuVasive, Inc.

We can.

Joanne Karen Wuensch - BMO Capital Markets (United States)

Excellent. Can you maybe flesh out a couple of the things that happened this quarter? Number one, you had a selective departure of certain accounts that you chose to do. Number two, you have the impact of flu. And then number three, West Carrollton, is there a way to exactly say how much of that is maybe slowing down either gross margins or maybe just in general some of your sales cycle?

Gregory T. Lucier - NuVasive, Inc.

So let me work with Skip who's here on the commercial side, Raj and myself to give you some quantification. The flu impacted us certainly in our European results. However, we still delivered 20% constant currency growth internationally. So think of that as going away in the second, third, fourth quarter and International results should actually go up from here. Skip, maybe just a few words on International?

Harry Skip Kiil - NuVasive, Inc.

Yeah, absolutely, Greg. Joanne, I think the key takeaway from International is we continue to scale this business and focus our efforts on eight to ten key markets, and the UK being one of those markets, hence the reason we highlighted the push relative to the bed exposure and the flu. Obviously, we're feeling great around where that International business is going. There's a strong focus on better commercial execution. We're hiring great talent and we're building our brand awareness. We have 4.5% to 5% market share across that International business and there's plenty of headroom by us showing up in a meaningful way in certain accounts and certain markets. So we're again excited about where we're going with International.

Gregory T. Lucier - NuVasive, Inc.

So again the flu will have been a temporal item in the first quarter. Raj, maybe NCS, just say a few words about that? About the case volumes and where we go from here?

Rajesh Asarpota - NuVasive, Inc.

Yeah, yeah. So in the first quarter we saw NCS case volumes down roughly in the 7% range. But having said that, like I said in my prepared remarks, some of that was due to accounts that we purposely chose not to – we exited those accounts for internal sort of margin threshold.

Having said that, we are now going into the second quarter with a little bit more of an aggressive approach in terms of getting new accounts and making sure that we put this back on track in terms of growth. So we expect that the core services business should turn around. And the other thing like I also mentioned was a little bit of a sort of balance between integration and executing on our core business. So I think they are going to be a little bit thoughtful in terms of making sure that we have resources more committed to executing on our core business and a lesser focus on integration like we initially aggressively tried to go after. So that's the color on NCS.

Gregory T. Lucier - NuVasive, Inc.

And then maybe you and I, Raj, can just answer on West Carrollton. I can give the medium-term impact. You could talk to 2018. But just to remind the investor, the West Carrollton investment was to deliver 400 basis points of gross margin improvement. Interestingly enough in the first quarter, we took a step backward as we said because the output (48:30) cost yet. We're still very committed to the full 400-plus – the 100 basis points improvement in gross margins, which will take this business to the high 70% range gross margins in the medium-term. In terms of 2018?

Rajesh Asarpota - NuVasive, Inc.

Yeah. So in the first quarter, we already quantified the impact of NML through our gross margin. So 120 basis points of the 350 basis points of erosion came from the NML side. And like I said, as we move forward into Q2, you will not see that 120 basis points of erosion. It will be more a little bit neutral. And then you'll see significant accretion in the second half of the year, so that overall for the year we will deliver 80 basis points of improvement versus the 130 basis points that we committed to. That's how I see 2018 playing out.

Joanne Karen Wuensch - BMO Capital Markets (United States)

Thank you very much.

Rajesh Asarpota - NuVasive, Inc.

Sure.

Operator

Thank you. Our next question comes from the line of Richard Newitter from Leerink Partners. Please go ahead.

Richard Newitter - Leerink Partners LLC

Hi. Thanks for taking the questions. I just wanted to clarify what the organic constant currency was in the quarter and then what your guidance organic constant currency is, and what it compared to as of your last call? Can you just run through those? Because I know you gave organic guidance but I think that includes currency assumptions change. Can you just remind us those three metrics?

Gregory T. Lucier - NuVasive, Inc.

Sure. So including SafePassage – actually let me take that back into excluding SafePassage here. So organic growth, we guided to a range of 4.7% growth for the year and ex-currency that growth rate would be 3.7%.

Richard Newitter - Leerink Partners LLC

Okay. So for the quarter your constant currency organic rate is somewhere between 1.5% and 2%, right? Is that right? Just...

Gregory T. Lucier - NuVasive, Inc.

Yeah. If you look at ex-currency growth, organic was about 2%.

Richard Newitter - Leerink Partners LLC

Okay. And for the year?

