Bumrungrad Hospital Public Company Limited (BH) Earnings Call Transcript & Summary

[Foreign Language] Welcome to the third quarter 2022 Analyst Presentation for Bumrungrad Hospital Public Company Limited. We had another excellent quarter in Q3, and the main themes remain the same as what we talked about in Q2. The momentum has been sustained significantly due to ongoing strength in our international markets for which we will delve more deeply into at a later stage in this presentation. But also we had rather solid Thai and expat revenue, especially when you consider in 2019 or pre-COVID levels where we saw flattish growth in year-on-year terms during that period. And there was a bit of concern as to how we were able to sustain growth in the Thai and expat market when we were continuing to reduce our discounting and promotions in line with our purification of margins going forward. When we look at also forward indicators that we talked about in the previous quarter, you will see that, once again, volumes remain very bullish in forward terms because we started to see continued momentum in inquiries and appointment requests across all of our channels: voice, chat and e-mail. And that, as a forward indicator, is rather strong in our expectation into Q4. And I mentioned earlier about discount reduction being something that we have been embarking on. Since the beginning of this year, we do continue to expect the discount rate to fall as well as economies of scale as we continue to ramp up volumes within the hospital itself. And we will talk a little bit more about how that played out in the quarter. Moreover, we're thrilled to expect that bed availability will increase in Q4 and with the renovation completion of the seventh floor wards in the hospital, we would be able to open new beds and, therefore, welcome additional patients as well. And this should be a positive for us going forward into Q1 of next year. You can see on the graph, we continue to break through the pre-COVID levels quite solidly across the board, not only on revenue terms and also in net profit terms. You might expect that, oh, there was a dip in Q2 versus Q3, that was mainly due to the one-off charge we booked in Q2 of 2019, and that created a low base effect with which to compare to. Factor that out and the graph becomes a lot smoother and a lot more solid in terms of the upward trend trajectory. This is a new graph that I wanted to show you. We looked at the third quarter's profitability. And we were quite impressed with the margins that we were able to achieve, 26% in Q3 is nothing to laugh at. And when I look at it, amongst the competitive environment here in Thailand, i.e., the health care listed providers, we compare very favorably with not only in margin terms but also growth terms for Q3. On the right-hand side, in the box highlighted there, is where you want to be: high growth in operating revenue terms but also high profit margins. And you can see there, we exceeded strongly all other peers that we compare ourselves to. This is data as of the 11th of November where we had 12 companies in the comparison. And it's quite clear that we've had an excellent third quarter as a result compared to many of our peers. On to discount rate development that I talked about earlier, that continues to fall. It's at 12.4% as of the third quarter of 2022. And we continue to expect that to reduce going into Q4 and furthermore in next year as well. That would continue to help benefit our margins as we continue to purify into areas where we want to focus on and remove unnecessary discounting where we can in order to unlock additional incremental revenue. I'm going to talk a little bit about what I think is interesting for you to take into account when you look at how our margins have been so strong. One very important part of the cost structure in the hospital is the supply costs. And I'm comparing with you now the supply costs to operating revenue ratio. On the graph there, you can see that in 2020, the contribution to the cost structure was around 15.6%. That increased in 2021 to 16.2%. It was somewhat expected because we saw a reduction in revenue as a result of the continued closure of the country and the heightened COVID situation during that period. But you can see from the beginning of this year going forward, so Q1 to Q2 to Q3, that has come down significantly and that has helped to uplift our margins to what we see now at around 26% as of Q3. That compares very favorably with what we saw at pre-COVID levels as well. And we do expect that continued cost management programs that we have in place will drive further improvements in this area. In addition to that, economies of scale for sure, will help support this as we get more volumes into the hospital. There was some fear that the inflationary impact as a result of higher oil prices, energy prices and so forth would impact negatively margins. That did not turn out to be the case in Q2 and Q3, as you can see, we continue to benefit significantly as a result of our prudent management of costs. Another major element is on salaries, wages and benefits, SW&B, and that development also mirrored what we see on supply costs. We had a rigid program in place in managing manpower, and we had continued to work on developing additional operational efficiencies during the COVID years and going forward as well. And that has borne a lot of fruit to us, as you can see in the graph there. In 2020, the SW&B costs as a percentage