Narayana Hrudayalaya Limited (NH) Earnings Call Transcript & Summary

Sure. Damayanti, I can take that. So I guess you're talking about integrated care business. The insurance business has not been kicked off. We expect -- we're just in the kind of final stages of putting -- finalizing the product as well as the systems and everything else, and we expect to go live next quarter with the insurance business. In terms of integrated care business, which is the one that we're piloting, that's going well. We've got 7 clinics in Bangalore at the moment growing as per our plan. We will add several more clinics in Bangalore this year. And then integrate the offerings with the clinic and insurance once the insurance business goes live.

Sure. And my last question is, did you mention in your opening remarks that you are looking at some newer markets where you are not present and if so which market or regions you are focusing apart from your existing markets?

No new markets as of this point. We are only in the Caribbean looking at anything that may come inorganically in certain markets. But at this point, it's still exploratory. In India, where our focus is on our core geographies.

Gagan, please go ahead.

So the first question is around the funding of the CapEx. I think all put together, it's a figure north of INR 1,600 crores that you budgeted for the coming year. How do you plan to fund it? I mean, debt equity mix?

Around 20% will be internal accruals and around 80% we'll fund through debt.

So gross debt, where does it stand currently? And where do you see that going ahead in the next year?

Currently, we are -- go ahead, Nishant.

Yes, the gross debt currently, India plus Cayman put together will be around INR 1,400 crores. With the borrowing plans, which we have out of that INR 1,500 crores, we'll borrow, say, another INR 1,200 crores. So the gross debt we'll see be around INR 2,400 crores, if we do borrow all we plan to borrow. And the cash in hand will also be roughly, say, half of it. So the net debt, in the worst case, if we were to do all the expansion projects with all the debt we have planned for, will be around, say INR 1,200 crores for the group.

I'm just wondering, in the last 2 years, you had operating cash flows of INR 1,000 crores each, right? If I go by the numbers reported in Q4 of this year for the balance sheet and you have cash on book. So I would have thought that it would have been possible to fund a higher share of this CapEx through internal accruals than what you are indicating. So I just wanted your thoughts there.

Conservative indication we have given, Gagan. Obviously, we will logically first use cash accruals and then we will go to debt, but this is more a conservative estimate. Let's assume we find a good use for the cash we are able to deploy, so therefore, we have just taken a view which is the max we could borrow.

Also, Gagan, a lot of the cash is parked in Cayman Islands. So bringing that cash to India for an Indian expansion is not a good strategy because we have to pay taxes. And we are still exploring opportunities to invest the Cayman money outside of India. So that's a big reason why we're not able to spend that cash.

But if I got it correctly from your presentation, a large part of the CapEx that you have for next year is for Cayman. Is it not?

Not for next year. See, if we look at the next year plans, we have only INR 270 crores for Cayman, the rest all of that is towards India expansion. But even that INR 270 crores is outside of -- if we do come across some good opportunities outside of India, then we'll probably spend more from the Cayman money.

Because I mean -- if I look at your presentation Slide 16, FY '25 projected. Perhaps I'm confusing the colors, INR 10,450 million is it for Cayman? Or is it for greenfield? Organic.

It is for greenfield organic.

And in the last 2 years, you've done a fair amount of CapEx, right, INR 1,000 crores each in '23 and '24. And while this would not have been for bed addition you've been consistently pointing out that this is meant to increase throughput. So I can understand that Rajarhat and Bangalore, they get commissioned a while away from now. But over the next 3 years, with whatever CapEx, it's almost INR 2,000 crores of CapEx that you've done in the last 2 years, what headroom for growth does that give you? It would help you could enumerate in growth band. I can understand a specific number guidance is not possible. But if you could enumerate to some degree of -- in growth band, perhaps what potential for growth is there over the next 2, 3 years?

Yes, Anesh. Go ahead.

No, I didn't say anything.

