Welcome to Max Healthcare Institute Limited earnings conference call. As a reminder, all participant lines will be in the listen-only mode, and there is an opportunity for you to ask questions after the presentation concludes. Should you need assistance during the conference call, please signal an operator by pressing star then 0 on your touchtone phone. Please note that this conference is being recorded. I now hand the conference over to Suraj from CDR India. Thank you. Over to you.
Thank you. Good morning, everyone, and thank you for joining us on Max Healthcare's Q4 2023 earnings conference call. We have with us today Mr. Abhay Soi, Chairman and Managing Director, and Mr. Yogesh Sareen, Senior Director and Chief Financial Officer of the company. We will begin the call with opening remarks from the management, following which we'll have the forum open for an interactive Q&A session. Before we start, I would like to point out that some of the statements made into this call may be forward-looking in nature and a disclaimer to this effect has been included in the earnings presentation shared with you already. I would now like to invite Mr. Soi to make his opening remarks.
A very good morning to everyone. I'm pleased to welcome you to Max Healthcare's fourth quarter earnings call. At the outset, I would like to state that this has been a seminal year for Max Healthcare on many accounts. An important one of them being the overall translation of INR 1,636 crores of EBITDA to INR 781 crores of free cash flows. In spite of a decadal opportunity for investment in the hospital sector, we have been encouraged to declare our maiden dividend. I want to sort of go back into proceedings of Q4. Q4 was a robust quarter for us and exhibited results of commendable execution of our strategy by teams on the ground. This quarter once again reflected our best ever performance across nearly all the financial and operating parameters, recording a significant growth year-on-year.
We commissioned and operationalized a 92-bed oncology block at Max Shalimar Bagh on first March. This contributed positively to both revenue and EBITDA in its very first month of launch. EBITDA margin on the incremental revenue was in the range of 35%-40% due to operating leverage and overall occupancy at the hospital was 83% in Q4. We expect this to contribute to the improvement in EBITDA both in absolute and margin terms in the ensuing quarter. Coming to the key highlights of our Q4 performance. Occupancy for the quarter improved to 67% from 68% in Q4 last year, but remained at the same level as in the previous quarter. However, it is pertinent to note that operating capacity moved up by 100 beds in March 2023 compared to December 2022.
Institutional bed share fell to 29% compared to 33% in Q4 last year and remained flat compared to the previous quarter. There was a higher capacity in the current quarter as well. PSU tariff for room rent and consults have been revised in mid-April. Discussions are ongoing to increase tariff for packages and diagnostics, etc. In view of these developments, we have not taken a hard call yet on some of the major accounts. All our hospitals have been tasked with improving their operating occupancy thresholds to accommodate growth in the preferred channels. Network gross revenue was INR 1,637 crores compared to INR 1,298 crores in Q4 last year and INR 1,559 crores in the previous quarter. This reflects a growth of 26% year-on-year and 5% quarter-on-quarter.
Year-on-year increase was driven by growth in ARPOB and occupied bed days. Revenue from international patients grew by 43% year-on-year and 10% quarter-on-quarter. This now accounts for around 9.1% of the revenue from hospitals and amounts to 120% of pre-COVID levels. Digital revenue grew to INR 292 crores and accounted for 18% of overall revenue. Led by improvement in channel mix and specialty mix, ARPOB for the quarter rose to approximately INR 77,700, reflecting a growth of 11% year-on-year and 6% quarter-on-quarter.
We reported our highest ever network operating EBITDA of INR 437 crores compared to INR 304 crores in Q4 last year and INR 419 crores in the previous quarter, reflecting a growth of 44% year-on-year and 4% quarter-on-quarter. The network operating EBITDA margin stood at 28.2% versus 24.8% in Q4 last year and 28.3% in the previous quarter. Annualized EBITDA per bed, most importantly, rose to INR 70.30 lakh, yet again our highest ever, noting a growth of 25% year-on-year and 5% quarter-on-quarter. Profit after tax was INR 320 crores versus INR 172 crores in Q4 last year and INR 269 crores in the previous quarter.
Year-on-year growth of 85% was primarily attributable to improvement in operating metrics of all the hospitals and lower finance costs. Free cash flow from operations stood at INR 425 crores. INR 55 crores was deployed towards ongoing capacity expansion projects. The net cash position improved to INR 733 crores at the end of March 2023 compared to net debt of INR 440 400 crores last year. Continuing our efforts to give back to the community, we treated approximately 36,600 OPD and 1,200 IP patients from economically weaker sections of society free of charge. Both our strategic business units continued to maintain their growth momentum. Max@Home reported a top line of INR 37 crores, reflecting a growth of 26% year-on-year and 2% quarter-on-quarter.
Max Lab reported a gross revenue of INR 31 crores, reflecting a like-to-like growth of 57% year-on-year and 10% quarter-on-quarter. Coming to the overview of the company's financial performance for the full year ended 31st March 2023. Network gross revenue stood at INR 6,234 crores, reflecting a growth of 13% on a like-to-like basis. Network operating EBITDA stood at INR 1,626 crores, registering a growth of 25% on a like-to-like basis. While ARPOB improved by 15% due to price and improvement in mix and case mix, leading to margin expansion by 152 basis points. EBITDA per bed grew by 22% year-on-year to touch a new high of INR 65.9 lakh.
Current status of expansion projects coming on stream by FY 2025 is as follows: We have recently signed an ATS for purchase of land to enable expansion of Max Vaishali, which is consistently operating at more than 80% occupancy. If and when the deal is consummated, it has the potential to add 100 brownfield beds to our network. For 300 beds at Dwarka, interior work is in progress, lifts are under installation and external development has started. Medical equipment has been ordered. As communicated earlier, we expect to commission the hospital by end of Q2 FY 2024 subject to the developer obtaining occupation certificate by that time, of which we are quite certain. For 329 beds at Nanavati, the work is in full swing at the site. Foundation and column work have already begun.
As you may be aware, Larsen & Toubro L&T is handling the project, and we expect to commission the facility by end of FY25. For 300 beds Phase Three at Sector 56, Gurugram in Phase 1, de-wall work is complete and excavation is underway while the civil contractor mobilizes for start of construction by end of June. In order to compensate the delays at Max Smart caused due to tree transplantation issues, we are fast-tracking the construction at the Gurugram site, which is part of the same complex. We have received in-principle environmental clearance approval and are expecting other approvals over the next 6-8 weeks. Lastly, we continue to actively but prudently evaluate inorganic growth opportunities for strategic deployment of our cash surplus from operations. With this, we open the floor for Q&A.
Thank you very much. We will now begin the question and answer session. Anyone who wishes to ask a question may press star and then on the touchtone telephone. If you wish to remove yourself from the question queue, you may press star and 2. Participants are requested to use handsets while asking a question. Ladies and gentlemen, we will wait for a moment while the questions are sent in. We have our first question from the line of Ashwin Agarwal from Akash Ganga Investments. Please go ahead.
