BEST STRATEGIES TO SUCCEED IN ASIA

Transcription

1 BEST STRATEGIES TO SUCCEED IN ASIA MDMA Webcast: October 18, 2017 Presented by Ames Gross, President Pacific Bridge Medical 7315 Wisconsin Avenue, Suite 609E, Bethesda, MD Copyright 2017 Pacific Bridge Medical. All rights reserved. This content is protected by US and International copyright laws and may not be copied, reprinted, published, translated, resold, hosted, or otherwise distributed by any means without explicit permission. Disclaimer: the information contained in this report is the opinion of Pacific Bridge Medical, a subsidiary of Pacific Bridge, Inc. It is provided for general information purposes only, and does not constitute professional advice. We believe the contents to be true and accurate at the date of writing but can give no assurances or warranties regarding the accuracy, currency, or applicability of any of the contents in relation to specific situations and particular circumstances. 1

2 INTRODUCTION TO PBM PACIFIC BRIDGE MEDICAL (PBM) is a leading medical consulting firm dedicated to assisting medical companies in Asia. Our consultants have helped over 500 medical companies with business development, regulatory affairs, sales, sourcing, and market research in Asia since our founding in We are very knowledgeable about the Asian healthcare market and have a great team on the ground in each Asian country with various medical expertise. 2

3 Overview of Asia 3

4 Asia Economic Statistics (2016) Per capita GDP Per capita GDP growth Source: World Bank and other PBM sources GDP (PPP) Real GDP (PPP) Growth Rate China $8, % $21.3 trillion 6.7% Hong Kong $42, % $427 billion 1.9% India $1, % $8.7 trillion 6.8% Indonesia $3, % $3 trillion 5% Japan $34, % $4.9 trillion 1% South Korea $27, % $1.9 trillion 2.8% Malaysia $9, % $863 billion 4.2% Philippines $2, % $801 billion 6.8% Singapore $52, % $486 billion 2% Taiwan $22,450 2% $1.1 trillion 1.4% Thailand $5, % $1.2 trillion 3.2% Vietnam $2, % $594 billion 6.4% United States $56, % $ 18.6 trillion 1.6% European Union $32, % $19.2 trillion 2% 4

5 Size of Medical Device Markets (2016) Global Medical Device Markets Region Market Size (US$) Asian Medical Device GrowthMarkets U.S. $140 billion Country Market 3% Size (US$) EU $130 billion 2% China $22 billion Japan $27 billion 1.5% Hong Kong $850 million Asia Pacific $34 billion 20% India $3.5 billion Latin America $12 billion 8% Indonesia $780 million Latin America 3% Global Medical Device Markets Asia Pacific 10% Japan 8% EU 38% U.S. 41% Korea Malaysia Philippines Singapore Taiwan Thailand Vietnam $3.9 billion $1 billion $300 million $530 million $2.5 billion $850 million $630 million 5

6 Asian Medical Device Market Trends 6

7 Asian Medical Device Market Trends Explosive demand for medical devices in the Asian markets attracts Western and local medical device companies. Western medical device companies increasing sales to Asia with basic models and lower costs of their top of the line Western products. Western device companies are sourcing/manufacturing in Asia more. Many more local Asian medical device manufacturers now in business making more sophisticated products with components of better quality as demand increases in the region and globally. More Asian device manufacturers compete with West. 7

8 Which Asian Markets Should You Go to First/Last? Is it a high technology device? Is the device very expensive? Can the device be easily reverse engineered? Which countries in Asia have the best healthcare systems? Which strategies should I use? Distributor network, joint venture, subsidiary 8

9 China: Medical Device Market China remains one of the most compelling markets for medical devices companies globally. The twin effects of an ageing population and a burgeoning, upwardly mobile urban middle class are placing strain on the country s public hospital system, which is pushing up demand for new products and services 9

10 China: Key Market Research Issues Research has to be well thought out Secondary research not normally that accurate; government statistics not reliable or non-existent Primary research is the best way to go Researcher should have worked for Western medical companies before Big research companies send out 20 year olds, may not have experience to get answers you need; maybe a few inperson quality interviews will do Determine if there is a market before product registration; many companies do not do this 10