No, actually, he started it. So I'm just saying that, see, we will not be able to give you a clear cut guidance on that, but we have been able to grow meaningfully within our existing capacity, and we will continue to do it until this expanded capacity kicks in and give you through a combination of all our throughput increase, improvement in payer mix, technology guided through digital initiatives. In the meantime, we've also added 2 floors in our Howrah unit with 5 OTs, wards, ICU beds. We also added LINAC in Shimoga, we plan to add LINAC in Ahmedabad. We keep doing these smaller additions as and when, and as and where it's feasible until the major expansions kick in. This is apart from our efficiency drive to create capacity. And with this, we will be confident of our growth year-on-year until these expansions materialize and we have actually demonstrated this in the last 2 years, and we are confident of repeating the same in the next 2 until we build up on the capacity and it starts materializing.

Sir, is it possible to...

Sorry, Gagan, just one second to clarify.

Significant chunk of the CapEx over the last 2 years also went into Cayman. So about -- that also you'll have to adjust. $70 million, $75 million has gone into Cayman in that CapEx number.

That's greenfield capacity with the headroom for growth for filling out all the departments that we don't have in our grade A location to ensure that in Cayman, we'll continue delivering strong performance. See, the reason we prioritized a lot of investment in throughput and capacity increase and things that are not necessarily adding beds is because greenfield capacity in adding new beds, one takes a very long time to break even and even longer time to generate a return on that capital. The most immediate and best use of the capital that we have is in the existing hospitals, and that's why FY '22, FY '21, FY '20, all the money that we spent was on improving the performance of our existing hospitals, which turned quite a lot of them around and made them into quite profitable entities. So we -- there is a diminishing returns aspect to that, which is why now you're seeing us deploy a fairly large amount of money towards greenfield, while keeping some amount of money still towards the existing hospitals and refurbishing the rooms and taking it up, to do a balance between both. Now if you have -- we have kind of a focus on ROC and trying to generate healthy returns, but that's not the only thing. The doctors, the patients, they don't care about our ROC. They care about being seen by the doctor on time. So for us, it won't be one or the other. There are times in which we want to do greenfield expansion. That time is now, and there are times in which we take a step back and try and consolidate, which was the story of the past 8 years.

Fair point. I mean I understand that. I'm just sort of trying to perhaps thrashing around a bit blindly here, but are we looking at a phase of perhaps high single-digit sort of growth and then you kick into double-digit when the new beds come in? Is that how one could broadly think of?

It's not fair for us to guide a number, Gagan. You have to...

You make us very sad if that were the case. We try not -- for that not to be the case.

All right. And from a tax rate perspective, this was a year where the tax rate was subdued. Q4 was higher than the balance 3 quarters of the year. Going ahead, what are we looking at in terms of tax rate?

Yes. So actually, this year, if you see Gagan for NH India, not just about NHL, but on a portfolio of NH India, we would have -- we've finished the tax at about 15.5%. That's because we had the deferred tax credit, which we got benefit given that we moved from the old rate to the new rate and, therefore, there was a reversal that came on the tax line. So that onetime benefit is gone now. So next year, the India business, which is the main business plus the subsidiaries, the average tax rate will be about 26%. And Cayman business will come at 0 tax and the average of that will be our tax rate for next year.

Are we looking at perhaps higher growth in Cayman starting second half of this year once you commission the new hospital at Cayman? And are we therefore over the next 2, 3 years, seeing an increased salience or share of Cayman, in both revenue and profits?

So definitely, once we commission the new hospital, we will see an expected amount of growth in revenue. But as we have said -- mentioned before, commissioning a new hospital brings online a very large amount of fixed cost. So there will be a very real amount of margin dilution until that hospital is able to breakeven over the next few quarters. And then we'll see where we end up on a long-term sustainable basis. So there will be revenue growth, but there will certainly be margin dilution because a big chunk of fixed cost will be coming online. And in fact, it already has started as we speak right now because we are very close to commissioning now also.

I mean for analysts, is it reasonable to assume that if the bed capacity, the new hospital is proportionate, in a certain way, to the old hospital, so would the OpEx stick or would it be a wrong surmise?

No, that wouldn't be very accurate. So certain costs, which are just related to the size of the building would be pretty identical on a per square foot basis, but the building is staffed very differently when the building is operationally very different. So that wouldn't be an acute extrapolation.