Congratulations to Abhay and the entire team for delivering industry leading numbers. We could not have thought 3 years back that, you know, you could have delivered these kinds of EBITDA margin and grown from here on also. Highest congratulations for that. Abhay, could you highlight what is your vision going beyond 3-5 years, beyond what have you announced in terms of organic opportunities? Whether you would be looking at the South and the other regions in the country. Secondly, you own around 54% shares now. Would you like to increase your stake so that you can use the stock as an option in terms of acquisition to help you evaluate?
Let me start with the last one first. You know, the consequence of this performance has been. Firstly, thank you for the compliment. You know, three years back when we were listing the company of the Indian health, healthcare or the hospital sector was that there was no free cash flow. You have to keep redeploying. I think, you know, with 181 crores of free cash flows coming, translating from 1,600 crores of EBITDA, which was 80% translation of EBITDA to free cash flow, I think we sort of answered that question. You know, that is, that is, as far as I'm concerned, right up there as far as our achievements.
Now, with respect to, you know, my vision over the next 3 to 5 years, I think there is a $ multi-billion opportunity in the Indian hospital sector. The kind of infrastructure which is required to be created simply because, okay, you need to address that demand. We're seeing this every day. You know, all the cash flows that we are sort of generating, we would be redeploying it into this. We've been looking at, you know, pretty much every project. We have been very clear about 2 things that we will only look at places where at least a few of our competitors have proven viability. We go there and we'll do it better like we do in each one of the metro markets that we currently operate in.
We have not been first anywhere, but we are the first, wherever we operate. I think, that is the sort of strategy that we want to employ. You know, that doesn't sort of include any place. Of course we like a cluster approach. If I were to just do one hospital in Kerala or just one hospital in Chennai or something, I wouldn't do it. You know, we prefer clusters, so we'll be looking at chains and we'll get clusters.
Anything on your stake in terms of using the stock as an opportunity in terms of M&A?
Look, I think, you know, my stock, one of the consequences of our success is it reflects on the market cap and the, and the stock price. You know, if to buy anything meaningful, I would effectively have to leverage my current stock, which I'm not interested in doing because, I don't leverage my stock at all. I think, you know, 1% of the stock would cost me INR 500 crores. Pre-tax that money is about INR 300 crores. As my only form of employment is Max Healthcare, the salary doesn't permit me to buy more stock.
lastly, sir, do you...
I would not be afraid of diluting if there's a great opportunity. Let me just put it this way.
Okay.
When I say diluting, if there's a opportunity for a merger or an acquisition, okay, for the growth of the company, I would not shy away from it.
Yes, that is what I was wanting to know.
There's never been an issue as far as that is concerned.
Would you be only city-centric in next 3-5 years in terms of opportunities or you would also look into tier two opportunities? Do you have opportunities like Nanavati which give you a gateway to any big city?
No, absolutely. I think, firstly, we are very happy doing tier two, tier three cities also. Our highest ROC business is Mohali. Second highest is Kolkata and Dehradun. It's not Delhi and Mumbai. Like I said, we will go to any city where any of our competitors or two or three competitors have proven viability. We have, I believe, a list of 21 such cities.
All the best, sir. Thank you.
Thank you.
Thank you. We have our next question from the line of Damayanti Kara i from HSBC. Please go ahead.
Hi, good morning. Congratulations on a good quarter, Mr. Grover. Where my first question is on your care change plan. You mentioned we have seen a decline in PSU tariffs, et cetera. Because of that, is there any rethinking from your side in the institutional bed share from 15%, which you highlighted earlier, from 29% currently?
Sorry, so what's the question? Yeah. Look, I think the trajectory is changing on account of two or three things. One is that we are finding marginally more capacity. You know, we're operating in higher levels than what we were thinking of previously. We are able to sort of keep that business and be able to do more. You are seeing that in your margins month on month. The best thing is that if you can... You know, we were pushing down that business because we wanted to accommodate our preferred channel of CTI. Now necessarily you're always gonna find some elasticity towards the end, so you see the operating levels becoming higher. Secondly, we've added more beds.
100 beds is 110 beds is about 3% more capacity that is being added, yet you see the number sort of still come down marginally. The third thing is that we have seen an increase in rates as far as PSU is concerned, increase in tariffs, which will work well for us in the current year. That's about 20% or 30% of the total tariffs that they've sort of revised. They've revised it quite significantly by about.
Around 70%.
Sorry?
Only four line items.
Yeah. Four line items, but that accounts for about 20% of the total, 20%?
No, no. Overall increase would be around 4%-5% on the million to PSU.
The rest of the tariffs are looking to be revised in the second of July. I think we have a little bit of a wait and watch here. If we have the same sort of increase by July, because I believe the, you know, it has been proposed that rest of the packages and everything else is being revised. July is the time which we've been sort of informed about.
Okay. Just to clarify, this 4%-5% 30 flight is for the PC contract so far. You are expecting.
No, no. What I'm saying is that the line items that they have raised prices on, the average price increase is around 70%. Those line items... In a way the contribution of line item is around 10%-12%. That means the overall, you know, raise would be 4%-5%.
Okay. In July, another round of.
Yeah. We are expecting another round of price hike. I think there is items. They haven't touched the diagnostics, they haven't touched the batteries, they haven't, you know, touched the other elements of the equipment, et cetera. They haven't done that. They just touched 4 items. One is room rent, you know, for ICU, room rent for single and then the only 4 item elements have been changed. Whatever they've touched is gone up by 70% on an average.
Okay. Okay.
Let's say there are 100 things or a 100, if the revenue is 100, 12% of the revenue has been touched by them. They've increased that 12% by, let's say about 70%.
Okay.
The balance 88%, okay, we're expecting that it'll be done by July.
Got it. Got it. Okay, great. My second question is on your, average revenue per occupant. Again, I think you have surprised positively quarter after quarter. In last 2 years, we have seen around 15% increase, and I understand specialty mix change is a big driver of it. Can you explain like, what has changed so significantly in last 2, 3 years that you continue to see better and better, specialty mix? How should we see this part moving ahead?
I think, you know, look, your ARPOB is being generated with payer mix and specialty mix. It's not only purely payer mix. You've also seen a massive increase in international business, which plays on to your ARPOB. You know, it's a combination of factors. You know, specialty mix, now you're looking at COVID in the middle, right? I think your ARPOB vis-a-vis a COVID year is going to be higher. You need to compare it to a pre-COVID period, pre-COVID years. Then you take up perhaps the cost increases over this recent period of COVID because, you know, the disease burden has come back after COVID. In the middle you're looking at COVID business, which was high occupancy but lower ARPOB.