of operating revenue was at around 23%. That fell in 2021 to 22.8%, mainly from attrition, as we did a hiring freeze. We did not hire any additional staff. But there was turnover during that period. And then as volumes ramped up in the beginning of the year, we maintained our headcount quite effectively as well as our OT costs. And that has helped to reduce those costs as a percentage of operating revenue significantly, down to 15%. And if you look at it on historical terms, it looks very, very favorable even when you compare with pre-COVID levels. And finally, I'd like to update you, this has long been anticipated and we typically do this in the third quarter of any fiscal year, and that is the campus master plan. I also now include the construction, CapEx of the hospital into this amount, and that mainly relates to the renovation of inpatient rooms that I talked about earlier that we completed on the seventh floor of the hospital. So currently, you can see there on a 5-year projection, we're looking to spend approximately THB 13.9 billion. The major part of that continues to be the Petchburi Hospital, THB 9.25 billion in 2027, so very long dated. It's been pushed back another further year because we believe that there is additional capacity coming online. And I'll talk about that a little bit right now. Under new construction, you can see in Petchburi, in Soi 1, we have the Phase 1 construction of the parking building. That is due to be completed within this year. If any of you come to the hospital, you will usually find that parking space is very scarce, and it's difficult to find parking. And we're trying to ameliorate that situation by adding additional parking facilities. That is soon to come online and sure to help in that respect. On the BH Academy building, which is going to be office space for back office and management staff, that is also going to be completed very, very soon. We are, in fact, in the process of moving staff to that building in the next couple of weeks. And that is expected then to free up space, particularly at Building C, or BI Tower, to move in additional clinics, additional revenue-generating capacity in that building. BH Annex, which is a building located adjacent to the hospital is a new development that we're expecting to construct within next year. And that will also have an access bridge connecting directly from the hospital to this annex. There will be additional clinics being built there in areas where we have noticed significant bottlenecks and significant traffic. And we have to look ahead at how we manage that in a way that benefits not only the patient but also drives value to the hospital as well. On Building A, not much change. We've done a lot of upgrades to MEP, et cetera. But what we plan to do is have a connecting bridge from the hospital to Building A in order to facilitate greater access between the 2 buildings. In Building B, a lot of construction is being done, particularly in certain specialties or clinics. We're looking at either expanding or renovating the hyperbaric clinic, the colorectal clinic, radiology and also digestive diseases, physiotherapy and the cath lab that will support our heart institute as well. The renovation of inpatient rooms will continue over the next 5 years, although we think the ongoing process will delay somewhat due to the high demand that we see, and that should help balance out the room availability for the benefit of the hospital going forward as we continue to welcome inpatients. And then on Building C's side, these changes remain the same as of last year. We're looking at moving out in certain levels, Level 8, Level 10, Level 11 offices and making changes to the clinics in order to support expansion on the outpatient side as well. So you can see there construction is mainly heavily skewed towards the next couple of years, and then that starts to pare down towards 2025 onwards with the exclusion of Petchburi Hospital. So I'd like to hand over the rest of the presentation to Neil Sorrentino, our Chief Global Strategist, who will elaborate further about developments in the various markets. Thank you.

[Foreign Language] Welcome to Q3 analyst presentation for Bumrungrad Hospital Public Company Limited. As Daniel has daylighted to you in his part of the presentation, the quarter was something remarkable for us and as I thought about as an operator of this business, along with the team, really what to say about the quarter. And we'll get into a lot of the detail, but I've almost come to the conclusion that saying less is more when you have these kind of numbers for the quarter. Our crystal ball was completely broken in Q2 when I gave guidance for Q3. We had high expectations, and we were optimistic about Q3, but what happened in Q3 was far beyond our expectations. However, I will say that we have spent the better part of 24 months priming the pump internationally across all of our markets. We never lost focus. We never lost attention to our 60 referral offices around the world. We never lost focus to all of our Middle Eastern sponsors and clients. We stayed very, very close to all of the embassies that we have close relationships with. So we did our homework in watching the business while we were going through this painful period called COVID. Let me get into some of the other aspects a little bit differently but similarly to what Daniel talked about earlier, but give it a bit of a different forward look to it. When you look at Q3 at a high