'Insurer Offers Option for Surgery in India'

It has finally begun.

A story in the New York Times last month, captioned 'Insurer  Offers Option for Surgery in India' caught my eye. Rewind to the summer of 2006, when I was in New  York trying to convince some of the leading health insurers to consider developing a  new low premium health insurance product for the huge numbers of uninsured in the US. Everybody I met heard me out patiently but was not willing to take the plunge. I tried hard but success eluded me. Some of my colleagues consoled me by saying that maybe I am ahead of the times.

Now it seems they were right. The New York Times report says that 'the health insurer Wellpoint is testing a new program that gives covered patients the option of going to India for elective surgery, with no out of pocket medical costs and free travel for both the patient and a companion'.  

This is exactly what I had in mind two years ago. The product logic is unbeatable. With close to 50 million individuals in the US either under or uninsured, a insurance cover, which covers for surgery/treatments in the best Indian hospitals is a wonderful opportunity for at least those who cannot access similar quality healthcare in the US. The product works for everyone. The insurer gets to tap into the a market segment, which could not afford its services so far, the patient gets a great shot at getting well and the Indian hospital the opportunity to expand its business.

The price differentials between a surgery/procedure in India and the same in the US are so compelling that even if one was to throw in air tickets for the patient and a companion and a week long post hospitalisation stay, enough money would be left over for everyone to be happy.The same report quotes Deloitte Centre for Health Solutions a consultancy saying that by the year 2010 6 mn Americans will be travelling abroad annually  seeking medical care. 

The downside, the low cost insurance product with a fulfilment option in India may lead to cannabalisation with people who could afford more expensive plans may also choose to go in for a cheaper product. I believe this fear is ill founded as only the desperate, would choose to travel half way across the world to a strange country to undergo complex surgery. In times of a medical crisis it is human nature to try to be as close as possible to ones loved ones. This product will appeal to only those who can not afford health insurance in the US.

For Indian hospitals, this may turn out to be a great beginning. The present trickle of patients can become a deluge if they handle this right. They need to improve the quality of care, raise the bar further, go in for international accreditations and roll out the proverbial red carpet. Maybe, the time has come to open facilitation centres in the US, where potential patients can interact face to face with hospital personnel, access information, connect with their surgeons over a video link and than make up their mind.

With its path breaking product Wellpoint has taken a gigantic leap and if this succeeds, I am sure other big insurers will also jump in. For the nascent Medical Travel industry, this is indeed a huge milestone.

'Insurer Offers Option for Surgery In India', New York Times/Nov 21 2008 Byline Roni Caryn Rabin

Our Attitude Towards Mental Health

Mental Illness in many societies across the globe including India is considered to be the  wrath of God, a punishment for past sins and people with these problems are often  shunned. Psychiatrists, are also often looked upon as 'emotionally unstable' characters lost  in their own worlds. The practice of Psychiatry is considered to be 'unscientific', 'imprecise'  and 'ineffective'. A study published in the Indian Journal of Community Medicine last year  titled 'Beliefs and Attitudes towards Mental Health among Medical Professionals in Delhi' revealed some of these and other sorry facts.

The study was conducted in 3 medical teaching institutions in Delhi and had a sample size of 76 doctors working in these institutions. A questionnaire was used to gather information about their attitude towards mental illness, knowledge about the causes of mental ailments and the treatment modalities.  

24% doctors believed that being in contact with mentally ill people may result in they behaving in an odd manner and 25% respondents said that they felt 'sorry' for a mentally sick person. 63% respondents felt that mental illnesses were solely caused by unfavourable social circumstances, while 18% attributed mental illness to 'poor diet' and 'loss of semen' (1.3%). 8% considered mental illness to be untreatable, while another 8% believed that psychiatric treatment to be more 'disabling' than the illness itself.  

One obvious question that springs to mind is that if this is how educated medical professionals in a metropolis like Delhi feel about mental illness, than what would be the attitude of the society at large towards those afflicted by mental illnesses. No wonder in smaller towns and in less educated societies mentally ill are routinely ostracised, treated with derision and remain uncared for. The disease is kept under wraps as the stigma attached with mental illness is often too much for a family to bear. Some people resort to unscientific hocus pocus, tantrik cures and the like, which make matters a lot worse. Very few patients actually get to see a qualified psychiatrist and get proper care and treatment.

It is strange but large well established private hospitals (the kinds that I have been working in) do not admit patients with mental illnesses. They claim that they lack the specialised facilities required to treat such patients. However, now that I reflect on this I do wonder whether these hospitals too suffer from the same prejudices that we see in the medical professionals and society at large. While, most of them do have psychiatrists on board, they do not allow them to admit patients. About a year ago, I had a relative coming from another city who suffered from acute depression and needed admission. I turned to Dr. Samir Parikh a friend and a well known psychiatrist for help. We were at our wits end to find a good hospital, which would accept the patient. The ones Samir recommended looked woefully inadequate to me and he was just not allowed to admit patients at Max Hospitals, where he worked.