Now you have business which is essentially high ARPOB, but your occupancy sort of moved up because there wasn't any capacity creation for those COVID years. I think you're gonna see this sort of move up, but obviously you can't do the comparison with the COVID year.
Not even with COVID year. If I look at the period of just 2019 before COVID, you were somewhere at, 56, 47,000 ARPOB, and now it has moved up to 70,000+. I'm asking from that perspective.
you know, What was ARPOB in? I just mentioned what the ARPOB was. Look, I think as you move up the occupancy curve, right, you're gonna distil your payer mix. you're talking about a time when my payer mix again, I think 40%+ was PSU, now it's 29%, right? you know, as you go up the curve, you know, you start getting that sort of operating leverage. When you start getting that better quality of patient. Okay. The thing is we still have hospitals in the portfolio which are doing an INR 90,000+ ARPOB.
Okay.
Our FY20 ARPOB was INR 50.3 thousand, right?
It was at INR 50,000. It's gone up to INR 70,000 in three years now.
I'm saying average is INR 67,000 for FY23. You take year-to-year average. It'll be, you know, 10%, 11% higher.
10, 11% increase.
Right.
50-67. Yeah.
Going ahead also say, this mixture should see better mix both in payer and specialty part.
I think from a payer mix itself, from distribution of payer mix, you should see increase in this thing. The clinical mix, of course, like I said, you know, there are always innovations sort of going on, not only at Max, but, you know, there are plenty of a single hospital in Mumbai, for example, which have been, you know, there for 20-odd years, which haven't sort of, there's no payer mix sort of saturated. There's no extra bed, not a square inch that they've been able to add. Yet the clinical mix sort of drives the ARPOB up. I mean, there are lovely examples of that, Hinduja Hospital, Breach Candy Hospital, and so on and so forth.
Okay. Comfortably, we should be seeing high single digit to double-digit growth in the ARPOB going ahead also.
You know, I avoid giving any forward-looking projections. You know that.
Okay. My last question is on your view on the competitive landscape in Delhi NCR market, given we have seen many of your competitors trying to set up their presence. Is there any possibility of bed oversupply in a foreseeable future, if not now?
I haven't seen any new beds come up in Delhi NCR or even under construction.
Actually, I think Apollo Hospitals has a facility coming up in Gurugram.
Apollo there's.
Yeah, it's going up a large space. This is already there, by the way. This hospital is already considered. Apollo has just done a. Yeah, I mean, it was not functioning. I think this has been there for quite some time. That's when it starts to operate. It's not yet fully operational, right?
Yeah. Yeah.
There's some litigation.
Okay.
There are some litigation issues. Yeah.
Okay. Thanks for your answers.
Thank you. We have our next question from the line of Nikhil Mathur from HDFC Mutual Fund. Please go ahead.
Hi. Good morning, everyone, many congratulations to the management on the superb execution. First, my first question is a kind of clarification. When I look at the audited cash flow statement, the capital incurred under the line item of purchase of property is around INR 65 crores, whereas in the pro forma numbers that we discussed with investors summary, the company has given a CapEx number of INR 208 crores. I guess there might be some technicality. Can you please explain me why this happened?
And just to, you know, clarify that point. I think when we report the INR 208 crores spend, that spend is on the CapEx expansion, right? These are on the projects, INR 208 crores. Whatever is the routine CapEx in the cash flows that come in the property line, that eventually when we report numbers to investors, we take it out from the free cash flows, right? When Abhay says that we have INR 281 crores of free cash flow against INR 1,636 crores of delta, in that INR 281, that whatever amount that is spent, the total net worth spend is around INR 211 crores on the routine CapEx. That amount is detailed out of the, you know, free cash flows.
We only report the number of INR 208, which is the on CapEx expansion, which is basically on the projects. Does that clarify?
Yeah. 208 is the right number to look at.
One is the routine CapEx, right? There's a replacement happening in running hospitals. One is the CapEx, which is for the CapEx expansions, right? INR 208 is number for the CapEx expansion. Whatever is the number on the routine, you know, replacement based on in the hospital, running hospital, that is taken off from the operating cash flows. When we say cash flow operations, that number is already next year. In the audited financials, that number by virtue of the fact that the cash flow is as per a particular, you know, Ind AS requirement, that number. Both numbers flow into that number.
Okay. When you look at the pro forma, this.
Book number will be around INR 419 crores because what you see is only the consolidated financials, right? These consolidated financials don't have the EHS numbers, the partner health facility number. The overall number, in fact, if the network cash flow will be INR 419 crores, of which 211 will be routine clinics, 208 will be 3G stations.
Okay. INR 419 crores. Okay.
Yeah.
In the cash balance, difference of INR 100 crore, again, in the audited and the pro forma financial statements you have given. Is some technicality here in that thing?
You understand that if actually, if you read the very first page that we put it up on our, you know, our investor, you know, earnings update, you will find what the difference is for, right? Basically we have this EHS. Here we control the medical patients through the hospital management committee, right? We have a 3-to-2 ratio. We control the patients. Since it is a medical services element, they are not able to consolidate their financials in the group financials, right? What we do is that we do a memoranda consultation, we satisfy it, and that's how we report numbers to the investors, right? If you read the very first, you know, sheet, that will clarify this doubt that you're having.
Understood. Sir, on the bed expansion plans, I think in the last investor presentation there was the page that you shared particularly. Now that Shalimar Bagh has come on stream, we should refer to the bed expansion plan in the previous investor presentation, perhaps still holds for upcoming bed expansion plan.
That's right.
They're not-
There's a little bit of delay. Okay. The everything else will be online.
Okay. Okay. What's the CapEx plan for the five new, routine as well as ongoing projects?
Routine is about INR 100, INR 115 crore. INR 190 crores. INR 190 crores. capacity could be INR 800, INR 900 crores.
900 plus 170.
INR 900 crores will be for the Saket extension, which is on the ongoing projects, and around INR 170 will be on the routine.
Okay. Understood. On the international footfalls, how should we look at growth in this business over the coming 2, 3 years? Now FY 2023 has been pretty strong as compared to growth. Do we expect the growth grow in FY 2024 as well on the same pace? Just short term, what are your thoughts on what can be done in the international business?
I think, you know, like I've said on numerous occasions before, there's an exponential opportunity, okay. What we are seeing is only incremental. Now the government has sort of put its weight behind it, so hopefully we'll be able to tap it in the medium run. In the short run, we will still see incremental gain. I am going to avoid giving you any, you know, guidance on the numbers. I to avoid maybe for the financial parameter as well. Yeah. We are, we believe this is a space which is, you know, we have not even hit the peak of this.
Okay. Understood. I also read somewhere, I don't know how true this is, that the Delhi NCR accounts for almost 70% of international footfalls coming to the country. Is this the?