Gregory T. Lucier - NuVasive, Inc.

Versus the reported growth of 4.6%. And for the year this growth would be 3.7% for the total year organic ex-SafePassage.

Richard Newitter - Leerink Partners LLC

Inclusive of currency?

Gregory T. Lucier - NuVasive, Inc.

Ex-currency.

Richard Newitter - Leerink Partners LLC

Or is that excluding currency?

Gregory T. Lucier - NuVasive, Inc.

Excluding currency.

Richard Newitter - Leerink Partners LLC

Okay. Got it. So 3.7%. So that's very, very – a couple of – tens of basis points below what it was. Is that correct?

Gregory T. Lucier - NuVasive, Inc.

No. I mean, it's noise.

Richard Newitter - Leerink Partners LLC

Okay. And just one housekeeping item. It looks like you restated for the ASC 606 accounting that all companies are doing. I had thought that you guys had already restated for that. One, am I getting that incorrect? And if so, I apologize. But if not, can you just tell us what was the additional restatement related to today?

Gregory T. Lucier - NuVasive, Inc.

We did and it's on our website and the impact is on there. I mean, we filed that clearly. So the impact that you'd see for the year was $2.8 million on top line. And you'll see that in our reporting.

Richard Newitter - Leerink Partners LLC

Okay. Thank you.

Gregory T. Lucier - NuVasive, Inc.

Yeah.

Operator

Thank you. Our next question comes from the line of Isaac Ro from Goldman Sachs. Please go ahead.

Isaac Ro - Goldman Sachs & Co. LLC

Good afternoon, guys. Thank you. I wanted to spend a little bit of time on the Carrollton update you guys gave us. I'm not an operations person by training, I totally appreciate if you could maybe break down a couple of the key operational goals you need to hit to realize the 400 basis points margin improvement and you can break that down however you want, but I'd appreciate just a little bit of detail under the hood in terms of what's happening there to realize the improvement?

Gregory T. Lucier - NuVasive, Inc.

You bet. So just to remind everybody, we shut down the old factory at the end of last year December. We put everybody into the new plant starting in January. And so we're talking about the first three months of full operation of this plant.

The plant is producing; obviously, the output we need in addition to items that we outsourced continues – that we still outsource to meet the overall sales demand for the company.

On those units we're producing out of West Carrollton, the unit cost that is think of a widget and how much it actually costs, is meeting our expectations. It's 20% below what you could buy it on the outside. And so that's good. The issue for us is we're not producing enough of them yet.

So the key measurements you would want to know is output per day and getting that to a level that absorbs the fixed cost of all of that factory. So the output per day is going up. It's got to go up faster but it's going up. There's no invention required here. It's just work to continue to scale the plant. And as it gets past the threshold of the cost of the fixed operations, it starts to produce accretive gross margin to the company. That will happen in the mid part of this year and gross margins will start to escalate in the second half per the guidance.

Isaac Ro - Goldman Sachs & Co. LLC

Okay. That's helpful. And so I think last quarter you had given the forward quarter guidance. This quarter you're just updating for the year. Is that because there's some swing factors between 2Q and 3Q as it relates to the items you just touched on, or was there another consideration that makes it difficult to kind of provide us a forward quarter outlook? Thank you.

Gregory T. Lucier - NuVasive, Inc.

Our crystal ball isn't that perfect, we're still saying second half of the year and so you shouldn't read into anything we're saying here.

Isaac Ro - Goldman Sachs & Co. LLC

Thanks guys.

Rajesh Asarpota - NuVasive, Inc.

You bet.

Operator

Thank you. Our next question comes from the line of Kyle Rose from Canaccord Genuity. Please go ahead.

Kyle William Rose - Canaccord Genuity, Inc.

Great. Thank you very much for taking the question. I just wanted to circle back to your LessRay and then the broader – your Surgical Intelligence push into NASS in September. I guess, maybe what has the first six to nine months of LessRay as far as that sales process and the capital sales process really helped teach you when you think about you're starting to roll up the broader initiative of Surgical Intelligence into year end. I mean, I guess what makes you more confident that that will have a bigger push here this time versus how we thought about LessRay maybe this time last year impacting 2018?

Gregory T. Lucier - NuVasive, Inc.

So LessRay was our first piece of capital equipment that the company has itself. It's allowing us to develop the kind of muscle memory, the ability to sell capital in addition to spinal implants and we're getting better and better at it. We're building out a capital selling force. We're creating the models in our CRM system. We're learning how to deal with the value committee, the hospitals, something we've never had to do before.