I have worked closely with Dr. Parikh, who is a young high energy individual, very passionate about his calling and none the worse for seeing close to 50 patients a day. He believes that psychiatry is as much a valid medical discipline as any other, involves treating patients with medicine and counselling. Like any other discipline some of the afflictions are incurable, some require long term continuing treatment and many are prefectly curable. He also believes that with our fast paced lives, the endless quest for 'success' and little time for self, mental illnesses are only increasing. There is an acute paucity of trained medical professionals and facilities and unfortunately not too many medical students are still willing to opt for Psychiatry as a discipline.

This is sad, as society gradually moves towards accepting mental illness as a medical problem and seeks a cure for it, we just do not have enough doctors and hospitals to go around. 

Ref: Indian Journal of Community Medicine/Volume 32/Issue 3/Year 2007, 'Beliefs and Attitudes towards Mental Health among Medical Professionals in Delhi' authors Dr. Jugal Kishore, Dr. Radhika Mukherjee, Dr. Mamta Parashar, Dr. RC Jiloha, and Dr. GK Ingle, Department of Community Medicine and Department of Psychiatry, GB Pant Hospital, Maulana Azad Medical College, New Delhi, India.

The Preventive Healthcare Conundrum

It really takes a lot to understand the truth in the old adage that Prevention is better than Cure.

Marketing of Preventive Healthcare Programs in hospitals is a tough call. While one would expect consumers to grasp the importance of Prevention and thus the need for regular health checks, in my experience as a healthcare marketer in India, this is one of the most difficult products to sell.

Hospitals have spent money by the bucketful to understand the underlying consumer psyche and device products, which the consumers may find meaningful, but rarely have they succeeded in attracting customers for Preventive Programs. They have resorted to gimmicks like the Max Platinum Healthcare Program, but nothing really seems to be working.    

Some of the reasons cited in consumer research for such apathy towards a product, which after all can help save a life are quite eye-opening.

Many of us believe that we are quite healthy and serious illness will not affect us at least in the near future. That we have no symptoms of any disease automatically means good health, is a dangerous proposition. However, we the consumers of healthcare do not think so. Our faith in our own well being is tremendous. Thus in true ostrich fashion, what we do not see does not exist.

Another reason, which is cited for avoiding going for an annual health check is the often heard 'I am far too busy'. The daily chores and routines of our increasingly busy lives make us take our own good health for granted. Ironically, we always find time to take the car for a wash and the routine service always happens on time!

Many of us are terrified of hospitals and hate to visit it unless compelled by circumstances to do so. Since a Preventive Health Check is hardly a compelling medical condition we avoid getting it done. There is also a belief that the doctors and the huge machines in these hospitals always conspire to find something or the other wrong with us. Their sole aim is to find something to scare us with and lighten our pockets by more extravagant testing (CT's, MRI's, PET CT's the works). 

Their are others, who believe that these programs rarely detect anything. These are hypochondriacs, who keep looking at the reports hoping to find something amiss and can not help but feel a tad disappointed when the doctors give them a clean chit. They believe that a clean bill of health from their doctors is really such a sorry waste of their hard earned money and time.

Somehow, the truth that these programs are a set of tests designed to detect commonly occuring ailments before they really happen, just does not register. Healthcare Marketers have tried advertising, direct mailers, reminders on sms, promotions et al but we are just not convinced. Healthcare communication has been designed to appeal to us, our spouses (Give the gift of good health, this karva chauth!), our parents (wish your son a long life!) and even our children. (Mom's health is the most important and the least cared for in the family). Nothing works.

Can someone help me understand this conundrum better?

Doctors and Grassroots Marketing Initiatives

During my many years as a healthcare services marketer, my biggest challenge has been to  involve doctors in the marketing of their service lines. I have tried to think through this.  How can I possibly have a greater and an in depth involvement of doctors in the marketing  of a program. It seems that many are just not interested and consider getting involved in  something as prosaic as grassroots level marketing beneath their dignity as doctors.

Frankly, as a marketer I would hate to start a marketing program, without a complete buy in from the doctors concerned. That unfortunately happens rarely. I recall my efforts at starting a relationship program for individuals with a high risk of cardiac diseases as well as those, who are currently under medication for the treatment of heart disease.    

The marketing team was excited at the idea, a name for the program was identified, a logo was soon developed, marketing collateral were organised, program protocols including enrolments and services outlines were prepared, the front office teams were trained in enrolment and service protocals, separate phone lines were installed and the advertising was developed to launch the program.