Yes, [ Praveen. ] Can we have your question, please?

So I don't have any comments on your numbers, but I have a feedback to provide to the management. Please tell me if I should go ahead and do that.

Go ahead.

Yes, sure. So the thing is that recently, I had to reach out to Narayana Hrudayalaya, Bangalore facility, okay? And I had to reach out to this cardiology department. I somehow felt a little demotivated when I went for -- when I took my parents for the appointments, okay? I observed a couple of things, which I want to bring to your notice because. Look, I'm the owner of this business and I want my business to be growing and serving more and more people efficiently in a peaceful way, at least from the patient perspective. So what happened was, I reached out to cardiologist and he asked us to do echo, ECG, some of the normal things. And then by the time I came back, it took me almost 3 and 4 hours, okay? And the person who manages the appointments to the doctor, right, she said, doctor is in OT, you can't meet him today, okay. And then I went to reception and then complained about this thing. Madam, we waited for this many hours, please at least give us some supporting doctor so that we can show our documents, and we can leave the premises with a peace of mind, okay, if there are no issues. And then I was connected to some junior doctors, okay? And then junior doctor came into the picture and he started looking at our documents and then he was a little confused there, and he couldn't...

[ Praveen, ] sorry to interrupt. What -- you have our e-mail address and our contact details and we're really sorry for the experience you've had. I would just, to respect everyone else's time. We can address the service complaints on a separate thing, okay, but I truly sorry for the experience you've had. If there is any shareholder-related question?

Right. So I don't have it then. I'll roll back and I'll send out a mail there.

[ Dipankar, ] can we have your question, please?

Sir, I just wanted to know if the surgical procedures that are offered in Cayman and the hospital services, are they reimbursable by insurance companies in the U.S.?

Yes. Thank you for your question. So most insurance companies in the U.S. will reimburse for overseas care. So there are 2 principal ways this happens. If you're a holder of a U.S. insurance policy and you have an emergency while traveling, almost all of them will reimburse. Electively, most of them will reimburse if somebody chooses to come. Most of the large insurers will because the rate that they would reimburse that is much lower than what they would pay. But it depends on which insurance, et cetera.

We'll wait for the other hands to come up. I'll answer some questions that came in the chat. One was about, what is a better indicator of hospitals, ARPP or ARPOB? Why? Just for those who are not familiar, ARPP is average revenue per patient. Average revenue per occupied bed is ARPOB. Since we've focused a lot on looking at the throughput and the utilization of our existing beds, what will happen is that we realize that ARPOB is an instrument that you can use to really manipulate numbers in a strong way. And so it doesn't give you a true picture of what your realization per patient would look like both in an outpatient and inpatient basis. The other is that the medical field keeps changing. Things that require discharge over a couple of hours, things that require overnight admission are all moving to day care procedures. So they are physically occupying the bed for most of the day, but they don't count as an inpatient, they aren't reimbursed by the insurance company as inpatient stays, done as day care. So in reflection of the way in which the entire field is moving, we decided to move towards ARPP model, which gives a more moderated less prone to manipulation way of thinking about what your realization per patient looks like. Not to say that one is better than the other. I think that gives a better reflection of the state of our business and it gives you a more fair and honest assessment of how we are doing as a company when it comes to being able to price our services. There are 2 more questions in the chat about how our services are differentiated from its peers and how do we price our surgeries to the customers? Dr. Rupert will respond to that.

Yes. So the Narayana services, how is it differentiated from the peers is in the geographies where we serve. We do give our patients and our customers, the cutting-edge work irrespective of what is the paying capacity and what is the class. For example, we -- in the 2 centers where we have the robotic knee replacement procedures, we have converted 100% of our procedures into robotics. And we are one of the highest use of robotic work for noncancer surgeries as well. The numbers are very high. So we do differentiate quite a bit on the peers and we do monitor the outcomes and other things in a much more stringent way and keep a very close watch on the outcomes and the way we go about with that. So from that point of view, it is a value for money for the patient because we get the best of the class and the outcomes as well as the cutting-edge work, and that is what we've been doing. As far as the pricing goes, wherever it is, predictable clinical pathways, we prefer to have package the procedure so that the patient knows there is a predictable amount that they know that they have to pay. But for the things where it's a little unpredictable, that's only where we go for the open billing kind of a system, and that is where we work towards. Overall, from a price perspective, it is lower than what our competitors would be doing and mainly because 80% to 90% of the procedures are all very predictable. So the patients also know exactly how much they need to pay as well.