40%.
40.
40.
Okay. Got it. One final question. The RFX, whether on the PSU front or whatever you are contemplating on the private side, is this a reflection of supply-demand balance being in favor of the hospitals that responded to the RFX? Do you foresee this likely to be an industry phenomenon, or it was specific to Max?
No, this is an industry phenomenon. I mean, this is not, this is not CGHS, et cetera, rates are for the whole country.
This is in response to the news story that come in that, government has allowed some price hikes on the CGHS services.
Yes. Yes. Yes. Manikanda, this is after, you know, this is the last price was in 2014. It's a revision after 9 years, anyway, at CGHS level, 14.
Okay. Are you also considering revising prices for the packages, right? I mean, this is also on.
Not we. Governments.
Oh, this is also on the government's-
Yeah, yeah. They're just providing the basic of four elements. Other lean items, for example, pathology, radiology, blood bank, you know, packages, surgeon charge, et cetera, all those things are. Lot of things we do under package, right? It's not itemized billing. You say CABG, okay, or whatever. C-section. Okay. They haven't increased the C-section or the CABG. They increased the room rents, the doctor visit charges, et cetera, et cetera.
Okay. Understood. Thank you so much and all the best.
Thank you.
Thank you. We have our next question from the line of Lavanya from UBS. Please go ahead.
Hi. Thanks for the opportunity. Congratulations on the results, members. Most of my questions are mostly answered. I just wanted to get your clarification on this packages. Is the price hike is only related to CGHS packages or does it related to diagnostic business of Max also?
No. Right now they have not increased the diagnostics. Okay?
Mm-hmm.
Like Yogesh mentioned, out of 12% of the revenues, okay, or line items which account for 12% of the revenues have beenIncrease that will happen over there. It's up to 70%-88%, which includes diagnostics, includes packages, includes a lot of other things, which has not happened, which is under consideration by the government. We are told by July there may be some visibility on this. Ma'am, don't mix the CGHS price increase with the other price increase, right? There's a 29% share is by PSU, where the tariff is, you know, given to us by the State, right? State government, actually. Yeah. This is. We are talking of that element of the business. The other business we do increase prices.
We also increase prices as and when we correct them too. I don't mix the two, right?
Yeah, yeah. That's the reason I'm just asking for clarification, that this is everything the discussion is related to CGHS, nothing related to the Max-.
That side. That side.
Max Lab diagnostics is different, right?
Yeah.
Max Diagnostics, are we expecting any, I mean, are we planning to put any price increases for diagnostics business?
We have it for CGHS or just generally?
In general. General Max Diagnostics business.
There are two elements to Max Diagnostics. One is in-hospital diagnostic, other is outset. In in-hospital diagnostic, we do increase prices every April, and we done some bit of it in this year also. The non-pathology business or the retail business, we haven't increased any prices.
Got it. Thank you there. On the ARPOB, I understand that increase in ARPOB is supported by higher international contribution this quarter. Do you expect increase in international business in the coming year, FY 2024, or do you think that we have reached the optimal level in Q4?
I think I answered that question in the last this thing. You know, as I said, you know, there's a immense opportunity, exponential opportunity in the medium run. In the short run it is still incremental. Nevertheless, I think, it's fully incremental.
Okay.
I mean, nowhere near the peak. I mean, with the sort of, comparative advantage that we have, there's no reason for it to sort of slow down. It should only snowball and grow much, much higher.
Got it. I just wanted to check because we have already crossed the pre-COVID level, so it should be incremental from here, but not a jump or significant jump that we have seen over the last few quarters. I just wanted to check that.
It's a % growth quarter-on-quarter, right? In fact, even pre-COVID, you had a very good rate of growth. If you look at towards the even pre-COVID levels, okay, the growth rate was not slow. I mean, actually two years later to go up 20%, over pre-COVID levels, you still haven't got up to the rate of growth.
Okay. Got it. Thank you. Thank you so much for the opportunity.
Thank you. We have the next question from the line, Sanjitha Poovathingal from Cogito Advisors. Please go ahead.
Hi, this is Andrei from Cogito Advisors . Congratulations for the great set of numbers. I just from Q4 2023 compared to 2022. I can make out that there is an increase in international business. I can make out that there's an increase in insurance business. I can make out there's an increase in efficiency. Could you give some more granular insights as to what are the elements of the channel or payer mix that have contributed to this 87% increase? If you think that many of these profit drivers will remain in the future.
You want me to describe this 87% increase?
Yeah. Yeah.
You highlighted them all, right?
No, no. You highlighted them. You said, you know, I identified 3 of those factors. Could you just give us a broad sense of what are the other specific factors, you know, in the channel mix and payer mix that have additionally contributed to this 80% increase?
I think it, you know, it is a payer mix. It is clinical mix. It is better cost management, lower consumption ratios, a lower, you know, finance cost. I mean, I think it's pretty much everything, but it's cost management other than payer mix and channel mix. Yeah.
Anything specific in payer mix apart from what outlined?
Oh, channel payer.
Payer mix is reduction of PSU, reduction in PSUs, increase in international and CGI business.
I'm sorry? The cash insurance and international business has grown.
Okay. Okay.
Okay. Effectively it's that. It's not about reducing PSU, it's about increase of these three elements.
Yeah. Do you think that the operating margins of 18.2% are maintainable in this year?
Look, I, you know, I focus more on EBITDA per bed, not operating margin. Because, you know, rather do a $10,000 surgery and have a 20% margin than do a $2,000 surgery and have a 50% margin, right?
Okay.
I think, the question really is, the EBITDA per bed, okay? Even if it means lower margins tomorrow, is EBITDA per bed going to increase tomorrow or not? Because that's really what matters from EBITDA overall standpoint, growth standpoint, as well as ROC standpoint.
Right.
That, in my mind, will grow.
Mm-hmm.
It will continue growing.
Yeah. Also if we look here at the numbers, quarter one was 26.6%, quarter two was 27%, quarter three was 28.6%, this quarter is 28.2%. Obviously that means it's consistent, right?
There's been increase in EBITDA per bed.
Right.
Right. If you see.
Margin.
Our margin, it's much very lower actually.
Right. Right.
You have to hear about the fact that EBITDA per bed is increased, right? That's why your overall EBITDA is increased.
Okay, great. Thanks and congratulations once again. It's a great result.
Thank you. Thank you, Thomas.
Thank you. We have our next question from the line of Prakash Agarwal from Axis Capital. Please go ahead.
Yeah, good morning, thanks for the opportunity and congrats on very good set of numbers.
Thank you.
Yeah. Just trying to understand this, you know, the 4%-5% in price increase is limited to the 17%-20% of the total mix, right? Is that right?
No, no. 29% of the beds are occupied by the PSU, which constitute around 17 and a half percent of the revenue base.