The program could still never see the light of the day because we failed to convince the cardiologists and the cardiac surgeons that it made sense to try this out. In meetings after meetings we were told that this has not been tried before, going directly to a set of identified customers with a value proposition like this is just being too adventurous, and we may end up with people being offended by as direct an approach as this.

The subtext was also this that many of those enrolled in the program might be high risk but are hardly patients for the moment and seeing them in a hospital OPD is a waste of time for a cardiologist. My view as a marketer simply was that the exercise helps build a relationship with a potential patient and it is certainly better than sitting in an idle OPD waiting for the real patients to show up. 

Since the success of the program depended so critically on the complete buy in of the cardiologists, we decided to shelve the program. 

Another program involved establishing clinics in well to do condos, which surrounded our hospital in Gurgaon near New Delhi. The idea was again to build a relationship with the the local communities and be their first port of call in a medical need. The Marketing team engaged with the leaders of these communities, mostly retired and elderly folks, who gladly allowed to set up our clinics in their apartment blocks. They have gave us space and access to the residents. We were to ensure the presence of our specialists for a couple of hours per day to run these clinics. Thus a doctor from a particular speciality say cardiology was to go to these clinics once a week for two hours a day.

Sadly this initiative also did not work out as well as we thought it will. We could not convince our doctors that it was worth their while to do this and engage with the local communities. Many thought that it was just beneath their dignity. Eventually we started sending doctors from our Emergency teams and junior doctors, who had no choice but to follow orders. The local community folks were very disappointed and I had to answer pointed questions on promises made and not kept. In many cases we ruined the relationship even before we started establishing them.

I am still none the wiser on how to sell these programs internally, where huge egos and plain disdain for grassroots relationship marketing often stands in the way of executing a good marketing program. 

A Recent Experience with a TPA

A few days ago a colleague mentioned to me that his wife has developed a painful swelling on the underside of her wrist. Knowing that I have worked in hospitals in Delhi, he wanted me to guide him to the right doctor.

An MRI was duly done and the problem was identified as a cavernous haemangioma. Cavernous hemangiomas are wild, jumbled growths of blood vessels fed by numerous tributary arteries. They are probably all present at birth, but start to enlarge rapidly after delivery.

My colleague fixed an appointment with Dr. Atul Peters a laparoscopic and general surgeon at Max Healthcare in New Delhi. Dr. Peters recommended surgical removal of the growth indicating that the patient will need to stay in the hospital overnight.  

My colleague, like all of us, is covered by an insurance policy provided by our employer and sourced through a nationalised health insurance company. We submitted our pre authorisation for a cashless service to the third party administrator (TPA), expecting a quick approval.

That is exactly where the trouble began. The TPA turned down the request citing a clause in our policy, which excludes 'congenital' diseases. We were quite befuddled as we thought 'congenital' meant 'from birth'. The patient in question is a 25 year old lady, a mother and a wife and this problem was not more than 3 weeks old. At this stage I decided to accompany my colleague to Max Hospital and meet Dr. Peters and check with him. We discovered that these haemangiomas can be congenital in origin, but in this particular case, it seemed unlikely. We got Dr. Peters to write this down and sent the document for reconsideration to the insurance company. We also used the services of a company, which acts as a go between the corporates and TPA's to sort out issues like these. Sure enough the TPA agreed to do a cashless transaction and my colleague's wife is now scheduled for surgery next week.

This is what bothered me in all this.

I was quite amazed at the alacrity with which the TPA declined cashless service, and how we had to fight this out to get what one would assume was our due. How can a TPA doctor sitting in his office decide, whether the problem is congenital or not? Why did he not bother to check with the surgeon, who has access to all medical reports as well as the benefit of examining the patient?

The moment somebody with the knowledge of the industry started intervening, the TPA found a quick solution and agreed to do a cashless transaction. How is it that a problem, which the TPA previously thought was congenital in nature suddenly resolve itself into something, which has developed over last couple of weeks only and was payable by the insurance company.

The simple answer to this question is that the TPA is obliged to keep the 'claim ratio' (Claims Paid/Premium Collected) low, so that the insurance company makes a profit. It is least bothered about the customer and the trouble he has to undergo, in getting his due. If somebody challenges the TPA, they are quick to go back on their earlier stance. It is pretty much like saying that let us first try and browbeat the customer and if he pushes right back, we will pay.

This callous system needs to change.

VIP's with their peccadilloes are always tricky to handle and in a hospital the problem magnifies manifolds. If the VIP happens to be a politician, than he believes that he owns the hospital and everyone must be at his beck and call. This includes hospital staff, which is supposed to take care of the VIP at the exclusion of everybody else.