11 China Distributor Search US medtech company (about $200 million in sales) sells product to Chinese importer Chinese importer buys about $3 million per year from US medtech company Re-register similar products Undercover find out copycat manufacturer owns Chinese importer Copying NOT illegal in China if no patent, exact same copy 11

12 Chinese Medical Device New Regulations (October 1, 2014) 2000 Regulations only 6 chapters and 48 articles. Now 2014 Regulations 8 chapters and 80 articles Class 1 Notification, not registration, but more documentation needed than previous class 1 registration Class 2/3 devices more local clinical trials needed Class 3 device clinical trials require CFDA protocol approval Registrations now good for 5 years not 4 More information required on outside labels in Chinese Advertising 12 Copyright 2017 Pacific restrictions Bridge Medical

13 Chinese Medical Device Registration Getting a lot tougher and longer for approvals (new regulations October 2014) New standards released Testing delays (only 10 centers) More supplementary reviews requested by the CFDA Will clinical evaluation reports work? Class 2 and 3 medical devices need more local clinical trials; new exempt list too Approval in country of origin still required (can you make in EU) 13

14 China Pricing and Reimbursement Pricing Oftentimes follows the national price list, but now is determined more and more by the provincial pricing bureaus (need to go province by province) Reimbursement Mostly for procedures with domestically made products. If patient wants a foreign stent, they must pay out of pocket Adjunct devices are normally not reimbursed 14

15 The Overall Market Access Process In China For Imported Medical Device Products After Product Approval CFDA approval B Patient-price application & approval B B B Provincial bidding & procurement Hospital Listing Patient B National and Provincial MD Reimbursement List(s) P P Reimbursement status is granted to a product category (by Product Code) Everything else in Market Access is brand-specific A complex, lengthy, and uncertain process First started in the late 90 s, and has been upgraded over the years in an effort to ensure transparency, minimize corruption, and bring down the cost to the payer and to the patient Since late 2014, more significant changes and experimentations throughout the country have led to huge uncertainties. B 15

16 THE PROVINCIAL/LOCAL PRICE OF HIGH-VALUE MEDICAL Disposables And Implantables Have Come Down In The Last Couple Of Years Case study GanSu Province Purchase Prices for Stent Products (2015) Number 16 Product Catalogue Code Product Sub-type Stent, coated with rapamycin and derivatives Stent, coated with rapamycin and derivatives Stent, coated with rapamycin and derivatives Stent, coated with rapamycin and derivatives Stent, coated with Taxol Stent, coated with rapamycin and derivatives Stent, non-drugcoated National Catalogue GanSu Province Product Name / Brand EXCEL Coronary rapamycin, Eluting stent system (FIREBIRD) Coronary rapamycin, Eluting stent system (FIREBIRD2) YINYI ( 垠艺 ) Manufacturer Lepu (Beijing) Shangdong JW Shanghai MircoPort Shanghai MircoPort Liaoning Biomedical Materials Manufacturing Location Beijing Price (RMB) Price (RMB) 10,800 9,100 Shandong Province 10,900 9,100 Shanghai Shanghai ENDEAVOR Medtronic Ireland 10,800 9,100 11,000 N/A Liaoning Province 11,000 9,100 16,500 10,100 Compared to 2008 National Price ~15% reduction ~15% reduction ~15% reduction N/A ~15% reduction ~30% reduction local made new product R-STENT OrbusNeich Holland N/A at RMB7,200 in GanSu Sources: 2008 National Catalogue (for Cardio 5,800 Intervention; GanSu Bureau of HRSS) 2015 Catalogue

17 Chinese Competitors: Look Out! Local Chinese medical devices compete with foreign-made products (Lepu, MicroPort, etc.) Chinese government is financially incentivizing local device companies to make innovative products Chinese hospitals are encouraged to buy China-made devices Locally made innovative products -- fast track registration Chinese locally-made products compete globally with Western products in Brazil, Indonesia, etc. Chinese companies will acquire or invest in more Western device companies in the future MicroPort purchased Wright Medical s OrthoRecon business for almost $300 million; this is just the beginning 17

18 March 16 th,2015 The China Association of Medical Equipment (CAME), which is authorised by the NHFPC, issued the first portion of the Outstanding Domestic Equipment Catalogue, covering digital X-ray, colour ultrasound and fully automatic biochemical analyser machines. Of the 218 products submitted for consideration by 57 companies, 95 products from 27 companies were selected. Despite many applications for products manufactured in China by the local factories of foreign multinational companies, all of the products selected were from Chinese-owned brands. 18