level, there were 3 pieces of business that drove the performance. Apart from the cost control, which has been good for the last 2 years, and it had to be good during COVID because we didn't have the revenue drive that we now have which makes things more forgiving, but the 3 considerable aspects of our business for Q3 were obviously the Middle Eastern business. Let me start at the top. Our revenue quarter-over-quarter grew almost 16%, 15.7%. But what was most dramatic about the quarter was our Middle Eastern business. Our Middle Eastern business grew 70-plus percent. Our international business grew 33%. And the overall impact on total revenue was 15.7%. So when you step down the pieces of that business, you need to look deeper as to really who we are, and I covered this at times in some other analyst presentations, it has to do with revenue intensity. We drive a great deal of bottom line revenue. And if we manage the cost properly, we drive profitability as a result of the balancing act between revenue intensity, length of stay and conversion of patients in and out of our workflow. I'm going to talk about each of the pieces of the business that drove Q3 in just a moment. But at a high level, that's what made the quarter. If I look at the international business contribution, I've given you the percentages. But that's the story for the quarter, international business contribution. I will talk about Thai business. I'll talk about expat business. They are always contributory. They're always important to Bumrungrad. But we are an international health care provider of services. We are the industry leaders in national medical tourism. And there was nothing more pronounced in that kind of thing, improving that, than in Q3. I'm going to slip down now to 2023 budget assumptions for you because we get asked a lot about optimistic guidance for the upcoming quarters. I'll talk about Q4 guidance in just a moment. But let me touch on 2023 budget assumptions, and you are most welcome to ask questions during our livestream Q&A next week with respect to the 2023 budget assumptions. But for next year, 2023, we see the optimism continuing. Our business optimism now seems to be wide open with a number of different business channels that we haven't pursued before. We have attracted some very strong and outstanding leadership talent experienced in other international markets, which we'll be introducing you to as time goes on here. But we've identified a number of markets we're not in now and some markets that we're in, in a small way that we expect to get in, in a big way, how does that translate to in terms of budget assumptions for 2023. On price, given wage inflation, given inflation overall, which could be pushing very, very low double digits in Thailand, we expect on price a 6.6% increase. On volume, we're taking a fairly aggressive point of view on volume, budgeting 7.8% increase on volume year-over-year at the medical center. But even more importantly, we're budgeting 2.9%, call it 3%, on revenue intensity. We expect to drive even higher revenue intensity. And when we get to the presentation by my CEO, Khun Lin, she's going to talk about the existing as well as the new centers of excellence that will be driving additional business and revenue into the hospital. So those 3 components are going to be what we're going to strike towards insofar as 2023 performance goes. And you can translate that any way you like in terms of your model for those of you in the investor relations community, doing modeling for the upcoming quarters. We've done our own budget assumptions. And of course, they're a budget, they're a forecast, but we need some kind of guidepost to go forward with. So that's our plan for 2023. For Q4 guidance, in this presentation, I'll work backwards instead of forwards as we've done in the past. Crystal ball is still broke. The optimism continues for Q4 2022 guidance of 15.7%, it was the top line revenue growth in Q3. We would not be surprised if it didn't make that number, but it's difficult to know. Usually, the last 2 weeks of December are slower times because of the holiday period. Many people practice Christmas festivities, New Year's, et cetera, so we expect a bit of a slowdown at the end of the year. But to date, we're in Q4 now, and the performance continued strong like it was in Q3. Let's get in a little bit to the numbers themselves and give you some clarity beyond what we've talked about. As shown, the format, sort of the data modeling presentation of this slide in the last couple of quarters, but it is very, very revealing a slide because it shows you, the investor community and those interested in the company, what has been happening since 1Q 2021. And I'm not going to go through the numbers for you. But if you look at just Q2 and Q3 alone, the variation on those grew from almost THB 5 billion to THB 5.740 billion. On EBITDA, the EBITDA grew from THB 1.7 billion to THB 2.090 billion, up 36.4% on margin. If you look at the EBITDA margin, it's gone from 28.2% in 1Q to 34.4% in 2Q and Q3, 36.4%. And along the net profitability line, you see the same strong trend line from THB 1.1 billion to THB 1.5 billion, 26.2% margin. What's even more interesting about this, which I'll show you later, is that I had a look going back to the top quarter in 2019. This is pre-COVID for everyone. And in the top quarter for us in 2019, I will show you these numbers later, but with respect to this slide, we exceeded all of those metrics for our