Ironically what escapes these VIP's is that in many ways a hospital is a great leveller. You might be the mightiest of the  mighty, an illness treats you exactly the same as anybody else. It does not differentiate amongst its victims. When a doctor examines a VIP he does it the same as (I would presume) anyone else. The medicines work the same way, the course of the disease is not impacted by the office that the VIP holds. Thus logically a spell in the hospital must be a lesson in humility to the mighty ones. Alas, this happens but rarely.  

Many years ago, while I was working at Max Hospital, we had a minister hospitalised with us. The minister needed an angioplasty, which was duly performed by Dr. Ashok Seth, the resident high priest of Cardiology. The minister was soon on his way to recovery. However, all through his stay the hospital had to endure scores of people, his so called well wishers, breaking every conceivable hospital rule. While the minister recuperated, he and his cronies had virtually a free run of the hospital, largely at the expense of other patients. To make matters worse, the minister, decided not to pay and asked that the hospital collect its dues from a PSU, which came under the ministry he was heading then. It took the hospital more than a year to recover its money.

Another former chief minister who suffers from a delicate problem, has a fetish of never undressing in front of a female person. Thus for him the hospital has to ensure an all male staff, including the nurses, orderlies, doctors et al. 

Business tycoons too have their peccadilloes. One family insisted on occupying a suite, which is fair enough. However, when they were informed that no suite was available, they still insisted on being accommodated in a suite. They ran circles around the hospital administrators, pressurising everyone to organise a suite, fully realising that this can only be done by asking someone else to vacate their suite. The hapless hospital managed to offer them two adjoining rooms, which they grudgingly took but never stopped cribbing about it.

I have never understood, what is it with people vested with power or money (or both), which makes them think only of their creature comforts, even in a hospital. What makes them believe that because of their position in society, they automatically have a right to jump a queue and that too in a hospital, where suffering and emergent need must always be the rightful criteria for getting ahead in the queue.

As far as hospitals are concerned, they quite often are a willing accomplice in this charade. They go out of their way to keep the power that be happy. While I can understand a policy of least confrontation and bending backwards to accommodate a VIP, to do so at the expense or discomfort a more deserving individual is just plain wrong. 

The Family Physician Revisited

This is the era of specialisation, nay super specialisation and more. In healthcare services, the immediate casualty of this madness has been the family physician. And what a loss it has been.

During my childhood and teenage, which happened in the eighties, we always had Dr. Bajpai as our family physician. Dr. Bajpai had a clinic in the MG Road area in Indore, where we lived. He also ran a clinic from his residence and we were regular visitors at both these places. His residence was closer to ours and we would visit him there more often. I still recall his magnificent dog 'Sultan', who would invariably greet us with his loud barks. Dr. Bajpai was a kindly soul, who would usually prescribe simple oral medicines and we would be back in school in a day or two. I do not recall being asked to submit to the needle too often or visit a radiologist for X-Rays. The only time we were sure of needles, was when we would be taken to him for cuts and bleeds. He would get his ancient compounder to give us a tetanus shot. After this trauma, our mother would buy us a Limca from a neighbouring store (Ratan Sweets if I recall correctly)  

Family Physicians of yore were very often family. They were always invited to a family wedding, were welcome home and really in a broad sense were family friends. I vividly recall my father taking a box of sweets to Dr. Bajpai, when my sister started medical school and Dr. Bajpai stopped charging her his fee as is the custom amongst doctors. 

We never ever saw a hospital in all those years in Indore. We grew up with our share of illnesses, which Dr. Bajpai had no problems in fixing. To us he was the final solution to all our medical problems. 

Now, when I see parents with young children in hospitals seeking specialised care for their family, I wonder where have all the old fashioned family physicians disappeared. I understand young graduates passing out from medical colleges hardly want to get into family medicine. The lure of a large hospital, big bucks and the the possibility of trying their hands on the latest gizmos drives most of them away from Family Medicine. Over the years 'Family Medicine' has slipped down the totem pole and many family physicians hate to be called family physicians!

This is sad but true. The gradual loss of the Family Physician is inducing more and more people to self medicate. Many people (including, I must confess, me) prefer to tryout self medication before going to a specialist. This I know can be very dangerous. Why would I do this? I believe I do not need a specialist for minor ailments, I would hate to undergo a battery of tests that a specialist would inevitably prescribe and for many folks going to a specialist is too expensive an option.

I would also like to believe that a Family Physician represents the most benign face of medicine. Big doctors in big hospitals around bigger machines are scary. A gentle family physician, with his stethoscope conjures up a friendlier image.