19 205 Made in China (MIC 2025) When initiated May 19 th, 2015 What is point substitute Chinese manufacturing for international foreign manufacturing, reduce imports in China 19

20 The Minister of MIIT, Mr.Miao Wei, and the Chair of the National Health and Family Planning Commission, Li Bin, signed a cooperative agreement for the two ministries to research and develop locally-produced medical devices and advance indigenous innovation capabilities. 20

21 Which Specific Products Are Targeted? The plan focuses on medical imaging equipment, medical robots, wearable medical equipment, mobile and remote diagnostic equipment, radiotherapy equipment, medical high value supplies, new medical biomaterials and equipment, new biodegradable materials, new implant materials and implant, medical device products based on tissue engineering technology, new medical biological dressings, minimally invasive treatment/implant products, rapid detection technology, gene detection products, high risk infection disease diagnosis reagents key technology and key aspects of the prospective standards of research. 21

22 22 Japan: Key Market Research Issues Has the opportunity been confirmed by good primary research (size of market and growth rate)? Have Japanese market research executives talked to KOL s about your product; not just Western executives from a foreign manufacturing company? Are the Japanese KOLs double agents? Will the reimbursement justify the investment? Best to know upfront to make sure you can have

23 Japan Distributor Search Takes time to find the right distributor/partner Moving registrations can be difficult and costly DMAH Continual follow-up a MUST to keep the relationship and business moving forward Just because there is a market in the West does not mean there is a market in Japan 23

24 Japan: New Regulatory Issues November 24, 2014 new regulations The Pharmaceutical Affairs Law (PAL) became the Pharmaceutical and Medical Device Act (PMD Act) More products approved by third party certification QMS inspection has been simplified conducted according to product groups, not individual products FMA simplified changed from license and accreditation to just registration; key is GM of main manufacturing facility Cellular and tissue products less upfront clinical trials Software stand alone now 24

25 Japan Pricing and Reimbursement Category A1 A2 B C1 C2 F Description (Inclusive) Included within the technical fee. No separate reimbursement is made for the device itself. Product examples: gloves, gauze, sutures (Designated inclusive) Technical fee granted for use of the device or class of devices. No separate reimbursement is made for the device itself. Product examples: MRIs, CTs, and most types of capital equipment (Individual evaluation) Me-too products that are similar to other products on the market. As a result, these products fit into existing technical fee and STM reimbursement categories. Product example: CoCr hip stem (New function) New products based on existing products/therapies. (New function and New technology) New products that result in a new therapy or procedure. No predicate product or treatment exists. Products that do not match the reimbursement system in place or are not suitable for insurance coverage 25

26 Japan Pricing and Reimbursement Foreign reference pricing R-value Product not reimbursed, sales will be limited (except aesthetics) New technology better mousetrap, will reimbursement increase or put in existing category where the prices may or may not meet your expectation and provide company profit Must be checked upfront, NOT after registration 26

27 Do the Right Market Research Before You Start in a New Country 27

28 Do Market Research and Develop Best Business Strategy Client has new implantable permanent contraception device Client is trying to determine if there is an opportunity in China In 2012, China was still under the one child policy Client requests Pacific Bridge Medical to examine the situation and make recommendations 28

29 Do Market Research and Develop Best Business Strategy The most popular methods for contraceptives are Condoms, Withdrawal Method and Rhythm Method 29

30 Do Market Research and Develop Best Business Strategy What s your perception on contraceptive methods in terms of their effectiveness? 30

31 Do Market Research and Develop Best Business Strategy Currently IUDs followed by tubal ligation are the most common contraceptive methods for married couples in China based on current usage 31

32 Do Market Research and Develop Best Business Strategy Physicians think Client #1 s product has clear benefits over tubal ligation, but believe there are many hurdles for this product to succeed in China Perceived Benefits Non-invasive and quick recovery are significant benefits compared with traditional tubal ligation. In cities, tubal ligation is a tiny market. All physicians felt irreversibility is a significant weakness of this product Perceived Barriers Infrastructure: hystereoscope might serve as a hurdle of this product in the countryside where most tubal ligation surgeries are performed Price: Birth control procedures (IUD placement and tubal ligation) are almost fully reimbursed Therapy competition: Advanced IUDs are now more reliable and are not that expensive 32