top quarter in 2019, principally again driven by strong revenue intensity. So let's look at the markets. The most indicative aspect of this slide is what you see in the last column, the Q3 2022 percentage contribution. And take a look at the brown numbers going back to Q1 2021, 25% for international, went from 25% to 56%, more than double. And so it goes in reverse, the decline in expat and the decline in international. So when you add up what we call international business, that equates to expat and Middle Eastern. So you add 56% plus 11%, pushing 67% of our revenue is now coming from international business, meaning expat, meaning international combined. Our Thai business is down to normal numbers, 1/3 of our revenue. If you go back in history, you'll see that at our peak performance, we were 2/3, 1/3. Actually, we're now back a little better than that number because the higher the international percentage to the total, the higher the revenue intensity, the higher the profitability, assuming we're managing our costs effectively. And that's what you really saw in Q3 in a very, very, very dramatic way. So I mentioned earlier that the Q-over-Q change was almost 16% on revenue. Pretty strong numbers when you consider the baseline revenue for Q2 over Q1. It was double digits, and now this is double digits again. And if you look at 3Q '21, the comparative is not so for 3Q 2022 year-over-year because you're not really looking at apples-to-apples business basis for business basis. For Thai business, it was almost a push, call it, a little short of 1% or 0.1%. That's a little bit deceiving because while the Thai business was flat, if you look deeper, the complexity of the patients, Thai patients we were taking care of in the quarter, was quite high. And that drove a lot of revenue intensity. If you compare our business base quarter-over-quarter, the revenue contribution quarter-to-quarter was much different in Q3 for Thai business than it was in Q2. So while this says, oh, well, the volume is flat, it's not -- to revenue contribution. On the expat business, it was predictably down 5.8%, 6%, quite predictably, look at the lower part of that slide, if you will. And you will see 2021 Q3, you see the dip. The dip is traditionally low in Q3 for us. And why is that? The dip is low because expat nationals, classically, their employment contract or the consultant contract expires at the end of June, either they renew or there's a new wave of expat nationals coming into Thailand working here for international companies. So there was always this lag in Q3, which drives down the business in Q3 for expats. The revenue intensity for those patients we took care for expats was, on average, about the same as Q2. We won't talk about Q1 because it's not relevant. All international, as I said earlier, in total, was up 33% over Q2, again, driven by Middle Eastern business. I've talked about that already as well as Daniel has discussed this, so I won't go into that level of detail. But look at the bottom part of the slide. You'll see the rise variation over the quarters, what has happened over the quarters, in the all international business, very, very strong performance. This slide here for me as an operator was very, very impressive. When you look at all of these international countries that drove business into BH in Q3, there's only one that didn't perform versus Q2, and there's a very good reason for that. That happens to be Mongolia. They have the equivalent of Songkran there in Mongolia, a holiday, it's a big national holiday called Naadam and all companies shut down. In addition to the Naadam holiday, which is a full 12 days, we also took advantage of closing an IPD ward to renovate it. So the variation between the quarters is explainable by that amount. But look at all of the other countries in terms of the growth. I have typically gone through the base revenue changes. I won't take the time to do that now. I'll do that during our Q&A livestream next week to give you a magnitude of the number. But just quickly, Kuwait, Qatar, Myanmar, not only were the percentages, in some cases, huge, Qatar and Kuwait, but even with Myanmar, only growing 1.7%, it was the #1 or #2 large volume country contributor for Q3 for us. But the others are doing nicely, too. China is not so much traveling Chinese nationals. It's more Chinese expats living in the country. There was a few Chinese nationals coming from China, but very, very few. This is mostly Chinese expats when you look at item #10. Same for the United States, 3/4 of that were expats living either part-time or retired here in Thailand. The U.A.E. grew very, very nicely. It's been a big success story for us. So we work very, very hard in regrouping that market for ourselves and doing many things in-country that has brought that volume up by 300% year-over-year. Bangladesh, Cambodia, very strong markets for us in Indochina. This slide needs no comment whatsoever except to say it grew 77%. Tremendous pent-up demand in the Middle East for patients wanting to come both to Thailand and wanting to come for very complex care at Bumrungrad. Throughout the quarter, we had more demand than we had beds. Throughout the quarter, we did struggle with staffing, trying to staff our beds to accommodate the number of patients who wanted to come to our hospital. Fortunately, we'll be adding more beds, we'll be adding more staffing and we'll be expanding our capacity in Q1 of 2023. Because the demand is there, the pent-up demand