Family Physicians have traditionally been the repository of the entire medical history of the family. They knew when the little one had a upset stomach last, and when a bug had the elder one down with measles and when the naughtiest one broke his arm. All this and more allow for great continuity of care.

Here is my salute to Dr. Bajpai, and all those family physcians, who have kept the tradition of the friendly neighbourhood doctor alive. I would love to see their breed thrive and grow from strength to strenght. 

They have my best wishes.

Better

I recently read 'Better' by Dr. Atul Gawande. This is his second book after 'Complications', which I had read many years ago. Dr. Gawande is a staff member at the Brigham and Women's Hospital and Dana Farber Cancer Institute. He is also an Associate Professor of Surgery at the Harvard Medical School, Associate Professor in the Department of Health Policy and Management at the Harvard School of Public Health, and Associate Director for the BWH Center for Surgery and Public Health. Dr. Gawande is also a staffer at the NewYorker Magazine.

'Better' is a rare and a wonderful book and I thorughly enjoyed it. 'Better' brings forth a great understanding of issues facing the medical fraternity today, the constant quest to do better, to improve the delivery of medicine and care as we know it today. I discovered the importance of hand washing and how this simple act on the part of caregivers in a hospital can avoid infection and save lives. I mean I do know that handwashing is important but had never given a second thought, while I marched into a patient's room in any of the hospitals I worked in.

I was amazed to learn how the medical corps embedded with the American troops in Iraq, would save lives of soldiers seriously injured in terrible warfare. It is mindboggling to imagine soldiers being surgically treated in makeshift hospitals, stabilised and than being sent halfway around the world to Germany for the surgery to be completed and than if needed being sent to the US for more surgery and recuperation. Mortality Rates for those injured in battle have fallen significantly. We are doing better.

Another chapter focuses on the dilemmas of doctors, whose job is to supervise state sanctioned executions. Those condemned to death, must die with dignity and with the least amount of pain. Ironically, it is only doctors, trained in saving lives, who can ensure that a condemned man dies without suffering. Dr. Gawande brings out the issues facing the medical community and doctors with rare sensitivity.

The heroic fight against Cystic Fibrosis, a genetic disease, which limits the cells' ability to regulate the chlorides in the body, is captured in another poignant chapter. The painstaking effort, the diligence and the resolve to have better outcomes shines through Dr. Gawande's prose. Similar tales of WHO's unending battle against diseases such as Polio, takes the readers to rural India, where the logistics of reaching out to millions of illiterate and prejudiced people and convincing them about having their infants vaccinated against Polio comes across as a huge challange. Yet, their is tremendous hope as we know Polio has been on the verge of eradication for many years now.

Dr. Gawande writes with rare luminosity. His accounts are riveting. He documents failures and triumphs of his profession and his own journey as a surgeon, with candour and great understanding.

A must read for everyone and particularly those who have a stake in healthcare.

For a Hospital 'Doing Good' is Great

'The business of Healthcare allows you to do good, and maybe also make money', Analjit Singh, Chairman of Max Healthcare, once said this in my presence and since then I have never stopped wondering about how 'doing good' is just as much a part of healthcare business as is making money.

If one was to stop and ponder for a minute, one would realise that healthcare business allows one to do good from the day one starts a hospital, while the making of money takes time, sweat, blood and tears. 'Doing Good' to my mind is the soul of this business and anyone, who does not have this objective at the back of his mind may as well never get into this business. For as Mr. Singh would say 'there are dozens of easier ways of making money, if that alone is the objective'.  

Before, I proceed further, let me hasten to add that I believe that the twin objectives of 'doing good' and profits are both equally important. Profit in my lexicon is not a dirty word at all. No business would remain a business if it was to steer clear from profits. However, to rush towards achieving the profits goal at the exclusion of everything else is foolhardy.

While working in hospitals one comes face to face with desperate people needing urgent medical care, which is beyond their means, accident victims arriving in the Emergency unable to pay for their treatment, children from disadvantaged sections of the society requiring complex surgery. For a 'for profit' hospital the dilemma is acute. They have a responsibility towards the share holders, which means free treatment can not be offered (certainly not beyond a point). However, being part of the community turning away people, for want of money is difficult for most doctors. Often ways and means are found to accommodate patients. Doctors, waive off their professional fee, ask medical devices manufacturers to donate expensive devices, hospitals waive off room rent and charge only for medicines consumed. I consider myself extremely fortunate to have been part of hospitals, where we would do all of this and more to ensure that as far as as possible we did not turn away someone truly deserving of help and support at a difficult time.