33 Do Market Research and Develop Best Business Strategy Due to the large amount of investment required in marketing to overcome the negative preconceptions related to permanent sterilization, we would recommend a subsidiary or hybrid model Advantages Subsidiary Higher amount of control Higher Gross Margins Greater market understanding Better ability to brand and develop market National Distributor Less distraction from other business endeavors Lower upfront and operating costs Quicker to get up and running Hybrid Higher amount of control Greater market understanding Better ability to brand and develop market Less distraction from other business endeavors Quicker to get up and running Higher Gross Margins than National Distributor Lower upfront and operating costs than subsidiary Disadvantages Higher upfront costs and operating costs Requires more focus (diverts from other endeavors) Takes longer to get up and running Less control Lower Gross Margins Lower Marketing Understanding Less ability to brand and develop market Lower Gross Margins than subsidiary Higher upfront costs and operating costs than national distributor 33

34 Do Market Research and Develop Best Business Strategy Based on these costs and typical hysterioscopic procedure fees we estimate the total cost of therapy at approximately 12K RMB. USD RMB Import Price $450 2,835 VAT $188 1,187 Dealer Cost $222 1,397 Dealer Profit $166 1,048 Hospital Profit $ Marketing Costs $0 0 Service, Infrastructure and Training Costs $0 0 Import Tax $ Insurance Costs $3 20 Customs Costs $5 28 Shipping & Storage Costs $1 6 Retail Price $1,108 6,983 Procedure Fee $397 2,500 Total Therapy Cost $1,975 12,445 Assumptions 1. Little to no investment by dealers in marketing and service, or training 2. Procedure Fee is similar to other hysterioscopic procedure fees in SH/GZ (2K-3K RMB) 3. Import Price is $450 34

35 Do Market Research and Develop Best Business Strategy Product registration 2.5 years including clinical study $500,000. Reimbursement: Excellent reimbursement exists for current procedures - IUD insertion, tubal ligation. What will reimbursement be for new product? Patents: 3 exist in China; can they be enforced? 35

36 Do Market Research and Develop Best Business Strategy Financial Projections: Scenario 2: Moderate Number of Affordable Couples 531, , , , , , , , , ,558 1,031,784 Percentage of Couples that would consider 5% 6% 6% 7% 7% 8% 8% 9% 9% 10% 10% Number of Couples that would consider 26,594 32,351 38,685 45,281 52,509 60,126 68,092 76,350 84,969 93, ,178 Penetration Rate 1% 2.5% 4.0% 5.5% 7.0% 8.5% 10.0% 11.5% 13.0% 14.5% 16.0% Total Units ,547 2,490 3,676 5,111 6,809 8,780 11,046 13,617 16,509 Total Revenue $0.1M $0.4M $0.7M $1.1M $1.7M $2.3M $3.1M $4.0M $5.0M $6.1M $7.4M Gross Margin 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% COGS $0.0M $0.1M $0.1M $0.2M $0.3M $0.5M $0.6M $0.8M $1.0M $1.2M $1.5M Gross Profit $0.1M $0.3M $0.6M $0.9M $1.3M $1.8M $2.5M $3.2M $4.0M $4.9M $5.9M Regulatory Costs $0.04M Clinical Trial Costs $0.54M Marketing & Education Costs $0.3M $0.5M $0.5M $0.6M $0.6M $0.7M $0.7M $0.8M $0.9M $1.0M $1.1M $1.2M Product Launch $0.3M Service & Infrastructure Costs $0.1M $0.1M $0.1M $0.1M $0.1M $0.1M $0.2M $0.3M $0.4M $0.5M $0.7M $0.8M Total Costs $0.6M $0.0M $0.6M $0.6M $0.6M $0.6M $0.7M $0.8M $0.9M $1.1M $1.3M $1.5M $1.8M $2.1M Total Operating Profit/Loss ($0.6M) $0.0M ($0.6M) ($0.5M) ($0.3M) ($0.1M) $0.2M $0.5M $0.9M $1.4M $1.9M $2.5M $3.1M $3.9M Accumulated (Break Even) ($0.6M) ($0.6M) ($1.1M) ($1.6M) ($1.9M) ($2.0M) ($1.8M) ($1.3M) ($0.4M) $1.0M $2.9M $5.3M $8.5M $12.3M 36

