MANAGEMENT DISCUSSION AND ANALYSIS

Mr. Rajit Mehta

Managing Director & CEO

Mr. Anas Abdul Wajid

Director - Sales and Marketing

Mr. Anil Vinayak

Director & Zonal Head – NCR 1

Mr. Atulya Sharma

Director – Legal, Compliance and Regulatory Affairs

Mr. Neeraj Kumar Mishra

Director & Zonal Head - NCR 2

Mr. Rohit Kapoor

Senior Director and Chief Growth Officer

Dr. Sandeep Budhiraja

Group Medical Director

Mr. Sumit Puri

Director - IT & Chief Information Officer

Ms. Swati Rustagi

Director - HR & 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

Chairman, MIND and Max Neurosciences Forum

Dr. Anant Kumar

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

Dr. Anurag Krishna

Director - Paediatrics & Paediatric Surgery

Dr. Harit Chaturvedi

Chairman - Max Institute of Oncology & Director - Surgical Oncology

Dr. K.K. Talwar

Chairman - Cardiac Sciences and Cardiology

Dr. Pradeep Chowbey

Chairman - MAMBS, Chairman - Surgery & Allied Surgical Specialties

Dr. Sandeep Budhiraja

Group Medical Director

Dr. Subhash Gupta

Chairman - Max Centre for Liver and Biliary Sciences

Indian Healthcare Sector

Healthcare has become one of India’s largest sectors both in terms of revenue and employment. The Indian healthcare industry is expected to grow at a CAGR of 17% between FY 2008 and FY 2020; and by FY 2020, this industry is expected to have a market value of US$ 280 billion. A growing and ageing Indian population, with the burden of several diseases, increased government focus, rising health awareness and insurance penetration among the populace are expected to drive the growth of this sector. The last few years have also witnessed a sharp rise in Medical Value Travel and private equity investments in the sector, showed an upward graph. 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 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 gaining focus with the emergence of newer needs and with India establishing a firmer footprint as a global healthcare delivery destination. The medical tourism 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. However, to emerge as a top medical value travel destination, India needs to focus on quality of services and increase transparency and accountability in every part of healthcare delivery.

The healthcare budget allocation for FY 2018-19 is ₹ 52,800 crore, an increase of 5% over last year’s Union Budget, revised estimate of ₹ 50,079 crore. The government has announced an ambitious plan called the National Health Protection Scheme (NHPS) to provide government-sponsored insurance to roughly 500 million people or nearly 40% of India’s population. NHPS should be considered a significant move towards universal health coverage. Exact details of the scheme are being worked upon. Also, the effectiveness of its implementation will require strong centre-state coordination and a substantial fiscal funding.

The Company

Max Healthcare has a network of 14 facilities in North India, offering services across all 30 specialities. Of this, 11 facilities are located in Delhi & NCR and others in the cities of Mohali, Bathinda and Dehradun. The Max network includes state-of-the-art tertiary care hospitals in Saket, Patparganj, Vaishali, Smart, Shalimar Bagh, Mohali, Bathinda, and Dehradun. Secondary care hospitals at Gurugram, Noida & Greater Noida and an out-patient facility and speciality centre are set up at Panchsheel Park, Pitampura and Lajpat Nagar (Cancer Care). The Super Speciality Hospitals in Mohali and Bathinda are under PPP arrangement with the Government of Punjab.

Max has a network of 2,300+ leading doctors with international level expertise who are committed to provide 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. Our experts have treated 2.8+ million patients (both from India and from 80 countries across the world). Our hospitals are equipped with the most modern Cath labs, OTs with HEPA, LINAC for Radiotherapy and MRI and CT scan machines to ensure that our customers have access to all the required medical facilities.

