MANAGEMENT DISCUSSION

AND ANALYSIS

Mr. Rajit Mehta

Managing Director & CEO

Mr. Anas Abdul Wajid

Director - Sales and Marketing

Mr. Anil Vinayak

Director & Zonal Head – Saket, Panchsheel Park & Gurgaon

Mr. Rakesh Prusthi

Director - Legal, Compliance, and Regulatory Affairs

Mr. Rohit Kapoor

Senior Director and Chief Growth officer

Dr. Sandeep Budhiraja

Clinical Director & Director - Internal Medicine

Mr. Sumit Puri

Chief Information Officer

Ms. Swati Rustagi

Senior Vice President and Chief People Officer

Ms. Vinita Bhasin

Director - Service Excellence & Customer Operations

Mr. Yogesh Sareen

Senior Director and Chief Financial Officer

GENERAL MEDICAL

ADVISORY COUNCIL

Mr. Rahul Khosla

Chairman, Max Healthcare

Mr. Rajit Mehta

MD & CEO, Max Healthcare

Dr. A. K. Singh

Director – MIND, Senior Consultant & Head – Neurosurgery

Dr. Anant Kumar

Chairman - Urology, Renal Transplant, Robotics & Uro-Oncology (Max Saket)

Dr. Anurag Krishna

Director - Pediatrics & Pediatric Surgery

Dr. Harit Chaturvedi

Chairman – Cancer Care, Director & Chief Consultant - Surgical Oncologyy

Dr. K.K. Talwar

Chairman – Department of Cardiology

Dr. Pradeep Chowbey

Chairman- MAMBS, Chairman - Surgery & Allied Surgical Specialties

Dr. Sandeep Budhiraja

Clinical Director & Director – Internal Medicine

Dr. Subhash Gupta

Chairman - Max Center for Liver and Biliary Sciences

Indian Healthcare Sector

A robust healthcare delivery system is going to play a critical role in driving inclusive growth in India over the next few decades. The large unmet medical needs of India’s growing and ageing population presents a significant market opportunity for healthcare service providers who can provide high-quality, affordable care to a larger section of the population.

The Indian healthcare industry is expected to grow at a CAGR of 17% between FY 2008 and FY 2020; and by FY 2020, the industry is expected to have a market value of US$ 280 billion. Further, the Indian healthcare sector is expected to generate close to 7.5 million direct employment opportunities by FY 2022. With a shift in focus towards the quality of service, particularly with the rising demand for tertiary and quaternary care, the industry requires specialised and highly skilled resources. Medical value travel, also popularly known as medical tourism, is being considered as India’s next crown jewel. The medical value travel market in India is expected to grow at a CAGR of approximately 30% from US$ 3.6 billion in FY 2015 to US$ 10.6 billion in FY 2019. People from different parts of the world are travelling to the country to avail high quality healthcare services at comparatively much lowers cost. However, to emerge as a top medical value travel destination, India needs to focus on service quality and increase transparency and accountability in every part of the healthcare delivery.

The Company

Max Healthcare (MHC) has a network of 14 facilities in North India (including 3 where it is a service provider), offering services across all 29 specialities. Of this, 11 facilities are located in Delhi & NCR and the others in cities of Mohali, Bathinda, and Dehradun. The Max network includes state-of-the-art tertiary care hospitals in Delhi/NCR in areas such as Saket, Patparganj, Vaishali, Shalimar Bagh, and outside Delhi in Mohali, Bathinda, and Dehradun. The Company has secondary care hospitals atGurgaon, Noida & Greater Noida and an out-patient facility and speciality centre at Panchsheel Park, Pitampura and Lajpat Nagar (Cancer Care). The Super Speciality Hospitals in Mohali and Bathinda are under a PPP arrangement with the Government of Punjab. Besides these, MHC also has Patient Assistant Centres in Lucknow, Meerut, Moradabad and Srinagar.

MHC has a network of 2,700+ leading doctors with international level expertise who are committed to providing highest standards of medical excellence at a fraction of international costs. JCI, NABH, and ISO accredited hospitals offer best-in-class services to the patients. In February 2017, Max Super Speciality Hospital, Saket became the first hospital in the network to get accredited by Joint Commission International (JCI).

MHC is a pioneer in the introduction of technology to provide the highest standard of medical care. Some such examples are the first Brain Suite in Asia at Max Saket, Da Vinci Robot at Saket, Spy Angiography for OT’s, HIPEC for Chemotherapy, etc. Max Hospitals are equipped with advanced medical equipment like state-of-the-art Cath Labs, OTs with HEPA, Nuclear Medicine, Neuro-Navigation, Ortho Navigation, Digital Radiography System, LINAC, PET-CT and advanced MRI and CT scan machines.