I'd further remind the investor that LessRay is the first element of now what we believe is a long trend of systems going into the operating room. A few years from now I just don't see a company being in the spine business unless it's integrated like we are going to be, and I'm sure some of our larger competitors.

So come NASS, you're going to see the launch of a much bigger set of operating room technologies. And by the October timeframe, our capital selling force will be bigger, we'll sell more LessRays. All of this is just stepwise stepping towards becoming this totally integrated spine company.

Kyle William Rose - Canaccord Genuity, Inc.

Great. That's very helpful. And then just one quick follow up. Obviously, biologics came in a little bit better than I think you were expecting. Maybe just talk about, were there any changes to how you think about your sales force incentives in order to maybe drive better attachment rate there, as well as some of the underlying hardware strength we saw into Q1?

Gregory T. Lucier - NuVasive, Inc.

Yeah. Good question. So what we did in the first quarter with biologics was we adjusted our prices to meet the market price. That was long overdue. We started to actually work with our sales people to make it integrated into their selling where candidly we had probably left that discipline last year. So we're doing that. And both of those things have combined to produce in the first quarter a little bit better results.

As we said, we think we're at the nadir, we're at the trough of where the biologics business will be and we think we'll continue to get a little bit better every quarter now. What you could expect from us in the subsequent quarters in biologics is broader product offerings, a more complete focus, so that we can be a more formidable biologics player in and of itself. And we think that's what you got to do today to be in the biologics space.

Kyle William Rose - Canaccord Genuity, Inc.

Great. Thank you for taking the questions.

Operator

Thank you. Ladies and gentlemen, that is all the time we have for Q&A today. Mr. Lucier, I would like to turn the call back over to you for closing comments.

Gregory T. Lucier - NuVasive, Inc.

You bet. So as we conclude today's call, I'd like to announce that Carol Cox, our Executive Vice President of External Affairs is going to be transitioning to a strategic advisory role and will remain with the company through early 2019. Carol's decision to move to an advisory capacity is something we have been discussing together for a few months, and I'm in full support of her desire to move to this new role.

As many of you know Carol and I have worked together many years. She is a true IR and communications professional. Over the past four years at NuVasive, she has achieved a lot, including building out our Investor Relations function and ensuring our investor community understand the value of NuVasive and where we are headed. She has also led other functions during her tenure including Public and Government Relations as well as the NuVasive Spine Foundation. She's had a direct hand in many accomplishments that have made this company better. I've learned a great deal from Carol. I appreciate her mentoring others in the organization and can't thank her enough for her leadership and counsel to me personally and for the good of the overall company.

As Carol transitions, Raj and Suzanne Hatcher will work together managing the Investor Relations function. Many of you know Suzanne and interact with her frequent already. You're in good hands with her along with Raj and the NuVasive finance team. Carol, I'll turn it over to you now to say a few words.

Carol A. Cox - NuVasive, Inc.

Thanks Greg and everyone. First and foremost, thanks for the kind words and support that you and the board have shown to me at my tenure at NuVasive. I'm very grateful for the opportunities I've had here to broaden my skill-set, build out several kinds of teams and help mentor our next level of leadership. I'm proud to have been part of this vibrant culture that heroically puts patients first and strongly values, innovation and really the time to start giving back.

As Greg said, we've been discussing my plan to transition from my current role and while finding that optimal time is really not possible at all, I'm confident we have a strong team in place now with Raj and Suzanne and a very robust finance team to continue support the Investor Relations efforts really at the highest levels here at NuVasive.

So more than anything, I'd like to share through the transition and to do that as Greg said, I'll remain as the strategic consultant to NuVasive through the early part of 2019. For me it's really been an honor to be part of the NuVasive leadership team for four years and as we've evolved and further built out our strategy to be in spine.

Again, as we end this call, I'd like to thank Greg and the board of directors and really all the talented and dedicated colleagues here at NuVasive for your support and friendship over the years. And I'll look forward to catching up with everyone individually.

Gregory T. Lucier - NuVasive, Inc.

Carol, again thank you very much. We wish you all the very best and with that thank you all of those who called in on the call today. We look forward to speaking to you next quarter. All the best.

Operator

Thank you. Ladies and gentlemen, this does conclude our teleconference for today. You may now disconnect your lines at this time. Thank you for your participation and have a wonderful day.