Rajat, you have the hand up. We'll take your question, then I'll go back to the chat questions.

I had a couple of questions on the chat as well, so probably you could skip those. The first question is related again to the number of beds. While you shared the number of beds being added in Cayman, is it possible for you to share a minimum number of beds that are getting operationalized in this financial year in India?

None this financial year.

And the second question is related to the 2 subsidiaries, Medha and Samyat, are these being set up for captive purposes? Or is there a larger vision for them?

For Medha, yes, we will be commercializing our analytics engine. Samyat is for captive purposes.

Okay. And Medha will -- I mean, any guidance or any thoughts on how will this ramp up in the next couple of years?

This is our health care analytics arm and they have quite a few interesting AI applications that we are using. We have quite a few paying customers as well, but the amounts are very small, and nothing significant enough at this stage in time. But it is something we have an aspiration to build out because we do have very strong digital services and analytics capabilities and a lot of hospitals have expressed an interest in using these, both in India as well as overseas. So when there's more to show in this, then we'll start putting that out separately. But as of now, it is just something we wanted to highlight. So there's a question on INR 1,000 crores CapEx earmarked for 1,000 beds in Calcutta only include the land cost of INR 170 crores -- INR 180 crores, is that for building machine equipment. Don't go by the INR 1,000 crores CapEx or the 1,000 beds in Calcutta. That was more of a, let's say, aspirational statement. The cost of the land was about INR 180 crores. That was the cost that we'd have to pay to West Bengal government. We're still finalizing the contractors and the price over there. Once we have a better sense of how much the final cost will be, we will put it out. But what we have projected is how much we know we will be spending in this year for a combination of buying land and putting up the foundation and so on. But it's not specifically broken up into how much for Calcutta, how much for Bangalore. There's a question about the economies of outpatient, SBU and inpatient SBU?

Outpatient is -- first of all, we don't break out our numbers into outpatient and inpatient. Within outpatient, you have daycare and OPD. On OPD, a significant chunk of the fees goes to the doctors. Daycare is similar to IPD, depending on the cost -- recover. And inpatient is all our costs plus our margin. So it works in that typical range. We are not giving that breakup on what is the margin of each of these SBUs, but you can work that out, that's industry knowledge.

Next question on the chat. Reason for the rise in other noncurrent assets going from INR 89 crores to INR 350 crores?

That is because we are doing a lot of capital projects, and we have -- there are various capital advances we have given for those projects. So that gets grouped as noncurrent assets, so that's why you are seeing that.

Next question. There was -- last quarter, we talked about wage inflation, but they see that employee cost had dropped in the current quarter.

Employee costs have -- see, actually, this quarter, we have been able to manage some efficiencies in the employee cost because we have been able to add revenue without adding people, but that will not continue because our increments have kicked in from 1st April. And also, we have caught up on the employee backlog in terms of hiring, so therefore, you will see an increase in the employee costs going into the next quarter.

So another question on margin levers to leverage to improve the bottom line before the volume increase kicks in from a new hospital? That there are many, but it is more of the same, which is discharging people faster, admitting them sooner, making sure they check out, rather they get discharged from the hospital at 12:00, and we get patients who get admitted at 1:00. These are a lot of system-driven and a lot of digitizations involved. We've had a lot of savings from moving towards paper. We are doing a lot more things paperless and moving to kiosk for admission, that should improve the throughput a fair bit. It may not have that much of a swing as compared to pure volume increase would, but it does provide a very differentiated experience for patients, given that we're dealing with large volumes of them, and our pricing is not at a premium. And so if we are able to reduce the waiting time and improve the convenience most of the time, we believe that we'll be able to improve the bottom line a little bit, not a lot. There was a question on the insurance-related costs in the P&L.