During FY 2017, MHC has implemented a GE RIS-PACS solution which is designed to improve the quality of radiology reporting and reduce TATs. The year also witnessed strong progress across all dimensions of patient care and clinical quality. Some of the initiatives that were launched and were a huge success were Chasing Zero mission, i.e., MHC became the first Indian network with the best medical quality metrics which can be tracked online for all the 4 HAIs, thus, achieving near International benchmarks in clinical quality. On the strength of its processes, the Network Hospitals have embarked upon a new positioning statement “Eager to get you home” for its services.

Financial Performance:

In FY 2017, the Company and its subsidiaries reported a consolidated income of ₹ 1,677 crore, which reflects a growth of 14%.

The specialities such as Oncology, Neurosciences, and Renal Sciences performed exceedingly well and our clinicians carried out multiple state-of-the-art procedures through the year, saving precious lives, gaining appreciation from the patients and their families and the media alike.

The operating profit before interest and depreciation grew by 44% reflecting an expansion in operating margin by 2.7%. The consolidated cash profit was ₹ 108 crore, a healthy growth of 49.7%.

Max Network of Hospitals (including hospitals where it is a service provider) had a robust growth of ~17.0% in its Net Revenue in FY 2017 and achieved a total revenue of ₹ 2,454 crore as compared to ₹ 2,098 crore in FY 2016.

New hospitals (added to the Network) in FY 2015 have contributed to the majority of the growth i.e. 137% as compared to last year. This is partly because both the hospitals were acquired at different timelines during FY 2016 i.e. Vaishali (formerly Pushpanjali Crosslay) in July 2015 and Smart (formerly Saket City Hospital) in December 2015.

Revenue growth in FY 2017 was driven by a focus on multiple factors such as enhancement of service profile such as launch of Liver Transplant Programme, addition of new technology, improvement in operational parameters and increase in patient satisfaction. Max Healthcare has considerably invested this year in acquiring the latest and newer technologies such as Sim CT, High-end Neuro Microscope, LINAC/Brachytherapy, etc. which has resulted in the better clinical outcome, increased efficiency, and improved patient satisfaction.

The network also witnessed a significant increase in patient footfalls with 21.3% growth in OPD and 15.3% growth in IPD cases amounting to a total of ~1.8 million cases in FY 2017.

However, the revenues and operating profits were somewhat lower than expected due to a price cut of some of the drugs at the start of the year and demonetisation announced by the Central government in November, which led to lower footfalls and conversions during the November- January period.

The consolidated operating margin (before interest and depreciation) at Network hospitals has increased from 10.2% in FY 2016 to 11.4% in FY 2017 resulting in total EBIDTA of ₹ 281 crore in FY 2017. Max Healthcare has been able to maintain or slightly improve the margins despite certain regulatory price capping on medicines or stents. This is contributed by several cost optimisation initiatives along with the comprehensive integration of new assets that enable sharing of assets, manpower, etc. thus bringing the costs down. The Network hospitals reported a consolidated Net Profit of ₹ 23.6 crore.

consolidated income

  1,677 Cr.  with 14%  growth

Going forward, MHC expects to drive efficiencies from fundamental process re-engineering powered by a stronger set of tools (Lean, Six Sigma), technological investments (automation) and analytics. We strive to continually focus on investing in the latest medical technology, attracting skilled physicians & surgeons, and developing our expertise in high growth tertiary care areas to serve the increasing demand for sophisticated clinical care and procedures.

Max Super Speciality Hospital, Saket was awarded the prestigious JCI Accreditation in FY 2017

Max Super Speciality Hospital, Saket was awarded the prestigious JCI Accreditation in FY 2017

Operational Performance

MHC Network of hospitals has exhibited impressive performance on all key operational metrics during FY 2017 and steadily improved its revenue, gross margin and EBIDTA during the period. This growth in Revenue and EBIDTA was a result of improved performance by all the network hospitals.

IP Occupancy % – Bed occupancy for FY 2017 has been 72% as compared to 71% for FY 2016. Although occupancy has increased marginally by 1% as compared to last year, the number of occupied beds has increased by 81. The operational bed capacity has increased from 2,272 beds to 2,330 beds in FY 2017. The average occupancy during Nov-Jan period dropped to 67.1%.