Exactly. Okay. 17.5% moves up value terms by 4%-5% in terms of pricing.
Yes. I would say if I had, if nothing else nothing else happens, then there's a 4.5% to 4%-5% increase in price. We do expect the price increase in the other elements. You can't increase the room rent.
That is fine, yeah.
basically during the surgery, during the whole surgery. You have to increase the category, right? The moment you admit that the room rent has to go up, that means there's four
That is true. The current one is 4 and half% on 17 and half%. Is that right?
Yes. Yes. Yes. That's what I'm saying.
You also mentioned that in some of your, you know, every year you take some price hike around April. That is more standard across the board in the hospital business.
Yes, that's right. Yes.
That is 2%, 3% or it's like a high single-digit kind of?
No, no, it's like 2.5%.
Okay. What I'm trying to understand, we had fairly good ARPB increase last year and couple of years. Just in terms of headroom of growth, we do have international lever, we do have case mix, payer mix lever. That 10-12% is not way too off to model for this year as well. Would that be right?
I'm gonna avoid giving you a guidance on that because it's always hard. You know, there's no reason for it to not happen.
Okay, perfect. Secondly, on the volume side, occupancy side, we on a blended basis is 77%, and we would be having few hospitals which are 80-85%. I'm just trying to understand the headroom in terms of, you know, you mentioned that the, you have a focus on growth in the preferred channels, A, which is more on the pricing. Immediately there is. How can we improve the occupancy or we are already operating at an optimal level of occupancy?
Look, I think, certain places, okay, where you have absolutely hit the capacity sort of thing, where you automatically start distilling. The levers that we have is, are the following. One is that at the very sort of end, when you start pushing the envelope, there is some elasticity, right? in terms of operations. What we were earlier 75%-76%, now 77%-78%. We also operate at 80%-81%. Each one of these facilities will have a, you know, sort of more efficient system of discharging and so on and so forth when it starts coming to the, you know, coming to the edge. Second is, you know, we have mentioned there's about close to 100 odd beds, okay, that internally that we are unlocking. 10-bed here, 20-bed here, 30-bed here, so on and so forth.
A 100 beds is about 3% of total capacity. Okay. A couple of percentage points through occupancy. That's maybe about, let's say 4%-5%. On top of that, we also have, you know, the payer mix, sort of distillation that we need to as and where necessary. Third, finally, you know, what you want to do is first you want to maximize on the first two. Then you want to move to the payer mix, distillation. Finally you have another 300 beds coming in, then next year every hospital will sort of have its own beds coming through.
Got it. This, Care, that one is finally not happening, right?
Well, I won't say that because we've sued for specific performance and matter is in arbitration. To settle this I won't go into expressing, but we have asked for specific performance over there.
Okay. I read Blackstone is getting into that, so I was just checking on that. Okay. Lastly, on the regulatory side, of late there's been a lot of news flow, you know, on having reservations for the government as well as the poor and the needy. I mean, there's too much, you know, I mean, unverified information. Is it happening somewhat? Is it already happened? It was already happened, you know, in the past and it's just a rehash or if you could just-
Yeah. I think you rightly put it. Firstly, I think there's way too much made out of something way too little. First and foremost, please understand there is already a right of health across the country, okay, through a Supreme Court sort of a thing. If a patient comes in dying of trauma, basically comes into a hospital, you can't say, "Show me your wallet first." You have to take him in and stabilize him. That is right to health even as per Supreme Court. No hospital would ever even think of not doing that. You don't see it really. If somebody was to do that, you'll read it in the papers. You know, that's how rare it is. You've seen those situations before in the papers, et cetera. No proper hospital will, you know. Let's say somebody comes to a hospital, okay?
If the accident patient, number of these patients come year on year. I mean, if we were to actually reject that patient, firstly it's against our own policy. Okay? It's against Supreme Court strictures. More importantly, do something like that, the media will string you, will hang you. That is inconceivable any of these risks. Secondly, most states like Delhi NCR, Delhi already for the last 10 years has this Delhi Road Accident Scheme Force, which basically means that, look, any accident victim comes over there, they will pay you some money for it. The fact is the government sort of in any case we would take it free. The government rides on it because they get, you know, political sort of mileage by saying, "Well, we are actually minding your healthcare," sort of thing. Therefore we are paying people for the emergency more.
Now in Rajasthan, they pretty much rehearsed the same thing. No, no. Right to health. Right to health, right to health in emergency, which already exists.
This is limited to emergency and not routine surgeries, et cetera.
No, no. Purely emergency. Even in Rajasthan, purely emergency. In fact, they've diluted it down by saying it's not to the private sector. It's only to the hospitals which have been subsidized by the state government.
Also the trust hospitals.
Rajasthan government and it helps that it makes sense. It's not as if a private hospital somebody goes, "Okay, you wanna reject the patient," you would still do it free.
Just one last one on the trust hospitals. We also do set reservation for the poor and the needy. Is that right?
That's right. That's right. That's right. Every quarter when you see our results, you'll see those numbers big enough. Not only trust hospitals, but some of the hospitals where we have this option, you know, we bought the land in auction, you know, in the listed company. Therefore the obligation to have certain percentage and we do provide for that.
Okay. Lastly, congratulations for Shalimar Bagh, turning it EBITDA positive in month one itself in March.
EBITDA positive in the first month and giving a 35%-40% EBITDA margin on the integrated revenue. This is something we've always spoken about. Brownfields do not suppress your EBITDA. They are accretive almost, you know, we always say it's breakeven in the first quarter or two, and obviously we're gonna give you a more conservative sort of this thing. You've seen that, you've seen the operating leverage coming.
That is great. Thank you and all the very best.
Thank you so much. Thank you.
Thank you. We have our next question from the line of Tushar Manudhane from Motilal Oswal. Please go ahead.
Yeah, thanks for the opportunity, and congrats on good set of numbers. Sir, on PSU tariff revision will get, I mean, how much of the spread would get reduced in terms of EBITDA per bed with this price hike compared to, say, non-PSU or non-institutional patient EBITDA per bed?
Sorry, EBITDA per bed. Price.
No, I, the perspective here was that we are already in hospitals where we are already running up at a very high occupancy. That way we have a choice in terms of, selecting the patients or distilling the patient as you commented in the earlier commentary. Just trying to understand, you know, is this sufficient enough to reduce that spread, you know, for EBITDA per bed, through the patient care mix?
No. No, it will not. Answer is, it will not. What happens is that, look, if tomorrow I want to switch off 100 beds, right? Yesterday I only needed to fill 100 of PSU beds. Yesterday I only needed to fill 40 of those beds to breakeven, to get back the money that I'm losing by switching off 100. I get 60 more beds to sort of build it. Now, that number from 40 has gone to, let's say, 55. Okay, tomorrow that number will go to 70 or 80. What happens is it becomes marginal. Does it get to the same amount? No. Yes, I think what you're gonna do is your trajectory sort of changes, but directionally you're going in the same direction. You're doing it without impacting.