Clinical and Service Excellence are the core premise around which our healthcare operations are structured. We have a laser sharp focus on patient safety and adopt international protocols/standards of care across our network. We are the only network doing electronic tracking of hospital acquired infections and have strong clinical governance in place as well. Various projects relating to customer satisfaction and processes such as Queue Management, Customer Listening Forums, Discharge Process etc. are monitored continuously and results are mapped in order to bring improvement. Four black belts have been deployed across the zones who lead Six Sigma Improvement projects that impact patient experience and safety. Our Quality service is critical to satisfying our customers and retaining their loyalty so they continue to patronise us in the future. This sustained focus has helped Max to achieve high credibility and trust from its patients and hence, achieve high success rate in various areas of clinical care.

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

Major Achievements and Awards for FY 2017-18

Our quality service and steadfast focus in Clinical and Service Excellence have reaped rich rewards. Max has an impeccable track record and high success rate in terms of complex surgeries and patient care parameters. Max has been conferred with several awards and accolades in recognition of a variety of clinical service areas, which speaks volumes for our efforts.

Clinical Quality:

  1. Winners in AHPI - Quality Beyond Accreditation for Blood Bank and Infection Control (Max Vaishali)

  2. 2nd Prize for Oral Paper presentation in CAHOCON Annual International conference on monitoring Massive Transfusion protocol to improve survival and decrease overall usage of blood component (Max Vaishali)

  3. 1st Prize in Oral presentation - under category Safe Medication practice - PCSI conference (Paediatric Cardiac Society of India) (Max Patparganj - PPG)

  4. Best poster on Safe Medication practice - NABH’s 1st National Healthcare Quality Conclave (PPG)

  5. QCI D L Shah Platinum Quality Award for reduction in Ventilator Associated Pneumonia in ICUs (Max Smart)

  6. Times Healthcare Achievers Award - Legend of the Year - Cardiac Surgery (Max Smart)

  7. International accolade for VTE Risk Assessment Unlocked - IHF Taipei 41st World Hospital Congress

Operational Excellence:

  1. Bronze Award Winner for ‘Life Savers’ project (Max Bike Responder) at the World Conference for Quality and Improvement 2018, organised by the American Society for Quality (ASQ) in Seattle, USA

  2. Best use of Data and Analytics - American Society of Quality (ASQ)

  3. BMJ Awards South Asia 2018 (Max Smart)

  4. Best Green Project In Health Care - ABP News - Healthcare Leadership Awards

MHC Team being felicitated for their Bronze Award win at the ASQ Awards 2018 held in Seattle, USA

Service Quality:

  1. BPM Asia Star 2017 by Confederation of Indian Industry (CII) Institute of Quality - (Max Saket)

  2. QCI DL Shah National Quality Award – Gold Award – Enhancing Patient Experience

  3. Qimpro Quality Convention Award – Customer Centricity Award – Project AGILE - FY 2018

  4. Indian Express Healthcare Award – Best Patient Satisfaction Programme (Max Oncology Day Care)

  5. AHPI Award-Best Patient Satisfaction Programme (Max Lajpat Nagar)

Others:

  1. 1st Economic Times CIO Award for excellent technology delivery and innovations

  2. Digital Transformer Award for Smart Ambulance by IDC Digital Transformation Awards 2018

  3. Information Visionary Award for Online reporting of Clinical Indicators and dashboards by IDC Digital Transformation Awards 2018

  4. 3rd Prize for Effective Communication – Video Presentation - CAHOCON 2017

MHC’s Nurses Day celebrations

MHC’s Nurses Day celebrations

Financial Performance

The Company and its subsidiaries reported a consolidated income of ₹ 1,783 crore, which reflects a growth of 8.0%. However, the operating profit before interest and depreciation reduced by 8.4% reflecting a decrease in operating margin by 1.7%. The consolidated cash profit was ₹ 68 crore, a reduction of almost 18.2%.

Max Network of Hospitals (including hospitals where it is a service provider) achieved total revenue of ₹ 2,619 crore in FY 2017-18 and recorded an increase of ~9% as compared to last year. The consolidated operating margin (before interest and depreciation) at network hospitals has reduced from 11.4% in FY 2017 to 8.5% in FY 2018 resulting in total EBIDTA of ₹ 222 crore in FY 2018. The Network hospitals reported a consolidated net loss of ₹ 50 crore.