Ms. Vinita Bhasin representing Max Healthcare at the AHPI Global Conclave

Ms. Vinita Bhasin representing Max Healthcare at the AHPI Global Conclave

COE Revenue Share – Revenue for key clinical specialities or Centres of Excellence (COE – Cardiac Sciences, Orthopaedics, Neurosciences, Oncology, MAS and Renal Sciences) has increased by 15% as compared to last year. Renal Sciences, Neurosciences and Oncology have shown impressive growth contributed by addition in high-end procedures such as Kidney Transplant programme, etc. However, the share of COE has dropped from 54.6% in FY 2016 to 53.8% in FY 2017. The drop has been primarily due to acquired assets mainly focussing on secondary care. Continuous efforts are being made to upgrade the medical technology, manpower, and infrastructure enabling these hospitals to cater to high-end tertiary care patients.

Average Length of Stay (ALOS) or Patient Turnaround time has decreased from 3.3 in FY 2016 to 3.2 in FY 2017 due to a constant focus on improved care with faster turnaround. This also led to the availability of capacity to serve more patients with same hospital resources.

Average Revenue Realisation (ARR) is the average daily billing for each occupied bed. The IP (ARR) improved by 1.2%, while the hospital ARR improved by 2% during FY 2017.

Major Achievements and Awards for FY 2017

Due to the steadfast focus on Clinical Safety and Service Excellence, MHC has an impeccable track record and high success rate in terms of complex surgeries and patient care parameters. In lieu of the same, Max has received several awards and accolades at varied events:

  • ABP News Healthcare Awards:

    • Award for the Best Customer Service in Healthcare (Customer Listening Programme) and for Best Use of Six Sigma in Healthcare (Quality Program-MQS) for Max Healthcare

    • Award for the Best Green Hospital to Max Patparganj for reducing Carbon Footprint of Tertiary Care Hospital.

    • Best Quality Initiative (BCMA Medication Process Improvement) and Best Patient Safety Initiative Award (Prevention of Patient Fall) for Max, Saket.

  • Max Smart received Asian Patient Safety Award for Infection Prevention and Practices & Anaesthesia and Surgical Safety protocols.

  • At India Health and Wellness Awards, Max Healthcare was Gold Award winner in the category of Health Brand of theYear and Silver Award winner in the category of Medical Tourism Brand of the Year

  • Max Saket received the award for the Best Hospital for Patient Safety at Healthcare Summit Awards by Business World

  • Max Patparganj received Certificate of Merit for Discharge Process and Improvement at QCI-DL Shah Quality Awards and for Nursing Excellence Project at 28 Qimpro

  • Another outstanding achievement for MHC this year has been the attainment of successful JCIA certification for Max Super Speciality Hospital, Saket. This certification has proved as another testimony of our commitment towards the highest standards of patient care and safety.

MHC has recently launched a unique initiative of deploying motorcycle-borne paramedics to attend emergency calls for immediate care, while the ambulance is on its way in order to beat the traffic and attend to the patient at the earliest. The initiative has been highly commended by the press as well as patients and their families as it helps to save critical 10-15 minutes for the patient, thereby, increasing the chances of survival. We believe that this constant focus on patient care and clinical safety will help us enrich the quality of life of every patient and provide a caring and nurturing environment with utmost respect for human dignity and life.

Nurses Day celebrations at Max Healthcare

Nurses Day celebrations at Max Healthcare

Information and Medical Technology, Quality Certifications

MHC is constantly leveraging advancements in information technology to enable timely access to information to both patients and clinicians in order to enhance patient safety & care. In FY 2017, there were several notable technology interventions at MHC including rollout of RIS-PACS radiology imaging system across Max Healthcare locations, launch of Electronic Health Record system and enhancements across all major MHC network hospitals (with exception of new additions Max Vaishali and Max Smart), launch of e-Prescription system for Max Patparganj, Saket, Gurgaon and Vaishali and latest technology upgrade for centralised hospital information system.

There was also a significant progress made on operational and clinical analytics by the deployment of a best-in-class Qliksense tool for tracking operational performance. Overall, all these initiatives during the year helped to elevate the quality of medical care and decision-making process, while keeping the cost of care in check.

During the year, MHC installed Sim CT in Max Saket that helps radiation therapy team to determine the exact location, shape, and size of the tumour to be treated. Installation of LINAC, PETCT and Brachytherapy is underway at Max Shalimar Bagh and will help hospital expand its offering and provide holistic care to cancer patients. High-end Neuro Microscope, DR System in Radiology, Digital EEG and EMG are the other addition of equipment that will help gain a competitive advantage. New MRI Installation with silent scan technology at Max Shalimar Bagh will lead to lesser scan time, better clinical outcomes. High-end Ultrasound Machine - first of its kind in North India with advanced 3D Heart Model has been installed at Max Gurgaon, Vaishali, Saket, Dehradun & Patparganj. EUS and EBUS have been purchased for Max Shalimar Bagh and Vaishali to strengthen the Pulmonology and Gastroenterology Departments.