37 Acquisitions/Joint Ventures Acquisition do lots of due diligence and do not overpay Staged payments, with incentives to keep management interested Joint ventures do lots of due diligence More companies call us for break-up help than setting up joint ventures these days Make sure you know what you are buying 37

38 Due Diligence in Asia Can never do enough due diligence before investing Big companies often send 20 year olds to do due diligence Offering memorandums often lack sufficient detail Best way to do it is via phone calls (fake headhunters), examining competition closely and looking for information not in offering memorandums 38

39 Due Diligence in Asia Device companies and investors oftentimes call us to do this work. We only use experienced medical device executives who know how to get the inside information they need. ABC is a Chinese device manufacturer with a US office for sales. They make disposable, relatively low tech device products including syringes, IV products, urology, respiratory, irrigation products, etc. ABC is looking for an outside investor to increase working capital and pay for company expansion. They would like to sell a 49% interest for $50 million. 39

40 Due Diligence in Asia Offering memorandum can be misleading The offering memorandum says one of their competitors is Suzhou Linhua. Suzhou Linhua produces a range of IV products. It is described as presenting some competition in safety IV catheters and less competition in enteral irrigation syringes. New information: This company is large, with at least 900 employees. It claims an annual capacity of 120 million syringes and 80 million transfusion sets. It also makes scalp vein sets, IV infusion sets, enteral feeding sets, and urine bags. Its products do seem fairly basic, as stated in the offering memorandum. It was established in 1989 with equipment imported from Italy and Korea, and has done OEM for Medline, Bard, and ABC in the past. In a 2004 comparison of urine bag suppliers, its products were much cheaper than similar products from other suppliers. 40

41 Due Diligence in Asia Report from recent ex-abc employees Note: For this section, we called these people acting as headhunters. Mr. Xu, VP, Sales & Marketing, (US) Mr. Xu said that ABC management had some problems during his employment. Senior management was shifting, and some people were into kingdom-building. Although they have improved now, they are still struggling with who they want to be. He claimed the owner turned down a $60 million sale to XYZ because he felt a sense of allegiance to MNO. He said the people there are very honest. 41

42 Due Diligence in Asia Visit their offices and check if what they say is accurate Although ABC told PBM during the visit that we are seeing an irrigation syringe production area, we later heard from a contact at another company that ABC actually sources all of its irrigation syringes from their company (Suzhou Linhua Medical Device Co.), and does not manufacture them itself. We did not actually see irrigation syringes being produced, just syringes. This was misleading and not true. 42

43 Other Business Development Strategies in Asia Can you license your device in China? Can you source more device components/products from Asia? Increase sales to Asia, develop B line of products to compete with Asian device manufacturers, less bells and whistles What other Asian countries should you work in? 43

44 Reasons to Source or Manufacture in Asia Some labor costs and manufacturing costs are cheaper Vietnam, India Quality in Asia is quickly getting better Able to make high volumes with established device manufacturing bases in China More FDA/ISO factories in Asia now Device market growth is fastest in Asia; get closer to customers in Asia Per capita income growth and the increasing middle class demand better healthcare Increased number of hospitals/specialty health centers new hospitals, government investing a lot in healthcare coverage (i.e. Indonesia universal coverage) More device reimbursement In some cases, it may not make sense to source or manufacture in Asia if you want to (1) sell in the US/EU or (2) reduce supply chain risks and/or freight costs, etc. Make a B-line of your product with less bells and whistles 44

45 Medical Device Manufacturing Moving to Asia (to reduce cost in some situations and get closer to growing Asian device markets) US EU Japan Other US EU Japan Other (90% Asia) *Sources: Frost and Sullivan, Department of Commerce, and other PBM sources 45

46 Manufacturing and Sourcing in Asia China costs have skyrocketed, but quality has also improved. It may be cheaper for commodity devices and components to be made in Vietnam and India rather than China. Due diligence, close and continuous follow-up, monitoring, audits, and QA will be key. 46

47 India 47

48 TAJ MAHAL, AGRA Taj Mahal, Agra 48

49 India: Medical Device Market India s medical device market is growing faster than at any time in the last decade, with a projected growth rate of 12-16% over the next several years. With a population of 1.2 billion and a growing middle class, India has the potential for strong growth. India s medical device market is dominated by foreign device companies, which control roughly 70% of the market. 49