Actually, a more preferred sort of how if you're taking a physical call, this is that look, it is going to be more accretive with you in terms of rather than less.
If you could also clarify this. This PSU tariff or PSU patient pool, the proportion of PSU patient pool is higher in which hospitals or rather which cluster of hospitals in, of Max Healthcare?
We don't normally give No. We don't give you hospital data. I think, you can either understand the hospitals which are more, you know, fuller, then there the proportion will be lower, and where it is less full, we'll be having more. Higher occupancy, we always move away from that, right? The lower occupancy places is where, like, Yogesh said, you have higher amount of risk. Anywhere where your occupancy is getting higher to 85%, 80%, 85%, you start moving away from this business, right? You start distilling it over there. You do the business where you have idle beds.
Understood. Just, lastly on this Gurgaon thing, is any more land coming up for auction?
No.
we've seen other hospitals also having some land parcel in this area. is there more area available for hospital expansion at this point or this is more or less done from the government side?
No, no. Look, I think, you know, it's like, Bombay, Bombay, right? I think you can have several Bombay, you can have, you know, some base in Gurgaon also. If you look at Gurgaon, west is Gurgaon extension, now there's extension to the extension to the extension, et cetera, but where the main work was and the main business, et cetera, there's no land available.
Understood. No, so the intention to understand was within that particular area where the hospital's place is supposed to be, you know, sort of premium. In that sense there is no land parcel available.
Not that we know of, yeah.
Okay, sir. Thanks. Thank you so much, sir.
Thank you.
Thank you.
We have our next question from the line of Raj Rishi from Dcpl. Please go ahead.
Yeah. Hi. just wanted to find out.
Obviously, the situation is big for you guys. How long do you think this supply won't come in looking at the present interest rate scenario?
Sorry.
Like right now, demand supply is huge, right? That's why occupancy is what it is. Whenever the situation is so robust, obviously new supply is going to come in various geographies. How do you-
Not necessarily. I mean, no new hospitals come up in Mumbai in 20 years.
Okay.
Right? Because there's no land available. No new hospitals come up in Delhi for 12 years. Maybe one. Okay. Because no land is available.
Okay.
How do you get land in these metros and land at viable cost, right?
Yeah.
You have to understand, there is a height limit of 45 meters.
Mm-hmm.
When you set up a hospital. You want to set up a 400-bed hospital, you need 4-5 acres of land, contiguous land. Where do you get it in Delhi and Bombay?
That's right. That's right.
It's like saying putting up hospital. One of the biggest plus points that we have is that we have this land in our network, in our system.
Okay. Okay. You had mentioned about medical tourism going up many times by 230. How do you see it? What is the size potentially and when do you see it in 2030 sector, I'm asking?
You know, if you're saying 2030, I think, you know, we can... There's such a massive comparative advantage that medic we have in India. I mean, we are less than 5% of the cost of the U.S. We are less than 30% of Singapore. We are less than half of Thailand.
Mm-hmm.
I mean, look, it's not like people from the US will start coming to India, but in my case, it's the largest part of the world pyramid, only the bottom is all self-paid, right?
Mm-hmm.
For them, affordability is an issue.
Yeah, that's true. That's true. Another thing, how do you see the-
In a comparative advantage, I mean, look, this has the potential of surpassing IT sector. That's the amount of comparative advantage that we have.
Oh, yeah. Can you just repeat the last bit?
Sorry?
Just repeat the last bit. I didn't get it. It has the potential to surpass IT sector.
Absolutely.
Gotcha.
I think, you know, because of the comparative advantage that you hold in this field, no other country even comes close. Whilst in IT, other countries may come close. Here, there's nothing. I mean, the sheer volumes and complexities our doctors handle, what they do in a year, the Western counterparts don't do in a decade.
That's true.
Our skill sets are right up there. Our cost is a fraction of the global costs.
Mm-hmm.
Aging population, rising costs, most governments raising hands up, you see this is going to be a, I mean, this is going to be something else. This is not even the tip of the iceberg.
That's true. That's true. Another thing, just a thought. In general, even private equity guys, you know, are so heavy on our sector, it seems that it's, you know, sort of topping out. There are smart guys like Emami or Manipal, they tell you the private equity guys buy. It's just a thought. What are your comments on that?
No, I don't disagree. I think, you know, you had hospitals and hospital chains, you know, changing hands many times. Manipal, I think, this is the sixth or seventh private equity round that they've done in Manipal Hospitals over the last 10, 12 years.
Mm-hmm.
If I look at, you know, it's not as if Max wasn't up for sale, we bought them today. It's not as if other hospitals were not up for sale. Those transactions also happened in the past.
Yeah.
I don't think it's a question of tapping out. I think, you know, there is very clearly a multi-decadal opportunity to invest in this sector.
Mm-hmm.
In India, which has never been actually, it's much more true today. You know, it's not something which was lost in the past either. Only difference was the cost of care. I remember when we were listing our company in 2020.
Mm.
Most of you will bear this out, right? The biggest critique of this sector was, you know, the Indian private care sector is a great investment mirage because there are no free cash flows. How do you invest? You have to keep raising money and keep reinvesting.
That's true.
We have a INR 1,231 crore-
Mm.
-free cash flow coming with INR 1,650 crore. That is 8%, almost 8% throughput of free cash flow. You're seeing this. We have not raised any capital. My entire 2,900 beds, okay, is at a cost of INR 4,500 crore. That should give me 50% of my free cash flows in the next 4-5 years.
That's right.
That's a greatly balanced sheet. Today, look, this is a compounding. There's a massive multi-decadal opportunity to invest. I think, you know, to create infrastructure. We and all sorts of funds are going to be coming. Many of them.
Okay. Okay. If I just one last question, how do you see this asset check model? How heavy can it be for you guys?
Sorry, just to understand one thing. For PE.
Yeah.
gives him money, okay, at valuations.
Yeah.
They need to underwrite. Any private equity will need to underwrite a 20%-25% IRR in dollar terms.
Okay.
Okay? Only because they're seeing this opportunity, and I believe Manipal, for example, was done at 50x 2024 CAPEX.
Mm. Ah.
I mean, look, they're expecting to do a 35% CAGR from that on dollar.
Mm-hmm.
I mean, on the contrary, I think when PEs come in, they see opportunity.
Okay. Okay. I have one last question about the asset check model. How heavy can it be for you guys? Like, are you, will you be increasing the size of the business?
