The health of the hospital sector has been deteriorating since early CY2017 due to several factors that have adversely affected its profitability. These include the implementation of the Goods and Services Tax (GST) cap on prices of stents and knee implants by the National Pharmaceutical Pricing Authority (NPPA) and stiff regulatory actions by certain states, including putting restrictions on procedure rates, levying penalties and placing operational limitations on erring hospitals. Though the aggregate revenues of ICRA’s sample set have grown by 9 percent, from ₹132.6 billion in FY2017 to ₹144.9 billion in FY2018, the operating profit before interest, tax, depreciation and amortization (OPBITDA) has dropped by 4 percent, from ₹17.3 billion to ₹16.6 billion, this being the first fall in aggregate OPBITDA in the last six years. Further, the operating profitability margin has declined from 13 percent in FY2017 to 11.4 percent in FY2018, the lowest in more than six years; the highest was 15.7 percent during this period.
Hospital chains with a large presence in the National Capital Region (NCR) have seen the sharpest dip in the OPBITDA (up to 21 percent) due to additional Government restrictions placed on certain players, following media reports on alleged cases of medical negligence and overcharging. Avers Kapil Banga, Assistant Vice President, ICRA Ltd, “We expect wide-ranging regulatory restrictions from multiple authorities to continue to suppress the average revenue per occupied bed day (ARPOB)s of the players in the short to medium term though structurally, things are stacked in favor of the sector. This is due to the fact that there is significant shortage of beds in the country, as the disease burden continues to rise, the demographic profile shifts towards an ageing population, the per capita income and healthcare expenditure rises and medical insurance and medical tourism continue to grow in double digit figures.”
ICRA note mentions that on the operational front, all players faced pricing pressure in FY2018, primarily due to restrictions placed by the NPPA in February 2017 and August 2017. Consequently, ARPOB of the sample set has grown by a muted 3 percent in FY2018, the lowest growth rate in last five years and much below the five-year compounded annual growth rate (CGAR) of ~7.2 percent. The aggregate number of operational beds has gone up by 6 percent, from 19621 beds in FY2017 to 20825 beds in FY2018. The growth in occupied bed nights has been muted, at 4 percent, and the aggregate occupancy level has dropped during this period, from 61.5 percent to 60.4 percent, due to the sharp fall in occupancy for one of the largest hospital chains which, in addition to other regulatory measures, has also been impacted due to alleged cases of medical negligence/overcharging and internal challenges.
Excluding this, the occupied bed nights of the sample set have grown at a healthy 7 percent and despite the increase in bed capacity the occupancy level has been stable, at ~58.5 percent, indicating satisfactory volume growth. The regulatory environment continues to be the overarching challenge for the hospital sector. The NPPA has already published two office memorandums in CY2018 which indicates additional pricing restrictions. Further, the Governments of West Bengal and Karnataka have implemented the Clinical Establishment Acts in 2017 to overhaul the regulatory mechanism for the sector, setting up of a grievance redressal mechanism, fixing the procedure rates and laying down the criterion for levying penalties on hospitals.
“The proposed regulatory action from the Government of National Capital Territory of Delhi (GNCTD) and the Niti Aayog may further impact the margins going forward. ICRA expects that within the industry, hospitals based in the NCR are likely to face maximum pressure due to the sweeping changes proposed by the GNCTD,” adds Banga. On account of the increase in debt and pressure on OPBITDA, the interest coverage ratio of the sample set has dropped from 2.73 times in FY2017 to 2.44 times in FY2018. Consequently, the net debt/OPBITDA has deteriorated from 3.08 times as on March 31, 2017 to 3.33 times as on March 31, 2018. The aggregate debt coverage indicators of the sample set include the impact of non-hospital businesses as well, such as standalone pharmacies and diagnostics services, which have fared much better. – PharmaBiz