continues, it's not abated. And I'd like to remind you, if you look at the small print at the bottom of that slide, we talked about the 4 large Middle Eastern countries. But for each one of those other Middle Eastern countries, we are getting more and more patients. As an example, Saudi Arabia for the quarter was THB 48 million in revenue. That was 25% of that or less a year ago. Yemen has grown nicely. Iran has grown nicely. Bahrain has grown nicely. This is people wanting to travel. People wanting to come to Thailand. But all of these markets know this brand very, very, very well. And you can see how they frequented the brand in Q3. Indochina was, again, a strong market led by Myanmar, up 14%. Same financial dynamic, the dynamics of this business is almost as strong on a revenue intensity and margin contribution basis as the Middle East, but none is stronger than the Middle East for us. So we now go to the EBITDA and the net profit. Khun Oraphan, our hospital CFO, will be covering this in some deep detail, but suffice it to say that over the quarter, it went up 23% for the quarter. And if you look at the year-over-year numbers, it's hard to believe that it grew that much year-over-year. But what's even more indicative of our ability to drive earnings is our ability to manage costs. And managing costs in the kind of environment we were in, and now this huge upswing in volume and managing our cost relative to that volume and the drive intensity of that volume, is not an easy thing to do when you have those wide swings because this is not a traditional med-surg community hospital we are doing some things here that aren't even being done in the United States. The EBITDA, I put this together for you a little bit differently than the presentations in the past because I wanted to show you where we were 3Q 2021, which you would expect, given COVID, where we're producing EBITDA of THB 654 million. But look at Q3 in 2022, it's over THB 2 billion. And then if I take you back to our best quarter, pre-COVID, Q3 2019, the number was THB 1.574 billion against THB 2.090 billion, a huge jump in performance, apples-to-apples, pre-COVID, post-COVID. EBITDA margin at its best was 33.1% in Q3 '19, jumping well above that in 2023 Q3 (sic) [ 2022 Q3 ] to 36.4% and even a 2% leap from Q2 to Q3 2023 (sic) [ Q3 2022 ]. You wonder where the limit is here. Everything has a limit. Nothing is infinite. But we expect further growth as long as we continue to put high revenue intensity volume at the top of this funnel. And we'll have capacity to do that in 2023. In a different way, presenting the EBITDA margin for you to see in a very, very clear way, more than double the EBITDA margin from 1Q 2021 to Q3 2022, from 15.3% to 36.4%. In the history of Bumrungrad, I'm not sure if that number 36.4% is not the high-water mark for our company or not. In fact, I'll research that for you when we have our livestream presentation next week. If it's not, it's terribly close to the number. Profitability was up almost 30%, 28.8% Q-over-Q for all of the reasons I just have been mentioning to you and speaking to you about. Again, a similar presentation but different than what I've shown you in the past, showing you a high-water mark Q3 '19. 22.2% was our net profit margin there. This quarter, Q3 2022 is 26.4% (sic) [ 26.2% ]. And on the turnover number at the top, to drive 4 additional percent to the bottom on that proportional turnover number is really a very, very, very strong performance by this company. Profit margin, in the same way as I've shown it earlier but in a different format, so you can see the weakness during COVID at 3.4% profit margin in 1Q 2021 back up to what may be a historical high, too, I'll have to have a look at that, 26.2%. Now we didn't do this through raising prices, we did this to revenue intensity and good cost control. Our other prized asset among 18 different companies that are part of BHPCL was Vitallife. Vitallife now has 2 units operating, one on the campus and one at RAKxa there, both doing very well. If you look at the Vitallife financials, it was up almost 15% on revenue. And you can see the period-over-period performance growth at Vitallife. This scientific wellness center has just been on fire in 2022. As well, look at the EBITDA, up 16.5%, up 258% against Q3 2021, a year ago. And look at the Vitallife fundamentals for the last 3 quarters and as against 3Q '19 where it was THB 178 million, pushing almost THB 0.25 billion on total revenue; and on EBITDA, THB 97 million against THB 60 million in Q3 '19 and a nice jump from Q2 of 16.5% from THB 83 million to THB 97 million. It continues to grow and diversify into a longevity formula that patients are finding very, very informed about and very, very interested in because post-pandemic, we're very, very concerned about wellness and lifespan and health span. And it's attracting a great deal of attention, both domestically and internationally. This is a business that used to be 0.5% of our contribution. It's now pushing 5% of our contribution to the bottom. And we see this particular business growing dramatically over the next 3-year period in a number of different ways: physical expansion, virtual expansion and digital expansion. It has its own website now, and the digital component and the virtual component of this business are future growth opportunities for Vitallife and BH. You've seen them all. You understand what happened in the quarter. We're quite open and available to answer your questions next week during the livestream. With that, thank you very much for your attention and joining us, and we'll see you next week. [Foreign Language]