That's already answered.

Okay. That's been answered. The current CapEx plan we conducted versus current built up space. See the current built up space, just the Health City in Bangalore will be around 9 lakh square feet; in Calcutta, it will be around 5 to 6 lakh square feet; Delhi, another 6 lakh square feet; Bombay, 2 lakh square feet; Raipur, 2.5; Jaipur, 2. So it does add up to a fair bit. I would say that the number of square feet of space we plan to add eventually would be in the short term, about half of our current built up area. That's what we aim for. Now we don't have all of them in the pipeline yet. That's what we're looking to add, but it won't correspond necessarily to the same number of beds as before because the users of space in these new setups is very different from what it was in the past. Prior, we never had much day care work. We had a lot of space dedicated for inpatient beds, but now we're doing a lot more procedure rooms. And so the actual bed count would not be significant. There is a question on the occupancy numbers for Bangalore and Calcutta, if Venkatesh could share the rough occupancy percentages.

Viren, somebody else has their hand up.

Occupancy levels are stable at 60% plus at the group levels, flagships have higher occupancies. This occupancies may obviously vary between hospitals, but the flagships are obviously higher than this average occupancy. But again, as Viren said, we continue to reiterate that this is not necessarily the right measure given that our day care volume has gone up significantly, and we are doing more and more work in day care fashion. So obviously, the occupancy numbers may look very artificially low, though so much of our work is actually happening. We do largest number of cardiac procedures in the country. Cardiology procedures like angiogram and angioplasties are like morning-evening discharges. Robotic procedures are morning-evening discharges. So this means that the bed is occupied during the day, but at the midnight, it shows vacant. And that's why it should -- looks artificially low. But then we are more -- working more on throughput to -- through technology-driven initiatives to create more capacity and do more with what we have.

The bottlenecks that we talk about, and that's part of the question as well. We're bottlenecked in our OPD areas. We're bottlenecked in our billing counters, in the parking space, in the number of doctors chambers, in our operating theaters, in the cath labs, in the ICU and the emergency rooms. Those are places we have the most amount of the bottleneck. And so we have -- a lot of our infrastructure is built for a time when most work was long stay inpatient work. So we probably have too much space dedicated for that and we're trying to change the layout so that we're able to cater to a lot more very fast volume in and out. And so that's what you're seeing the bottlenecking show up. It won't necessarily translate to occupancy, but it does translate to the service experience and our ability to see more patients in the same space. Anyone else? Rajat, you still have your hand up?

Viren, there's a question on this. How do you read the Supreme Court observations on standardizing the cost procedures?

So the -- this was a stray comment made by a judge that, "Look and see if the Clinical Establishments Act has actually been implemented in all the states. Otherwise, we will force you to implement the CGHS rate or some rate." Now it was -- if you actually read it, it's taken as more of a threat. What has happened since then is that the government has spoken to all the stakeholders, all the state health ministers and a lot of industry associations have gotten together and spoken about how it is impractical to come up to a common pricing standard as the petitioners in this case, certain public health activist had brought about. It doesn't make sense for a country like India for the richest person in the country and the poorest person in the country to pay the same price. Then they're both getting -- the rich person should pay more for the service they're getting and the poor person should pay less. When you go to standardized pricing, that does not happen. And so the observations haven't been made. We're trying to work with them to say that the spirit of what they want, which is being able to provide different price points, being able to provide more clear and transparent billing is something all organized hospitals do. Certain hospitals that are in unorganized sector are not able to do it as well, but more transparency is required. So nothing that we're overall concerned of. Outside of the larger concern that health care is this massive societal issue. There is a very large private sector that is catering to it. And we need to be very cognizant about being able to meet patient needs and expectations at all price points. There's one more question on the chat. Our daycare procedure revenues captured in outpatient or inpatient revenues for domestic business?

Outpatient at the moment.

