Where to find high growth oligopolies in abundance?

Key takeaways:

• Healthcare’s resilient and robust demographic driven demand persists throughout all stages of the economic cycle and remains in the early innings of a secular growth tailwind.
• Sub-sectors of the medtech industry tend to form into natural oligopolies due to deep and wide economic moats.
  
• This oligopolistic industry structure has driven a period of strong risk-adjusted returns that we believe is likely to continue over the long-term.
  

The demographic tailwinds of an ageing population and growing middle class present one of the great investment tailwinds in the years ahead, and the raw numbers are truely staggering. There were 1 billion people aged over 60 years old in 2019, which will grow to 1.4 billion by the end of the decade and more than double to 2.1 billion by 2050¹. Alongside population growth, wealth is being created faster than ever before. From 2011 to 2019, the global high-income population grew at an average of 15 million annually, and the middle class by 54 million people annually².

Combining this ageing population with our current lifestyle – poor diets, toxic environments and sedentary behaviour – is leading to growing occurrence of chronic conditions, including heart disease, diabetes and obesity. In the growing population of older adults, ~95% percent have at least one chronic condition and >75% of have two or more³.

Indeed, the extraordinarily high growth in the prevalence of chronic diseases is a trend which is only likely to accelerate in the coming decades. This will continue to create an unrelenting demand for healthcare services that does not pay heed to economic cycles. While many trends play out over a multi-year period, the resilient and robust demand for healthcare is a true secular thematic that has decades to run.

Medical technology is a key part of the treatment toolkit used to address this growing problem, and for investors, medtech's appeal is in its industry structure. The high demand is funnelled into what tends to be natural occurring medtech oligopolies. This oligopolistic nature translates demand into earnings and ultimately drives valuations.

While each sub-sector within medtech has its own competitive dynamics and structural nuances, there has always been a trend for early players to corner the market. This is in the most part due to extremely high barriers to entry – also known as economics moats – that protect the early-to-market device developers. This first mover advantage often renders the time, effort and up-front cash required for sub-scale players too onerous. And unlike in the pharmaceuticals industry, there is no market for generic low-cost alternatives in the world of high consequence medical devices. The key barriers/moats that protect medtech incumbents include:

• Development & regulatory; medical device development requires costly up-front investments in research, development and clinical trials
• Brand reputation; a critical factor in an industry literally dealing in life and death
• Intellectual property protection; patent holders are granted a temporary monopoly when coverage is broad enough
• Distribution networks; the ability to get devices into the hands of physicians and operators
• Economies of scale; manufacturing cost advantage makes it difficult for smaller companies to compete

The natural oligopolistic structure is then further perpetuated by the industry standard practice of tuck-in M&A. Typically, large established medtech conglomerates will seed fund early-stage medtech ventures to guarantee first right-of-refusal to buy and own intellectual property should the technology develop into a winner. This plays out in fewer bigger competitors dominating the market.

A pertinent example of a medtech oligopoly is the market for blood glucose monitoring technology. CGMs (continuous glucose monitors) have been one of the most important steps forward in the treatment of diabetes in the past 20 years. The ability to track glucose continuously, rather than intermittently, has allowed patients with diabetes to better pre-empt and therefore treat their condition, all without the requirement for painful and socially burdensome finger-sticking to obtain a blood sample.

The first continuous glucose monitor was approved all the way back in 1999, and despite almost 25 years of progress, the market remains a three-way oligopoly today where the leading players hold >95% of global market share. These three key players – DexCom (NASDAQ: DXCM ), Abbott (NYSE: ABT) and Medtronic (NYSE: MDT) – have used this 25-year head start to build deep customer relationships, expansive distribution networks, efficient manufacturing scale and comprehensive clinical data that will protect them against new competition for many years to come.

An even more profound example is in the surgical robotic space, where Intuitive Surgical (NASDAQ: ISRG) – the global leader in surgical robotic systems – maintained a natural (non-regulated) monopoly for over 15 years. Its first generation da Vinci system was approved for general surgery by the U.S. FDA (Food and Drug Administration) in 2000 and remained the only approved device until 2017, as other players struggled to overcome the R&D hurdles that Intuitive overcame in the early 2000s. In the 17 years of monopoly operation, Intuitive’s stock returned over 5,800%, or greater than 25% per annum. In the period of duopoly operation since, Intuitive has continued to return in excess of 15% annually for shareholders⁴. As more competition comes to market, new players with little track record will find it very tough to compete with Intuitive’s body of clinical evidence, which includes a global network of 8,000 da Vinci systems that have performed 13 million procedures and over 34,000 peer-reviewed published articles⁵. Intuitive’s trusted brand reputation is likely to remain a key competitive advantage against new upstart competitors long into the future.

This favourable competitive landscape affords medtech companies the ability to be price makers, rather than price takers. Medtech’s customers – which are typically governments or private insurers – willingness to pay these higher prices is the first layer of defence when building up a firm’s profitability. This ability to pass on price is also an important characteristic in protecting earnings during inflationary periods and supported the medtech industry through the recent period of high inflation. 

The oligopolistic nature of this industry structure has led the medtech sector to a period of significant outperformance, as illustrated by using the Dow Jones U.S. Select Medical Equipment Index as a sector proxy. Since its inception in 2006, the index has outperformed the global equities market, as represented by the S&P Global 100. During this history of long-term outperformance, the medtech sector has delivered on a risk-adjusted basis. Although absolute volatility – as measured by the standard deviation – is higher, the excess returns translate into significantly higher Sharpe and Sortino ratios. The returns have also been consistent rather than unpredictable and lumpy, as suggested by higher a batting average and strong capture ratios.

In conclusion, the confluence of insatiable demand and oligopolistic structure in the medtech sector presents a compelling investment opportunity. With strong long-term growth potential, attractive risk-adjusted returns, and the potential for positive social impact, medtech offers a powerful investment proposition for those seeking both financial success and a chance to contribute to a better future.

1. World Health Organization, Facts Sheets: Ageing. Accessed at (VIEW LINK)

2. (VIEW LINK)
3. National Council on Aging. Chronic Inequities: Measuring Disease Cost Burden Among Older Adults in the U.S. A Health and Retirement Study Analysis. April 2022. Found on the internet at (VIEW LINK)
4. CapIQ financial data, as at 12/1/24
5. Intuitive Surgical Q2 2023 Investor Presentation, 20/7/2023