[Foreign Language] Good morning, everyone. I'm Oraphan Buamuang, Chief Financial Officer. I'm pleased to report to you the financial highlights and financial performance for third quarter 2022. So we'll move to see the financial highlights. As a result of Thailand reopening since 1st of November 2021, both Thai and non-Thai revenue grew substantially year-over-year. The higher contribution of international, medical, tourism, particularly from Indochina and Middle East, have a significant positive impact to revenue intensity. In third quarter this year, financial performance improved when compared to second quarter this year and third quarter 2021 and also above the third quarter 2019, which was peak COVID situation already, as shown in the table. In terms of the profit margin, in this quarter, EBITDA margin and net profit margin were 36.4% and 26.2%, respectively, which are the highest record. I will walk you through in more detail in this later. Financial performance. The consolidated revenue in third quarter this year was THB 5.740 billion, increased from third quarter last year by 92.1% and also above the third quarter 2019 by 20.6%. Year-over-year increase in revenue mainly came from both our non-Thai and Thai patients by 213% and 10%, respectively. When compared to pre-COVID situation, in third quarter 2022, revenue from hospital operation increased by 20.6% from third quarter 2019. This was mostly due to an increase in revenue from non-Thai and Thai patients by 21% and 18.1%, respectively. For the 9 months 2022, total revenue was THB 14.847 billion, also increased from same period last year by 71% and also above revenue 2019 by 7.9%, mostly due to an increase in revenue from Thai patient by 23.6%, while revenue from non-Thai patient recovered to nearly 100% of year 2019 already. In terms of revenue contribution by nationality. In third quarter this year due to an increase in revenue from non-Thai patient and Thai patient by 213% and 10%, respectively, as a result, revenue contribution from Thai patient was 33% while revenue from non-Thai patient was 67% for third quarter this year, which was the same proportion in third quarter 2019. For 9 months 2022, due to an increase revenue from Thai patient by 23.6%. While revenue from non-Thai patient recovered to nearly 100% of year 2019 level. As the result, revenue contribution from Thai patient was 38% whereas revenue from non-Thai patient was 62% for 9 months this year compared with 33% and 67%, respectively, for 9 months 2019. Move to see revenue contribution by service. In third quarter, this year revenue contribution from outpatient services increased to 52% from 47% in third quarter last year due to OPD revenue increased by 107%, while IPD revenue increased by 65%. In 9 months 2022, revenue contribution from outpatients increased to 52% from 47% in 9 months last year as well due to OPD revenue increased by 54% while IPD revenue increased by 47%. When compared to the proportion in year 2019, the proportion between OPD and IPD were coming back to pre-COVID situation. For revenue contribution by payor type, self-pay contribution increased from 65% to 70% in 9 month this year, mostly due to revenue from self-pay patient increased by 86%. The increase came from an increase in international segment. Insurance contribution in 9 months this year declined to 16% from 21% in 9 months last year due to revenue from insurance. In 9 months 2022, revenue increased year-over-year by 31% which is lower than self-pay revenue increase by 86%. The government third-party contribution in 9 months this year slightly increased to 13% from 12% in 9 months last year due to inpatient increase. In terms of the EBITDA, as the result of increased revenue and continued cost containment program, EBITDA in third quarter 2022 was THB 2.090 billion, improved from same period last year by 220% and improved from third quarter 2019 by 33%. EBITDA in 9 month 2022 was THB 4.966 billion, improved from the same period last year by 203% and improved from 9 months 2019 by 14%, with EBITDA margin 33.4%. For EBITDA margin in third quarter this year was 36.4%, which was the highest record. EBITDA margin in 9 month 2022 was 33.4%, which was above the third quarter 2021 and third quarter 2019 at 18.9% and 31.7%, respectively. The net profit of this quarter was THB 1.501 billion, which improved by 407% and 42% from third quarter 2021 and third quarter 2019, respectively. For 9 months 2022, net profit was improved to THB 3.392 billion which improved by 462% and 18.5% from 9 month 2021 and 9 month 2019, respectively. In terms of the net profit margin, in third quarter, this year, net profit margin improved to 26.2% from 9.9% in third quarter last year and from 22.2% in year 2019. And this is the highest record, as I already mentioned. For 9 month 2022, net profit margin improved to 22.8% from 7% in 9 months last year and was above year 2019 at 20.2% (sic) [ 20.8% ]. In terms of leverage ratio, net debt to EBITDA for 9 months 2012 was negative 0.3x due to less net debt after long-term debenture of THB 2.5 billion in December 2021. And net debt to equity in third quarter this year was negative at 0.1x due to less net debt as well. This is all the financial highlights and financial performance of third quarter 2022 and 9 month 2022. Thank you for your attention.