But starting from next year, I think we should start splitting up daycare separately, which from FY '25, Q1, we'll start doing that way. So it will give you a much clearer picture. Any other questions?

If there are no more of questions, we'd like to -- Gagan yes.

You indicated occupancy at around 60% and, obviously, it's a blend of higher occupancies in your mainstay hospitals and so on. But where is the theoretical limit of occupancy on the current capacity from 60%?

Maybe we've seen the highest occupancy in our hospitals, hover around 75%, 78%. That is -- but again, it's pretty much a moving target. Real numbers that we're trying to go after is having more people, more inpatients, more outpatients, more day care procedures for all the square footage of space that we have built up. The occupancy itself assumes a stagnant book of business like a hotel. In a hotel, there's only so much you can do spending on a per night basis. Whereas for us, we have a range of services that can be provided in our infrastructure.

I understand what you're saying. It's sort of difficult for us to distill it down to some numerical, I get what you're trying to say. On margins, I mean, what I can surmise is that in India, as Delhi, Dharamshila and Mumbai improve. And also you draw further cost efficiencies. There's perhaps some scope for margin improvement to a degree, it may be offset by the new hospital in Cayman coming on board. Therefore, on a blended basis, are we looking at a future where you can maintain the exit margins of FY '24? Is that a reasonable surmise?

So in the short term Cayman will be diluted, Gagan. I don't think India will be able to step up to offset the dilution that will come. But in the medium term, Cayman will catch up once the capacity start filling up. So that is one aspect. The second aspect is that, as you know, we don't pass on the complete cost inflationary -- cost inflation to price. And therefore, we absorb a lot of our cost inflation within our efficiencies. So therefore, all our efficiency and scale doesn't flow through into margins. Some of it goes into offsetting the cost escalations that we see. And we have seen a very high impact of inflation across all the lines, whether it is manpower, whether it is consumption, CapEx. So because of that, it's difficult to say that the -- even with the benefits that we are foreseeing from improved throughputs and improved performance of some of our non-flagship hospitals. Some of them can flow through to the bottom line, but a lot of it will go to offset the cost structures -- cost increases that we are seeing. So it will be a mixed bag for at least the near term. In the medium term, I think we'll be able to bring it back.

Right. When you say medium term, is it possible to enumerate that? Again, broadband and not...

18 months to 24 months' time period.

Yes, Parikshit?

I'm really appreciating the management's effort to educate us how it is -- your strategy is about being outpatient and you're delivering more value through that. But my issue is that even with the outpatient numbers, if you look on year-on-year for this quarter, you have not grown by much, right? That has also been about 6% and 7%. So question one is that, do you guys have any way of quantifying outpatient capacity? If so, that would be lovely to hear. And two is that, why the outpatient hasn't grown more than 6% in that case?

Outpatient capacity, so all we can say is that in the space that is dedicated to them, they are bottlenecked and there are only so many hours in a day. So our doctors are not able to put in more hours. Now with a simple fact is we need more doctors, but we need more doctors. They're not all going to sit in the same place because there's no space. There's no parking. There's no waiting area. There are not enough billing counters there. And so we create an entire new subsidiary around building clinics and outpatient centers all over the city, starting in Bangalore, then we move to Calcutta and all the other places. So those are things we would have to do to increase the outpatient numbers. Those are essentially the 2 things. So in terms of what is the theoretical maximum outpatients we can see in any hospital. That would just be a function of 20 minutes per consultation multiplied by the number of hours in a day patients will keep coming. But again, it's a moving target because we are adding more outpatient chambers and more spaces in the existing hospitals. So we are trying to address this both ways by adding infra as well as doing more efficiencies.

Our annualized revenue growth on outpatient is about 14%. And a lot of it is a day care. And so while there are 2 aspects to the volume, one is the count and another is the value of services that we are able to flow through. So because we are debottlenecking capacity across, we are able to move through high-value services through daycare. And that's also helping us, for example, a lot of procedures we are able to do morning, evening and discharge the patient before end of the day. So that also helps us deliver better throughput.