I know of many doctors who run programs, (supported by the hospitals they work in), which allows them to treat the poor. Dr, Anil Bhan a well known cardiac surgeon works with destitute children from the hills in Uttarakhand. His program is truly remarkable as he has found an anonymous benefactor, who pays for medicines and consumables, while Dr. Bhan does not charge any professional fee for the surgeries and the hospital waives off the OR fee and the room rents. Dr. Harsha Hegde an Orthopaedic Surgeon, works with an NGO in Gurgaon, which takes care of street children. I am sure there would be many more conscientious doctors doing the best they can to help individuals seeking their help. 

Apart from these unorganised efforts, which are but a drop in the ocean, I wish there was an organised program to help the not so well off access quality healthcare. A simple solution that guards the stakeholders interests as well as allows the hospitals to do good is to set up an NGO, partly capitalised by the hospital, partly through corporate and individual donations and partly maybe by government agencies. This NGO can then refer deserving cases to tertiary care hospitals, which can provide medical care and charge the NGO a much reduced sum equal to the cost of consumables and medicines for its services. 

Like I mentioned earlier 'doing good' to the society must be an irrevocable contract that a hospital must have with the community it works in. Unlike other industries say a cola manufacturer or a car company, hospitals have a completely different set of responsibilities towards the society at large. 

And finally, 'Doing Good' makes great business sense as well. A hospital known for its large heart and generous spirit will always attract patients.

Service Recovery and Word of Mouth Hospital Marketing

Goof ups in hospitals are always round the corner.

I dare suggest that quite often they are unavoidable. Do what you may, there will always be someone who will slip once in a while and you will have an irate customer. The headcount in a typical 300 bed tertiary care hospital in India can easily be 800 people or more. In spite of all the care in hiring the right set of people and putting them through rigorous training, they will still end up making mistakes.

Good hospitals, while trying to minimise errors also learn to accept them as inevitable and put in place systems, that help them handle difficult situations well. Great hospitals go one step further, they not only do excellent service recovery, they also ensure that the the patients leave the hospital with a positive frame of mind, in spite of the mishap.  

F&B and Billing are two areas in a hospital, where service failures are most common. The food would not arrive on time, would either be too cold or too hot, or too spicy or just unpalatable. Similarly the bill will take ages to get ready, it will have items billed, which in the patient's estimation were never used, there will be charges for doctor's visits, who never showed up or just came and said hello, while the hospital levied a big charge. All this and more are common in the hospitals. Too many such episodes, with a patient will lead to a bad experience and even if the medical outcome is fine the patient will (in all likelihood) have bad things to say about the hospital.

It is essential that the hospital actively seek patients' views on its services. While, a feedback form is usually available at the time of the discharge, it is of no use in service recovery.(The patient is afterall ready to leave the hospital).

Max Healthcare, thus employed a novel system called 'The Mentor Program' to collect patient feedback through designated executives called 'Mentors', while the patients were admitted in the hospital. The mentors meet the patients and their attendants on a daily basis and listen to their grievances and experiences in the hospital. They than pass on the feedback to the concerned departments (say F&B), which than takes care that the error was not repeated. The mentors check with the patients again the next day if all was fine and usually have a happy patient at hand.

I myself experienced the Mentor system at work, when my mother underwent a bypass surgery last year. She had complications and we spent a harrowing 3 weeks in the hospital. However, the mentor made our life easier by taking care of the smallest need that we had (even allowing us to break hospital rules at times). We got an impression that the hospital was willing to listen to us, really cared about us and was a partner in a difficult period in our lives. 

And look here I am talking about the our experience in the hospital rather than the infection, which my mother contracted after surgery leading to complications. I understand this can happen in any hospital across the world, the infection rate at Max compares favourably with other hospitals and we were just plain unlucky.

This is the power of a good experience and word of mouth marketing. A good customer experience and a positive word of mouth is never a product of an accident. It is only through a great understanding of consumer behaviour in a hospital, detailed planning and diligent effort, that magic happens.

Marketing Those Who Came Back

Step into a hospital anywhere in the western world and you are in all likelihood to run into an Indian doctor sooner than later. The medical education system in India churns out doctors in large numbers and many of them choose to go abroad for advanced training and skills enhancement. Many of these settle down in the new country, which is more than happy to welcome highly educated and skilled doctors to its shores. It works well for the doctors too, they learn new things, train in some of the finest institutions in the world and than are able to make a decent living in their adopted country.

This is the way it was till recently.

Now with India making rapid strides in healthcare and even attracting patients from across the globe, many of these doctors are choosing to return to India. They are able to find employment in the new high tech hospitals, which have sprung up in the last 8-10 years. The reasons for this are not far to seek. Indian hospitals can now easily be compared with any that they might have worked in earlier, in the west, the standard of care is often superior, the financial rewards far better than what they were a few years ago, and life in upmarket urban India quite comfortable. Moreover, India is home for many with responsibilities for aging parents. Some are also not comfortable with their children growing up seeped in the ubiquitous and consumerist western culture.