[Foreign Language] Welcome to my presentation today. I would like to update on hospital operations in the third quarter this year. My first slide, I would like to share with you about the performance of our highlights programs. As you can see, we have a big growth from last year. The first one that we are proud to present is TIF. This is anti-reflux procedure. We provide this treatment for patients who do not respond to their medication. This procedure requires advanced technology to help physicians operate with minimally invasive, less pain, less complication and fast recovery. It is a new technique, which we are the first hospital to provide this procedure in Southeast Asia in the past August. On the right-hand side, we call TAVR. TAVR, in the past, we call TAVI. This is a procedure used as an alternative to open-heart surgery in treating severe aortic-valve narrowing, which is commonly found among elderly patients. We grew more than 10x higher than last year, which is almost 30 cases year-to-date. And the price of this procedure is also very high, around THB 2 million. Number three, 3x increase in robotic assisted-surgery volume. This allows doctors to perform many types of complex procedures with small precision. This technology was widely adopted, especially in urology, such as prostate cancer, as it is safer to the patients and preserving sexual function. Pride clinic. We provide holistic treatment from psychological consultation, hormone therapy, which can improve patient well-being up to the surgery. Right now, 14 surgery cases success both in the top surgery, like breast augmentation, breast contour; bottom surgery, like transgender procedure. And last, but not least, is the sleep problems, which happen to more and more people these days due to modernized lifestyles, such as stress, tension, unhealthy food, which leads to obesity. Sleep test is one of our highlight service, serving patients which have sleep apnea and insomnia symptoms. This year, we achieved more than 200 increase in volume from 230 cases to 500 cases yearly. And this is the performance of Bumrungrad Health Network. The revenue from referral slightly decreased compared to last year, while there are some increase in revenue, around 24%, from the COE. And this quarter, we have 2 more COEs in our partner hospital. The first one is Horizon Cancer Center in Nakornthon Hospital, which opened in July. And another one is the Horizon Center in PrincUbon Hospital, which opened in October. This one is the Phuket Domestic Referral Office. We pushed forward in the domestic market with the opening of the Phuket first domestic referral office. This is the first facility located domestically. This office aims to facilitate the patients in Phuket and surrounding provinces, both international and domestic, who want to access Bumrungrad. Moreover, this initiative aims to support Thai government in their goal of being a top Asian medical and wellness destination. This is the Global Healthcare Accreditation Awards, we call it GHA. Vitallife Scientific Wellness Center was accredited by the GHA for excellence in medical travel patient experience awards. We chose GHA certification as it demonstrates to our international patients that we are committed to ensuring the satisfaction and well-being at every contact point along the patient journey to Vitallife. This is another proud [ moment ] of Bumrungrad members. Bumrungrad Hospital was ranked in the top 150 World's Best Smart Hospitals 2023. And this is the third year we're receiving this award. The survey is considered based on how hospitals adopt and utilize advanced technologies such as virtual care, AI, robotics to help deliver better outcome and efficiency. And here is our CSR activities during this quarter. We supported Lumpini Police Station by providing first aid and standard medical supplies. Apart from supporting the government policy for the free vaccination to community for around 67,000 doses, Bumrungrad Building A, on the 10th floor, I think everyone remembered that we provide flawless experience to the public. We also donated Moderna vaccines for more than 55,000 doses to almost 30 public sectors, which included government hospitals. As you can see on the right-hand side, this is the example of donation of 10,000 vaccines to inmates and staff at Bang Kwang Central Prison. As you know, Bumrungrad is competent in treating complex, critical and high-intensity cases by using cutting-edge technology. So we stay focused on our 5 centers of excellence, which are heart institute, oncology center, neurology center, gastrointestinal and colorectal centers and, lastly, comprehensive eye center. We just launched cornea transplant center in our comprehensive eye center. These centers provide full subspecialty of expertise, evidence-based practice, research and development, which are well accepted by patients worldwide. That's all for me.

And that concludes the third quarter 2022 analyst presentation. See you next year in February for the fourth quarter and full year results. [Foreign Language]