I understand. So did I hear it correctly in terms of your plans to increase your outpatient and day care capacity was to set up smaller clinics around Bangalore and other regions? Did I understand that correctly?

Yes.

So this is not part of your CapEx plans that we have discussed so far, the 8 lakhs and 10 lakhs, where you're doing massive land acquisition and creating hospitals? This is a different plan?

This is the entity called as NHIC, Narayana Hrudayalaya Integrated Care. So this is -- the CapEx isn't much. Each clinic is only between INR 1 crore to INR 2 crores, and we're putting about 20 to 30 clinics per year. So it's not a huge investment. Back to the questions in the chat. Is there any margin cap on the pharmacy? There isn't a margin cap on the medicines. Certain payers, I believe certain state governments, for example, will cap it at the price at which you are able to procure the medicine. Most of the medicines are actually capped on the MRP. So either they come under DPCO, that's the Drug Price Control or the payer themselves will decide that, I will pay this fixed amount. It doesn't matter what sort of medicine you use. So a margin cap system of any consumers or medicine does not exist in India like it does in other geographies. What is the impact we see on the revenue per patient? The DPCO and when every time the price capping happens on medicines, the impact is mostly on medical admissions. So these are patients who come into the ICU and get medical care or for item like chemotherapy or so on, that definitely does see an impact on revenue per patient. The next question is, how do negotiations with insurance companies change for medical packages and nonmedical packages? So insurance companies are obviously very hard negotiators. They will negotiate in fixed rate packages for knee replacement for a lot of these, but medical packages, it's very hard to quantify how much on the medicine side. So those are usually paid on actuals, whereas surgeries are paid on a fixed basis, so angioplasty or knee replacements are on a fixed rate. There's a question on the cash accrual in Cayman. Are there plans to bring it back? And what is the status of opportunities to deploy cash? I think we answered this a little earlier. Right now we're trying to find overseas opportunities. In the absence of that, we will definitely bring it back to India. But to do so involves a 20-odd percent hit that we would take. So that would be, I would say, the last possible opportunity. But definitely, there are places to deploy in India. There's a lot of opportunity here as well as abroad. So we want to build a diversified revenue base. And so that's why we're trying so hard to try and find something overseas. There's a question on the insurance business. Can you give a road map on the insurance business in terms of breakeven, long-term plans of hiring it off as a separate arm listing, et cetera. I'll just say, I mean, it's too early for us to declare on the breakeven time frame. The long-term plan is that, yes, it is a separate company by design insurance company, the IRDA norms say that it has to be listed as a separate entity and so on. There's no time limit per se, but it is something that is on the eventual road map. So the insurance is something we are very bullish on. We are billing it to be a very differentiated sort of product, and we'll have more to tell you about this in the coming quarters. Ravi, any -- have we given any projection on how much we spent on the insurance company in this quarter?

No, we've not. I mean the main thing is, of course, the IRDA capital of INR 100 crores, which has been infused into the company.

Yes. So we won't be able to give guidance on the cash flow and so on because we are yet to start the insurance operations, but it will not be as big as the amount that we'd be otherwise spending if we set up 400, 500 bed hospitals. So it's quite moderated since we're starting in just 1 city. Based on the response we get in Bangalore and Mysore then we look to ramp it up. That is a call we will take at the future point. Last question, I guess, on the chat. Any plans on the growth in your ancillary services? If by ancillary services, I would guess, it means all the subsidiaries that we have. So Samyat is an in-house distribution now. So that will mostly be catering to our in-house programs with our Athma and Medha. There -- again, these were set up as in-house units, but they're offering services to other hospitals, clinics, nursing homes and so on. But the revenue potential there at the short term is very limited. So it's nothing much to write about at this stage. Other than that, NHIC and NHIL are still very nascent businesses that we're incubating. And over time, they will start showing the numbers. But whatever they've done so far has given us a lot of confidence that this is a business worth investing in.

Yes. So I think we don't have any more questions neither in the chat nor in this forum. So with that, we'd like to conclude our session. Thanks, everyone, for the active participation as usual. In case if you have any further questions, please feel free to reach out to us. Thank you.