Max has achieved lower revenue and operating profits than expected for FY 2018 due to several government regulations during the year such as price/margin capping in stents and knee implants, price controls on drug prices, stoppage of re-usability etc. and other unfavourable events such as closure of Shalimar Bagh Hospital, GIPSA shut-down etc. that further resulted in lowering patient as well as clinician morale. Management has undertaken significant efforts in order to boost confidence of the clinical community and has revised policies and procedures in order to ensure better transparency, compliance and documentation so as to win back patient trust and loyalty.

Going forward, MHC expects to drive efficiencies from fundamental process re-engineering powered by 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 cater to the increasing demand for sophisticated clinical care.

The financial numbers reported above are as per Ind AS Standards. The company has successfully made this landmark change and this is considered a hugely positive move since Ind AS is substantially closer to the accounting standards followed by the global companies under IFRS.

Revenue for key clinical specialities or Centres of Excellence (COE – Cardiac Sciences, Orthopaedics, Neuro-Sciences, Oncology, MAS, Liver & Biliary Sciences, and Renal Sciences) has increased by 7.5% as compared to last year.

Operational Performance

Despite unprecedented challenges during the year such as regulatory headwinds, patient/ media activism etc., Max Healthcare did reasonably well with respect to development across operational parameters owing to strong operational control and focus on growth areas. Some of the parameters are defined below:

Inpatient (IP) Occupancy % - Bed occupancy for FY 2017-18 has been 73.1% as compared to 72.1% for the last financial year (2016-17). Although the occupancy YTD November had grown to 75%, however, due to negative sentiments around closure of Shalimar Bagh facility operational parameters across Max hospitals suffered a downfall. As of now, patient confidence is recovering and management is putting significant efforts to improve the morale of clinicians. The operational bed capacity has increased from 2,330 Beds to 2,378 beds in FY 2017-18.

COE Revenue Share – Revenue for key clinical specialities or Centres of Excellence (COE – Cardiac Sciences, Orthopaedics, Neuro-sciences, Oncology, MAS, Liver & Biliary Sciences, and Renal Sciences) has increased by ~7.5% as compared to last year. Growth is largely driven by Oncology in medical and radiation sub-specialities owing to new clinician hiring, technology improvement, internal referrals, sub-specialities and increasing patient loyalty & confidence. Further, Liver Transplant Programme was launched in January 2017 and hence, full year revenue was realised in FY 2018. Neurosciences ramped up well post Oct-Nov in response to new clinical team hired for Neurology as well as Neurosciences. Other specialities suffered a dip due to multiple factors such as temporary GIPSA closure, Shalimar Bagh incident, regulatory headwinds etc. Overall the share of COE specialities, however, has remained almost same i.e. 53.8% in FY 2017-18 as compared to 53.7% in FY 2016-17.

Average Length of Stay (ALOS)

Average Revenue Realisation (ARR)

ARR – Average Revenue Realised is average daily billing for each occupied bed. The IP ARR improved by 2.0% while the hospital ARR improved by 6.7% during FY 2018.

Average Length of Stay (ALOS) – or Patient Turnaround time has decreased from 3.25 in FY 2016-17 to 3.14 in FY 2017-18 due to constant focus on improved care with faster turnaround. This also led to availability of capacity to serve more patients with same hospital resources.

MHC’s new bike ambulance initiative has received wide acclaim

Information and Medical Technology, Quality Certifications

Max is constantly leveraging advancements in information technology to enable timely access of information to both patients and clinicians in order to enhance patient health, safety & care. In FY 2017-18, there were several notable technology interventions at MHC covering aspects such as patient safety, data tracking, employee communication and better customer engagement. Some of the initiatives that were launched are EHR enhancements such as mandatory ICD 10 diagnosis, JCI related clinical pharmacy requirements to ensure enhanced patient safety and adherence to standards in diagnosis. Multi-disciplinary reminders and template in CPRS to ensure medical treatment with requisite documentation, mortality risk scoring templates to proactively identify risk scores of admitted patients have been incorporated. New initiatives to strengthen Customer Service such as the launch of Practo, (SMS information system) across MHC for mobile scheduling of appointments and reduced wait times for patients, real-time IPD customer feedback on tablets has been rolled out. A revamped patient portal quickly provides medical reports and linkage of medical records for respective families.