MHC has recently launched a unique initiative of deploying motorcycle-borne paramedics to attend emergency calls for immediate care, while the ambulance is on its way in order to beat the traffic and attend to the patient at the earliest.

Medical Excellence is the strength of the Company’s brand. Max Healthcare’s vision is to be the most admired Company for healthcare needs of its customers, patients, and their families. This vision is founded on a clear set of values that are shared across the Max Group – Sevabhav, Excellence, and Credibility. Max Healthcare’s unique Clinical Governance framework, capably led by the Clinical Directorate, Physician & Nursing Leadership, has worked relentlessly to design safe, effective and efficient systems for patient care.

As mentioned above, the JCI certification for Max Super Speciality Hospital, Saket was one of the highlights of the previous year for MHC. Further unrelenting, undivided and continuous focus given to the fields of Clinical Governance, Medical Quality, Clinical Data Analytics & Clinical Research helps to keep our mission of establishing MHC’s medical facilities, clinical expertise, technology, safety standards, and medical research at the highest level, comparable to the best known institutions of the globe.

Some of the other key initiatives and achievements are: (i) Twelve hospitals under Max Healthcare network are NABH accredited; (ii) MedInduct - Induction programme for resident doctors has successfully till date trained over 800 doctors;

(iii) Have received several Awards & recognition at external professional forums; (iv) Formation and implementation of a centralised governance structure across the MHC network for ER, Cardiac and Neurosciences; (v) Implementation of Physician scorecards designed for around 40 clinical specialities at Saket; (vi) Successful completion of the 1st Annual Patient Safety Conference (APSC) at national level; (vii) Launch of the Annual Patient Safety Culture Survey which helps measure staff perception in the system and where we stand as compared to international benchmarks; (viii)Protocols and dashboards established for major specialities; (ix)Use of data analytics technology platform for tracking hospital acquired infections and antibiogram.

CSR and Community Initiatives

Patients belonging to economically weaker sections (EWS) are being provided free treatment at identified Max hospitals. In FY 2017, ~1.75 lakh OPD and ~11,500 IPD patients belonging to EWS were catered. Besides, the network hospital organised a number of free camps and outreach activities for the benefit of the communities

it serves. The profitable entities in the network contributed to CSR efforts of groups arm Max India Foundation through contributions for the Living Guard water purification system in a government school in Delhi and for treating cancer patients at Indo-Canadian Cancer Research Foundation.

Human Resource

Multiple people initiatives were taken during the year which ensured better employee experience for 10,000 people working in network hospitals. Our KHUSHI - an employee happiness survey conducted every year scores saw an improvement of 1% over FY 2016. The importance of HR analytics went to a different level with regulatory changes and improvised report with predictive trends was devised in FY 2017. Multiple new modules were introduced on DISHA - the ERP to automate several employee processes like recruitment, income tax computation, declaration & payslips, enhanced performance management, etc.

On employee benefits, MHC introduced NPS (National Pension Scheme) for all employees as a platform for saving tax and retirement planning. FY 2017 also witnessed new initiatives under the Talent management arm. Talent Mapping exercise and Talent Appreciation Process initiated for senior leadership. Front Office is the first interface for a customer in our hospitals. In order to maintain continuity of business operations, and have a funnel of employees who can be productive on day 1, we launched STEP (Skilled & Talented Employee Pool) programme for Front Office. Focussed and integrated training programmes were launched for different cadres with an aim to support clinical and service excellence.

Nurses’ engagement has always remained critical to our success. We had significant achievements under Nursing Transformation journey in FY 2017. From campus adoption to nurses’ career growth under Life Healthcare exchange programme, to Project Aarohan for Nurse Educator, each initiative witnessed an overwhelming

MHC’s first Oncology Day Care Centre in New Delhi opened its doors in 2016

MHC’s first Oncology Day Care Centre in New Delhi opened its doors in 2016

response from the nursing fraternity. Max Healthcare strongly believes in empowering of human capital with the necessary skills and knowledge and at the same time, creating a happy workplace that fosters camaraderie and work-life balance.