Well, in general, in life you mean? Yeah, I think so. No, asset-light business being heavy, I think quite heavy from that standpoint. I think over the next couple of quarters, you will be coming across some announcements from us on this front. This is really the way for us to grow. Particularly with any form of greenfield that we're looking at, we don't like to build on our own. We like to collaborate because it certainly creates the construction and development risk. Particularly in geographies that we're not presently presented. I think you're gonna see some of those come through now.
Okay. Okay.
That's gonna be a big focus area for us.
Okay.
You know, we have a 36% cash on cash ROC, so we can we can afford 8% yield to developers.
That's right. That's right.
Thanks.
Okay. Thanks. Thank you.
Thank you. We have our next question from the line of Neha Manpuria from Bank of America. Please go ahead.
Thanks for taking my question. Okay, you know, you mentioned improvement in specialty mix quite a few times. If I were to look at maybe through the profile, obviously there's improvement in oncology, a little bit in neuro, cardiac. You know, are the beds that we are adding essentially focusing on doing more higher ARPOB work, like adding more onco beds, et cetera? Or are we seeing a kind of work really within cardiac, within neuro itself increase that is improving the specialty mix? How do you differentiate between the two?
Look, I think it's a combination of the two, obviously. First and foremost, if I look at capacity spread, right? I mean, and you look at the overall ARPOB. Your ARPOB that you see of INR 71,000 is a summation of ARPOB, right?
Mm-hmm.
Like when you see occupancy of 77% is a summation of various weighted average. It also means there may be some hospital which is operating a 70% occupancy. There's another one which is operating in 90% occupancy. Similarly in ARPOB, okay, you'll have certain departments which are low ARPOB. You'll have certain payer mix which is lower ARPOB. Yet you are hitting capacity thresholds. Firstly, if you are hitting capacity thresholds, okay, you're gonna look at expanding over. Okay. Perfect. What we would see is that, look, if today I am creating more capacity, okay, and I was to take my lowest, payer mix and my lowest ARPOB, specialty, that's really what I'm creating it for. Are you with me?
Any expansion that you're doing is sort of serving the lowest common factor because that is what you're doing it for. Otherwise, if you were not to do that ground feed expansion, what you're gonna do is you're gonna tap out, you're gonna distill your payer mix and you're gonna distill your clinical mix.
it will also be. You know, I'm asking this, okay, one is let's say I'm adding more onco beds or I'm adding more, you know, OT or ICU beds because of the improvement.
Onco bed. What's the onco bed? You know, a lot of the listing is fungible. Except for some daycares et cetera that you have, but the beds are similar. I mean, for cardiac, for example, there may be some cath lab, but, you know, the OTs are similar.
Right.
It's not like it's sort of quite fungible within the hospitals. You have to understand that. Yeah, I may segregate it and may boost the clinical program. The way I will value it, please understand this, right? I mean, if I have 100 beds, okay, of which let's say 50% beds are very high ARPOB and 50% beds are low ARPOB, and it's fully occupied. When I look at creating another 50 beds, the way I calculate it is that, look, if I was to create my lowest ARPOB of 50 beds, then we're to put it over there.
Yeah.
Alternatively, my opportunity is to just pay the low ARPOB out and occupy my current facility.
Right. essentially that would mean you either add a new specialty or add, you know, doctors which will allow you to remove that lower ARPOB, right?
No, no. You see, even if you don't do that, there is a certain... A lot of that stuff is aspirational, right?
Mm-hmm.
Today, when you have a waiting list of three or four days or two or three days in your ER for patients.
Okay.
Okay, you know this is unappreciated demand at your, at your doorstep. Okay. You take Shalimar Bagh case in point. I put up a onco block over there, right? Immediately what happens is my oncology patients from my current facility or the pre-existing facility move into the new onco block, right?
Correct. Yeah.
What happens to the old block? Now, my high ARPOB business may have gone out, but the lower ARPOB is sort of planning in over there, right?
Yeah. Yeah.
When I evaluate setting up the 100 beds in the new block, I have to evaluate vis-à-vis the low ARPOB business, not the high ARPOB business. I may be doing it for the high ARPOB.
Okay.
What you see is without adding much doctors, et cetera, within the first month you break even, and you hit a 40% EBITDA margin. You have overall occupancy, and now this is what matters, of this incremental facility as well as the existing facility, the entire hospital, of 83%.
Mm-hmm.
I mean, I'm not saying it's 83% of the new 100 beds. I'm saying it's 83% of the 300 beds.
The reason why I'm asking this is, for example, we added the new onco block. That's not necessarily increasing my entire onco contribution quarter-on-quarter. It could just be, you know, moving patients to the new block to unlock through sort of free capacity to move up.
There is some increase, but really it's not, it's not a jump increase which happens just because you open a new block.
Got it. Got it. Okay. Okay. Understood. Thanks so much.
Your overall business is. Of course, the new onco block will have a disproportionate increase, right, in oncology.
Mm-hmm.
It's not as if other services are not increasing. Okay. Let me put it this way. You know, when a facility head says, let's say a hospital of mine has 50% PSU business and 50% this thing. Running at full capacity.
Mm-hmm.
When the question comes about expanding over there, okay, when a note is put up, "Let's expand," my first question is, who are you expanding for? Are you expanding for PSU?
Yeah. Yeah.
Alternatively, you should be displaying the PSU.
Correct. Yeah.
The expansion, whatever specialty goes there is irrelevant. You obviously put up the specialty with the highest ARPOB, which can sort of, you know, which will be more accretive et cetera. But it has to be evaluated looking at the close opportunity. Sameha, basically, the hospitals are tasked on both fronts. One is that during the specialty they have to work on increasing the quantum of procedures which are high-pay procedures, number one. And they are also supposed to allocate more beds and fill up more beds for high ARPOB specialty. Right? Both things play and that's what the hospital's job is.
Okay. Is there any way for us to sort of strategize as to how much of our ARPOB increases come, let's say, from an improvement in specialty mix versus other factors?
Quarter four. I can tell you for the quarter four. Let's say if quarter four increases 5%, around 2% is because of the procedures within the specialty. That means, with the same number of beds for each specialty. You know, the specialty ARPOB has gone up, and around 2% is because of relative change in the, you know, OPDs to the specialty, right? Market values of dermatology and cardiology, et cetera, has gone up, which means that they are higher ARPOB specialty. The mix has changed on the beds. The extra 2% beds is within the specialty the ARPOB has gone up.
Okay.
Overall. Overall. Yeah.
Okay. The entire.
Yes, I'm saying 5% is... 2% is from here, 2% is from there.
Got it. Thank you so much.
Thank you. We have our next question from the line of Amit Dawani, an individual investor. Please go ahead.
Hi. Thank you for taking my question. My first question is, can you tell me what the price increase that you have got in by the PSUs?