Several new and improved initiatives were undertaken leveraging state-of-the-art technology :

  • Use of CRM for digital customer acquisition

  • Max Lab pre sales to activation lead funnel automation

  • Revamping E-prescription launch across units

  • Launch of second phase of Max@Home new service lines at home

  • Introduction of smart ambulance on bikes and

  • Availability of life saving ambulance services under minimal lead time

The employee engagement tool - Sampark has been launched for employee communication as only 30% of MHC employees earlier had access to email. Already, 3,500 employees previously disconnected have started actively using the platform for policy dissemination, corporate communication, engagement and recognition. Overall, these initiatives during the year helped to elevate the quality of medical care and decision-making process while keeping the costs in check.

During the year, Max installed 2nd LINAC in Patparganj with the latest state-of-the-art technology, Rapid Arc and SRS to cater to the growing needs of patients in East Delhi and UP. Also, existing LINACs in Saket and Patparganj have been updated to ensure faster speed, accuracy and better clinical outcomes. Max Saket has also brought its first ultra low dose Flat Panel Detector Fluoroscopy machine with enhanced diagnostic capabilities and Digital EEG Machine-128 channel for diagnosis & treatment for Epilepsy. High End Ultrasound Machine for Max Saket, Max Smart and Bhatinda are the latest technological innovations (first of its kind) in North India. Digital Radiography Systems for Max Patparganj, Smart and Vaishali have been procured for better time efficiency through bypassing chemical processing and enhanced images. 128 Slice CT Machine for Max Patparganj has been bought for providing better equipments in the radiology department and also, to be future-ready for 4D CT Planning.

Max Healthcare’s Clinical Governance framework, capably led by the Clinical Directorate, Physician & Nursing Leadership, has worked relentlessly to implement safe, effective and efficient systems for patient care. The organisation has successfully sustained NABH, NABL Accreditations for all the units, JCI for Saket and has integrated clinical key performance indicators into the business review and appraisal cycle to ensure better efficiency. The achievements of these indicators have exceeded targets. This is the result of unrelenting, undivided and focussed attention of our teams in the fields of Clinical Governance, Medical Quality, Clinical Data Analytics and Clinical Research. This helps us to function in line with our mission of ensuring that MHC’s medical facilities, clinical expertise, technology, safety standards, medical research and quality service are comparable to the best known institutions across the globe.

MHC’s Service Excellence Awards recognise the Company’s best projects of the year

MHC’s Service Excellence Awards recognise the Company’s best projects of the year

Some of the other key initiatives and achievements include: (i) Twelve hospitals under Max Healthcare network are NABH accredited; (ii) MedInduct - Induction programme for resident doctors has successfully trained till date over 2,000 doctors; (iii) Many of the MHC hospitals have received several Awards & recognitions at external professional forums; (iv) Formation and implementation of a centralised governance structure across the MHC network for ER, Cardiac and Neurosciences; (v) Successful completion of the 2nd Annual Patient Safety Conference (APSC) at national level; (vi) Improved scores of the Annual Patient Safety Culture Survey which helps measure staff perception in the system and where we stand as compared to international benchmarks; (vii) Launch of VIOS patient monitoring system for reducing risk of return to ICU and lowering cost of admission to an ICU; (viii) Roll out of an expanded clinical risk management program to cover Left Against Medical Advice patients (LAMA), clinical risk management and bereavement handling.

Human Resources

The new healthcare reforms, regulatory changes and contemporary medical technology have resulted in changed HR roles within healthcare organisations. The past year has seen a lot of such changes coming through from authorities and the HR function at Max Healthcare has remained swift and proactive to adapt and adjust to these changes seamlessly and efficiently. In order to keep up the volume, velocity and variety of the changing business dynamics, the people function has enthusiastically embarked on a journey towards making MHC a preferred employer.