All this is great, except for the fact that some find going in India quite tough. The hospitals that employ the returning prodigals, soon realise that these doctors will take time to settle down and find their feet in the changed Indian environment. Having been away for years they do not have a bank of patients, who can start patronising the hospital. Often their salaries are more than those hired from other Indian hospitals and with no patient base to speak off, these doctors are immediately under pressure to justify their high salaries. They usually need urgent Marketing support.  

Marketing these doctors wouldn't be too difficult. However, marketers like me realise to our dismay that many are just not willing to make the effort, which is required to establish their credentials back home. Many believe that their foreign accents and fancy certificates will suffice to get them patients. Unfortunately, this never works.

Their are really no short cuts to building a practice. It requires painstaking engagement with the local doctors, establishing a rapport with the local communities around the hospital and delivering great experiences to patients who come in. Dr. Paramvir Singh a gastroenterologist, who returned from the US to join Artemis Health Institute in Gurgaon is a case in point. He decided early on that he will have to work closely with the marketing team and pestered each and every member of the team to take him out for meetings with local doctors, deliver talks in corporates and interact with the local community leaders. Dr. Singh also ensured that he called those referring patients to him, discussed the  case and politely thanked the doctor for his support. He also became friends with all the marketing executives, who found him very accessible and ready to go out with them on short notice. All this worked like a charm. Dr. Singh is today, about a year in pratcice in Gurgaon a very busy gastroenterologist indeed.

Sadly, many of those who returned find it hard to cope with the grind. Many carried a lot of baggage from the US, had an attitude which borders on arrogance and found it difficult to connect with the local doctors. Many confessed of not being comfortable interacting with some of these doctors, they questioned their practices and were just not able to treat them with respect. Not surprisingly the local doctors too turned up their noses at these 'upstarts'. The hospital sales team just couldn't make any headway.

Some of those who came back, found going out with the hospital sales team a chore well beneath their dignity, the heat and the grime of India beyond the air conditioned surroundings of the hospitals too much to bear. Others found it difficult to work long hours, 7 days a week, (which is the lot of most doctors in India) and cope with the relentless pressure of generating patients for the hospital.

No wonder many of them are contemplating returning back, others are holding on grimly, hoping with the passing of time patients will surly come. They may or may not, the struggle for these doctors is not ending anytime soon.

Pic courtesy www.flickr.com/yodababy79

Obesity is fast becoming a global epidemic. While so far the disease has largely been limited to the developed world, it is now rapidly spreading its wings to countries like India, where increasing affluence and prosperity is driving huge lifestyle changes.

Obesity is a disease of the affluent. The link is easy to establish. The intake far exceeds the requirement. In Indians, latest research also indicates the presence of a gene, which converts excess food into fats and deposits it in the abdomen. Thus the normal paunchy Indian, (I dare say pretty much like me!) can blame his genes as well as his lifestyle for his ample girth.

Obesity has been recognised as the underlying cause of many a disease including diabetes, coronary heart disease, joint and spine related problems, and liver diseases. The fight against obesity is now becoming a huge challenge and is a great opportunity for healthcare services marketers.

Here is what they can do to win this battle.  

Design a Great Product

Obesity must be treated like a disease. A great obesity management program should include a scientifically designed and customised exercise regimen, specially tailored diet programs, counselling and of course for the morbidly obese the choice of various surgical options. These should include a minimally invasive bariatric surgeon and a cosmetic surgeon working together to offer a comprehensive surgical package.

The Obesity Program should be marketed as a package. Quite often hospitals make the mistake of focusing too much on the surgical treatment and ignore non surgical options. This is a mistake because consumers tend to look upon this with suspicion. Afterall, if the choice is between surgery and exercise and dieting, most people will choose the latter with alacrity.

The marketing of an obesity program should involve engagement with customers through a well defined marketing program.  The communication mix should include multimedia advertising including print, radio, cinemas, and outdoors advertising. It should also include a generous dose of below the line communications.

1. A Testimonial Campaign

It is a great way to advertise an Obesity Management Program. I know it is cliched and done to death by a large number of Obesity Clinics. However, I believe it always works. There is nothing like an obese person's picture before and after joining the program to convey the benefits of the program. The trick here is to use this in a 360 degrees campaign. Use the same message in the newspapers, lifestyle magazines, bill boards, radio, TV and even in the below the line communication.