Regulatory Environment

Regulatory changes in FY 2017 have impacted the healthcare industry in a big way. Following are the major changes that happened in FY 2017:

Regulatory Environment

Regulatory changes in FY 2017 have impacted the healthcare industry in a big way. Following are the major changes that happened in FY 2017:

Stent Price Regulation

In July 2016, the government added coronary stents to the National List of Essential Medicines 2015, bringing them under price control. The government based its decision on a sub-committee report that recommended putting all types of stents, including the latest biodegradable stents, on to the list. Further, in February 2017, National Pharmaceutical Pricing Authority (NPPA) sets the ceiling prices of coronary stents at ₹ 7,260 for bare metal stents and ₹ 29,600 for drug-eluting stents. The revised prices are more than 40-50 per cent lower than the prevailing market prices. The notification makes no distinction whatsoever on whether a stent is branded or unbranded, manufactured locally or abroad. It is anticipated that this will enhance the affordability of cardiology procedures in future.

ESIC Enhances Wage Ceiling

Starting 1st January, 2017, employers will need to make contributions under the ESI Act for a larger pool of employees, since the wage ceiling for applicability of this statute has been increased from ₹ 15,000 to ₹ 21,000. The wage ceiling was last raised in May 2010, where the wage limit was increased from ₹ 10,000 to ₹ 15,000. With the current increase to ₹21,000, the wage limit for ESI Act has been brought in line with the wage limit under the Payment of Bonus Act, 1965 which was revised earlier this year.

Hike in Minimum Wages in Delhi

Delhi government has released a notification to increase the minimum wages of unskilled, semi-skilled and skilled workers by 37% w.e.f. 3rd March, 2017. Apparently, Delhi is the first state in the country to provide highest minimum wages to the working class population. Given Max’s dominating presence in New Delhi, this is likely to put further pressure on the margins.

Maternity Benefit Bill

The Maternity Benefit (Amendment) Bill 2016 has been passed by the Parliament on 9th March, 2017 which provides 26 weeks of paid maternity leave for first two children up from the earlier 12 weeks. The bill also makes it mandatory to provide crèche facilities within a prescribed distance.

Goods and Service Tax

The Constitution Amendment Bill for Goods and Services Tax (GST) has been approved by the President of India post its passage in the Parliament (Rajya Sabha on 3rd August, 2016 and Lok Sabha on 8th August, 2016) and ratification by more than 50% of state legislatures. The Government of India is committed to replace all the indirect taxes levied on goods and services by the Centre and States and implement GST by July 2017.

With One India One Tax, it is anticipated that the tax base will be comprehensive, as virtually all goods and services will be taxable, with minimum exemptions. It will be a game-changing reform for the Indian economy by creating a common Indian market and reducing the cascading effect of the tax on the cost of goods and services.It will impact the tax structure, tax incidence, tax computation, tax payment, compliance, credit utilisation and reporting, leading to a complete overhaul of the current indirect tax system.

Healthcare services have been exempted from GST. However, with an increase in the GST on medicines from 11% to 12% and with an increase in GST on services from 15% to 18%, healthcare costs are expected to grow by 0.75 to 1.0%.

Outlook

Max Healthcare was focused on strengthening its existing operations, integrating newly acquired assets with the network in terms of processes or policies and leveraging its operational strengths to register significant financial gains during FY 2017. The business will continue to identify and implement initiatives to achieve sustained revenue growth. This will involve adding new clinical programmes and sub-segmenting existing programmes. In three to four years, we want to become the most trusted name in healthcare, known for medical excellence and service excellence with dominance in the areas of Oncology, Musclo-skeletal sciences, Neurosciences, Transplant medicine, Cardiac Sciences and Bariatric/Diabetology. Further with pressure on margin consequent to some of the regulatory actions detailed above, the cost optimisation efforts will be accelerated and this will continue to be an ongoing focus area for the organisation. However, no cost rationalisation will impact patient safety or medical quality and will be more focussed on increasing the productivity of spending, eliminating waste, better negotiations with the vendors and weeding out nonvalue added activities. The other focus of cost rationalisationwould be to institutionalise a culture of cost consciousness and frugality across the organisation.

Max Healthcare is also incubating three alternate businessess viz. Max Labs – A pathology vertical currently focussing on B2B & in hospital labs, Max@Home – A vertical to provide highquality medical care at home and ambulance services. These verticals are expected to add to revenues and profitability in the years to come, but more importantly, will increase the depth and width of our coverage and offerings.

MHC core values of Sevabhav, Credibility and Excellence are deeply integrated with its strategy and are key in achieving its vision of becoming an admirable institution.