The infusion of new HR leadership in the organisation and re-alignment of the HR team for better support to stakeholders and business has brought in more synergies and focussed engagement. We strongly believe in creating a workplace environment where our employees are happy to work with opportunities to develop and flourish. We revisited our Rewards and Recognition framework and created a platform to recognise quick wins towards promoting “Sevabhav” in all facets of work. In order to cater to the varied needs of our nursing fraternity, we instituted the “Adamya” award to foster collaboration, participatory mindset and recognition for Supervisors / Team Leaders who build great nursing teams through excellent induction, improved skilling, motivation, engagement score and retention strategy.

In the spirit of “Khushita” (the highest form of happiness), we conducted focussed group discussions along with the employee engagement survey. This gave us real-time insight into our people’s minds and we took necessary action towards strengthening ourselves as an “employer of choice”. With the launch of “Sampark”, we strive to ensure that our employees are kept abreast of all business updates and there is a direct connection with the leadership and all employees alike, no matter their designation or where they are located.

We envision our employees as partners in progress and hence we have launched human resources management system at three of our units – Max Smart, Vaishali and Greater Noida. Change is driven from the topmost rung and our revised competency framework bears testimony to this fact. We rolled out the revised competency framework with eight core competencies for leadership bands this year. We plan to extend this to other units of the entire organisation in due course of time.

With due emphasis on employee satisfaction, motivation and building morale, we have articulated our compensation philosophy. It shall be a guiding light for all our people initiatives in the future. Keeping in view that the employee is at the centre of the people management function, we have simplified the performance management process for our operational cadres in front office and nursing.

We feel we are at the cusp of an interesting revolution in the people management function. We hope to create new milestones in the areas of our specialisation through collaborative participation and innovation in coming times.

We encourage children of our employees to showcase their creative prowess through a platform called “Rang”, a painting competition. To provide visibility, the final artworks of these designs were printed in Max Healthcare stationery for FY 2018. Sustainability remains the key to ultimate growth and development. We have taken baby steps towards making the earth a better place to live in by collaborating with local NGOs through Pankh, our corporate social responsibility (CSR) initiative. We actively work with Max India Foundation and support several useful initiatives like immunisation, health camps/screening and providing much-needed medical support in two villages in Uttarakhand.

Regulatory Environment

The following regulatory changes in FY 2017-18 impacted the healthcare industry in a big way.

Cashless treatment of RTA cases

In February 2018, Directorate General of Health Services, New Delhi issued mandatory RTA guidelines for cashless treatment of medico legal victims of road accident, acid attack and thermal burn injury in registered nursing homes or private hospitals in New Delhi. The victim is not required to carry any document for the purpose of verification except that the incident has occurred in the jurisdiction of Delhi Police. The expenditure incurred during the treatment of such victims is to be reimbursed through Delhi Arogya Kosh which would pay at DGEHS rate.

Revised Stent Price Capping

The National Pharmaceutical Pricing Authority has revised the price of drug eluting stents (DES) downwards by about ₹ 2,300 to just under ₹ 28,000, while marginally raising the cap on bare metal stents from ₹ 7,400 to ₹ 7,660. These caps are excluding GST. The trade margin allowed on stents remains the same at 8%. With Drug-eluting stents accounting for about 95% of all stents used in India, this means most stents will become cheaper.

Pankh, a CSR initiative by MHC

Knee Joint Price Capping

After coronary stents the previous year, the National Pharmaceutical Pricing Authority (NPPA) has wielded its powers of price control on knee implants. The drug pricing watchdog slashed the prices of total knee replacement systems and their individual components by as much as 69%. The price of total knee implants made of cobalt chromium has now been capped at ₹ 54,720, down 65% from its average maximum retail price of ₹ 1.58 lakh. Total knee implants made of special metals like titanium and oxidised zirconium can be priced at a maximum of ₹ 76,600. High-flexibility implants have also seen a similar reduction in the maximum price to ₹ 56,490. Revision implants, used in repeat procedures when the initial knee implant has failed, is capped 59% lower at ₹ 1.14 lakh, down from an average of ₹ 2.77 lakh. These prices are exclusive of goods and services tax, but include trade margins for manufacturers or importers, distributors and hospitals into account.