50 India: Current List of Notified Medical Device Families Requiring Registration S.No Name of the Device Notification Number Date of Notification 1 Disposable Hypodermic Syringes GSR 365 (E) Disposable Hypodermic Needles GSR 365 (E) Disposable Perfusion Sets GSR 365 (E) In vitro Diagnostic Devices for HIV, HBsAG and HCV GSR 601 (E) Cardiac Stents S.O (E) Drug Eluting Stents S.O (E) Catheters S.O (E) Intra Ocular lenses S.O (E) IV Cannula S.O (E) Bone Cements S.O (E) Heart Valves S.O (E) Scalp Vein Set S.O, 1468 (E) Orthopedic Implants S.O (E) Internal Prosthetic Replacements S.O (E)

51 India: Additional List of Notified Medical Device Families Requiring Registration 1. Blood Grouping Sera 2. Ligatures, Sutures and Staplers 3. Intra Uterine Devices (Cu-T) 4. Condoms 5. Tubal Rings 6. Surgical Dressings 7. Umbilical Tapes 8. Blood/Blood Component Bags 51

52 India New medical device requirements start January 1, 2018 Only existing families will require registration (CDSCO) through 2020 However, may be adding families/products in future Manufacturing licenses for class A and B responsibility of the State licensing authorities, class C and D under CDSCO (central) Notified bodies will become more relevant-3 NBs already accredited Price Controls, watch out! 52

53 India: Device Regulatory Update Recently, Prime Minister Narendra Modi s Ministry of Health published a 108 page notification on medical devices in India. Significant changes to medical device regulations include: Device licenses will no longer expire. The manufacturer will need to pay a renewal fee every 5 years to continue marketing the product. Device registration approval for imported devices will take an estimated maximum of 9 months. Registration will automatically imply import license and will eliminate the 3 month wait for an import license. If the Ministry of Health fails to complete a regulatory process in a pre-determined amount of time, then the license will be deemed to be approved. The new regulations will come into effect January

54 Nizamia Hospital 54

55 Vietnam: All Imported Devices Now Require Registration Vietnam has new regulations that now require registration for all medical devices imported into Vietnam. Starting in 2017, all imported medical devices are required to be registered for marketing authorization licenses. Previously, only 24 items required registration, and the license was valid for 12 months. Now, all medical devices must be registered. The device licenses for Class A products lasts forever, and the licenses for Class B, C, and D devices last for five years. The import licenses of companies currently selling imported Class A medical devices will only be valid until June 30, Import licenses for medical devices in all other classes will be valid only until December 31, The Ministry of Health began receiving registration dossiers for Class A medical devices on January 1, 2017, and will start receiving registration dossiers for Class B, C, and D medical devices on July 1,

56 Asian Ethnic Diversity Japan and Korea: very homogenous; small minority populations China: 92% Han, Over 50 National Minority Groups for other 8% Singapore: 77% Chinese, 14% Malay, 8% Indian Malaysia: 50% Malay, 24% Chinese, 7% Indian Indonesia: 40% Javanese, over 300 ethnic groups for other 60% Thailand: Majority Thai, 14% Chinese Philippines: Very diverse population in terms of language, religion and ancestry Tagalog 28%, Cebuano 13%, Ilocano 9%, Bisaya/Binisaya 8%, Hiligaynon Illonggo 8% Vietnam: over 50 ethnic groups Almost 90% Vietnamese Chinese (Hoa) around 1% India: 3 major groups 72% Indo-Aryan, 25% Dravidian, 3% Mongoloid and other 56

57 Relationships of trust is how business is done in Asia Relationships take time in Asia, unlike in the West. How do you write your s to the Japanese? Do you send holiday cards and do you write hand written messages on the holiday cards? Have you made an effort to understand the history and culture in the Asian countries you are working with? Good relationships can always deal with difficult problems. Lawyers do not dominate the regulatory and business practices in Asia, and should be used rarely. 57

58 T H A N K Y O U F O R Y O U R P A R T I C I P A T I O N A N D A T T E N T I O N For more information, visit us at Connect with us today: Address: 7315 Wisconsin Avenue, Suite 609E Bethesda, MD contact@pacificbridgemedical.com Phone: (301)