70% on 12% of. Amit, there are four elements on the price, on the listed price increases. One is on the ICU bed charge, other is the normal bed, the ward bed charge. Second is the. Third is the IP consult, fourth is the OP consult. Right? OP consult has gone up from 150 to 350. You know, IP from 300 to 350. Other than that, those are general price change. Overall average if I take, it's a 70% price hike we got. This is after 9 years, right? This is price rise last in 2014. Right. Now the point is this is only small quantum of the line items which are, which have been to the patients in the PSU.
We do expect that there'll be further price increase by the government because if the room rent prices increased, that means that the room rent which is part of package it will also go up. Right? Let's say cardiac surgery, that 12 days stay and there's a package charge that we charge to the EPS patients.
Should also go up.
That should also go up, right. That's government is, I would say the CGHS authorities have put up a note to finance ministry, et cetera. We expect that there should be a decision on that by July.
Just trying to understand, the institutional business is 20% of our sales.
No, no.
How much of it is?
Share. Understand. Share is 29%, revenue 17%. Right?
Okay.
17% of revenue, 12% of that 17% will go up by 70%. That's the net impact of 4%-5% on 17%, on the institutional part.
Okay. Okay. That's fantastic. That's fantastic. My second question is the digital revenue is about 18% of our overall sales. Just trying to get a sense of what the margins on that digital revenue are. Is it higher than the overall margin of the company or is it lower?
No, no. It's a channel. It's a channel. People used to call up earlier. People used to come to hospital, walk in, then they used to call up call center. Now they do it through digital platform. They're booking. Your margin doesn't change. You can go into customer acquisition costs and advertising, et cetera, et cetera, but that is meaningless here.
No. The press release said digital revenue from online marketing activities.
That's right. Digital revenues means digital booking. I mean, if you're basically...
Okay.
If you book a liver transplant, okay, through a listing, then that is a digital revenue. If you come on the website and then the You know, we track the patients who come on the website and then we see conversion from there. If they're converting from the website, that is counted as a digital revenue.
Got it. My next question is on the contribution of NOS to ARPOB. We saw the NOS go up this quarter. Can you?
Look, ALOS is meaningless, right? I mean, a hospital which does more complex surgeries will have a longer ALOS. If I do a bone marrow transplant, ALOS is 30 days. If I have a liver transplant, that's the business you want actually. The ALOS is longer than doing non-surgical work. When you do more surgeries, you have more ALOS. All of it plays out in ARPOB. Eventually, what is it that you have? You have inventory, right? You want to earn the maximum unit A from there. It all plays out to ARPOB. No point in having a very, very short, ALOS and having a lower ARPOB. Rather have a higher ARPOB.
Got it. Got it. Got it. Got it.
You've got beds in two days.
Right.
In a year. Okay, what you want is the higher amounts of revenue from each of the days.
Perfect. Perfect. Got it. Thank you so much, Abhay. Thank you.
Thank you.
Thank you. We have our next question from the line of Alankar Garude from Kotak. Please go ahead.
Hi. Good morning, everyone. Abhay, assuming the care acquisition does not go through, can you help us understand whether there are any meaningful acquisition opportunities?
Please of hospital chains, across India which, fits your criteria.
That's 20.
You don't have any preference, on geography, right? Just the criteria which you have of players being successful and, you preferring a cluster approach.
That's right. I mean, a little more sort of, less casual than just that. We've worked out a list of about 20-21 cities. That's pretty much, yeah, but that is important criteria. You know, what we find is, at the umbrella level, if a couple of distinct groups are places which typically will have the demand, supply, doctors, et cetera, et cetera. We feel comfortable over there. I mean, I'm putting it very simplistically by saying, at least two or three of my competitors have similar liability. Yeah, it, you know, in each one of these cases, this is what I find, common.
Understood.
This is the profile that we want to take. you know, we're not pioneers. We don't like to go to uncharted territories.
Fair enough. The question is, would it be fair to assume that most of these would be standalone assets now, or if at all, just two, three hospitals per chain, or there are still, say, chains operating five, 10 facilities across India which are on the block right now?
I think there's plenty of consolidation and you are gonna see consolidation. See firstly, consolidation happened because there's a requirement for consolidation, right? I mean, in case of Max Healthcare, you've seen 16 stitching of EBITDA translating into INR 1,280 crore of free cash flow. Okay? Now, if you have an EBITDA typically of company in most mid-sized players, as you would see, have a INR 500-600 crore EBITDA. And their EBITDA translates to INR 200-300 crore free cash flow at best. This is pre-indebts, post-maintenance CapEx, post any increase in working capital and taxes. Now, this is a capital-intensive sector. If you have INR 2-150 crore, okay, you can build one 500-bed hospital every four years. That's all you can do. One hospital every four years.
If you're a listed company or unlisted, where do you go from there?
Understood. Yeah, I mean, my question was more from some of our peers, especially the unlisted peers, being quite aggressive on M&A front and also private equity interest in the space continues to remain quite high.
Look, can I tell you something? There'll always be people doing fool's errands, okay, and outfitting or whatever. What is it that we look at? Our criteria is very simple, okay? I want to look at a 20% ROCE 3 or 4 years down the line, 4 or 5 years down the line. If we have a clear line of sight and visibility of that ROCE, okay, we will come in. A PE fund typically will be getting cited at, you know, the multiples that they bring. Our ability to underwrite a EBITDA or a business case, okay, 4 years down the line, 5 years down the line is much more pronounced, okay, than a PE.
I mean, for us to underwrite, let's say in a situation where we believe a 2x or a 3x or a 3.5x of EBITDA, okay, is very possible three or four years down the line. For a PE to, you know, sort of underwrite that case, very difficult.
Understood.
Higher multiples. Amount we are willing to pay at the outside is a derivative of that. Where I believe I can take the business four years down the line. Do keep in mind, our EBITDA per bed is the highest in the industry. You know that. It's about 50-55%. A PE can't underwrite my case. He has to underwrite the industry case.
Fair enough. Understood. The second one is more of a quick clarification. Is it now fair to assume that while we may not reach that 15% institutional volume mix number by March 2024, given that we are operating at high occupancies, the institutional volume mix will still gradually keep on coming down?
It will come down. The returns, we've done a bit of a call, like I said, so we're expecting some increments, although it is coming down. We've also found more capacity. We've have more elasticity in operations. The price is moving up. You know, look, it's not going to be, yes, you know, your trend is going to keep sort of reducing over there. Eventually, you know, it's finite, right? I can suffer that higher price for some time, but it's still not the same as my CTW business.
Fair enough. Great. Thanks and all the best.
Thank you so much.
Thank you. Ladies and gentlemen, that was the last question for today. I would now like to hand the conference over to management for closing comments. Over to you, sir.
Thank you so much for being on the call. I think, this has been a seminal year, for us on many, many counts. We are happy to have most of you as investors, and rest of you, we look forward to them joining our camp very soon. Thank you very much.