No Re-use of Single Use Devices for CGHS Patients

As per the directive of MoHFW, reuse of single use devices will not be permitted for CGHS patients in Cardiology and other specialities, despite such reuse norms being stipulated by clinician leaders based on their experience and clinical expertise. This, it seems, is a common practice across the industry globally.

Syringes Margin Capping

In December 2017, The All India Syringes and Needles Manufacturers Association (AISNMA) decided to implement trade margin cap at 75% post NPPA intervention. The NPPA had advised manufacturers to consider regulating price themselves; otherwise, the government would be forced to take steps as they have done to cap prices in the past for items like stents and orthopaedic implants.

Revised EWS guidelines

Delhi government has issued stricter guidelines for EWS compliance. All 4 notified hospitals have implemented all measures as prescribed including earmarking of beds (ICU / wards), treatment of dialysis out of IP, surgical medical mix and higher OPD compliances in hospitals.

DPCO Price Capping

The NPPA has capped the prices of 51 essential formulations, including those used for the treatment of cancer, pain, heart conditions and skin problems. The prices have been slashed in the range of 6 – 53%.

National Health Protection Scheme

The Government of India has announced the launch of its flagship National Health Protection Scheme (NHPS) as part of its fiscal budget 2018, with a focus to provide health cover of up to ₹ 5 lakh per family per year for secondary and tertiary healthcare services, with focus on around 100 million underprivileged families (~35% of national population). The comprehensive design of this scheme has not been shared yet. Also, the effectiveness of its implementation will require strong centre-state coordination and a substantial fiscal funding. Many states already run their own health schemes albeit with lower covers (typically ranging from ₹ 1,50,000 to ₹ 2,50,000), the number of new beneficiaries could be lower but still substantial.

CSR and Community Initiatives

Max India Foundation (MIF) founded in FY 2008, is the CSR arm of Max Group with a mission to provide quality healthcare to the underprivileged, holistic and focussed wellbeing of marginalised communities through village adoption, facilitate awareness of common health related issues and work for an eco-friendly environment. This is done by engaging Max Group employees and partnering with reputed NGOs in the execution of projects. In FY 2017-18, two villages in Uttarakhand – Dhakrani and Chandhrothi, were adopted by Max India Foundation for intervention on the pressing issue of health and hygiene. 21 multi-specialty camps benefiting 3,088 patients were organised with the support of Max Healthcare Dehradun during the year at these two villages. Through its pan India immunisation programme to provide health care, Max India Foundation gave 18,448 shots to 8,037 children in 142 camps organised during the year. MIF organises multi-speciality camps for the less privileged in various semi-urban and rural locations where there is no access to specialised medical treatment. Poor patients are screened and given free medicines. Surgeries and treatment are also facilitated for those in need. This year 1,70,201 patients have been treated through 719 camps across India. Besides these initiatives, several health awareness programmes were organised such as dengue control and prevention, nutritional diet, ill effects of tobacco etc.

Outlook

During FY 2018, Max Healthcare was focussed on strengthening its existing operations, integrating newly acquired assets with the network in terms of processes or policies and leveraging its operational strengths to improve financial results. 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 and service excellence with specialised knowledge in the areas of Oncology, Orthopaedics, Neurosciences, Organ Transplant, Cardiac and Minimal Access Metabolic & Bariatric Surgery. Further with pressure on margins consequent to some of the regulatory actions detailed above, cost optimisation efforts will be accelerated and this will continue to be an ongoing focus area for the organisation. However, we will ensure that no cost rationalisation will impact patient safety or medical quality and service. Cost control measures will be more focussed on increasing the productivity of spend, eliminating waste, improved efficiencies, better negotiations with vendors and weeding out non-value added activities. The other focus of cost rationalisation would be to institutionalise and develop a culture of cost consciousness and frugality across the organisation by introducing cost-cutting measures in a variety of work areas without comprising efficiency.