2. Public Forum

 Organising a public lecture on Obesity and its management helps connect with the right audience. At Artemis Health Institute, Gurgaon we organised many such lectures on varied topics and the response was always great. Moreover, we mostly had people in the audience, who either themselves were suffering with the disease or were caregivers to someone suffering from it. These were always interactive sessions with a team of doctors, physios and even patients with successful outcomes interacting with the audience.

3.Go to School

Childhood obesity is rampant and believe me there is nothing that worries a parent more. With all pervasive McDonalds, Domino's, Pizza Huts around the corner, and the shrinking spaces outdoors, the young are succumbing to obesity like never before. Schools, would be happy to provide an opportunity to the hospital to interact with children through lectures, talks and direct invitation to parents to help their kids stay healthy.

4.Engage Where you Can

An engagement activity with the obese at the nearby jogger's park might be a good idea. Similarly one can engage with them outside a popular food joint, a mall or a theatre. A message delivered on a table mat in a restaurant or a small film in a cinema theatre, while presumably munching a bag of buttered popcorns can work.

5.Educate Educate and Educate

Most people suffering from severe/morbid obesity are quite unaware of the surgical options available. Dr. Deep Goel, who Heads the Minimally Invasive and Bariatric Surgery program at Artemis Health Institute says ' Surgery is a viable option for the morbidly obese. In the hands of an experienced surgeon it is quite safe, is done laparoscopically and the patient needs to stay in the hospital for just 3 days'. A hospital will do well to develop literature about the surgical options available, the benefits and the associated risks. Put this up on the website of the hospital, use it as a handout to patients coming as outpatients, send them as emailers to patients with BMI index in excess of 35.

6.Stay the Course

From a hospital marketer's perspective the trick is staying the course. Looking for quick gains from the program is foolhardy. In my experience it should take at least a year before the program starts showing tangible results. The good news is that it is a self sustaining program once a critical mass of patients is achieved. Word of mouth starts spreading fast and patients follow patients.

Pic courtesy www. flickr.com/Henry Scow

The Dentist,Reader's Digest and Colgate

The current issue of Reader's Digest in India has a impressive looking (and if I may also add forbidding) dentist on its cover and a lead story about how a trip to a dentist can help predict all manner of disease. It is as if the dentist holds the key to deciphering all the medical problems that I may encounter in my life hereafter.

The story makes for strange reading.

Is this a surprise that a regular visit to a dentist may help detect oral cancers. I would be surprised if my dentist in today's day and age ignored suspect looking patches in my mouth, which may later turnout to be cancerous.   

The other point that this story makes is that untreated oral infections can have serious and sometimes fatal consequences. But wouldn't you think that this may be true of any infection. An untreated infection in the foot may also fester, the infection may spread, may become gangrenous, may require serious surgery and at times may lead to septicaemia and death. What is so special about an untreated oral infection?

Unbelievably the story makes the incredible claim that the dentists during the course of routine dental examinations can spot signs of Diabetes, Heart Disease, as well as rare skin and auto immune diseases. I would love to meet a dentist who can do this. Those I have worked with for many years have no such claims to fame.

And here comes the real gem' But the good news is that with good old regular brushing and flossing you may prevent all that. And by seeing your dentist often you can nip most problems in the bud'. For all of you who might be wondering what is so great about it, you are advised to look at the opposite page. The bright and the familiar red of a Colgate ad can hardly be missed. The ad headline reads 'Are your clean teeth hiding signs of decay? For a Free Dental Check-Up in your neighbourhood sms...' You get the picture now, right.

The story continues in right earnest about terrible afflictions of the gum, which can cause all manner of illnesses and of course the ad down below says 'For a truly healthy mouth you need protection from as many as 12 teeth and gum problems' Need I say more.

It is sad to see a venerable magazine like Readers Digest in such dire straits. I have been a reader and collector of Reader's Digest, since when I was hardly 10 years old. The most charitable explanation that I can think of for all this is that these must be desperate times for them. After all selling ones soul is never easy.

And as far as Colgate is concerned, I can only say that they have a very bright brand manager, who thinks all of us consumers are incapable of putting two and two together and see through what this is really all about.

Pic courtesy www.flickr.com/cjanebuy

Lessons in Healthcare Marketing Communications

Building healthcare brands is an arduous task. 

It takes enormous effort to get it all right. The mix of customer experiences at various hospital touchpoints, the look and the feel of the hospital, the people and of course the communication. No one goes to a hospital willingly or to enjoy a few days of well deserved rest. Neither is it a place, which attracts willing repeat customers. Customers in a hospital are necessarily driven by a misfortune, which involves something as precious as their or a loved ones health. A hospital visit is also usually fraught with risk. Fear and anxiety generally accompany a customer to the hospital.

Building brands by delivering great experiences to customers who are in this frame of mind is tough. Communicating with customers to influence their choice of a hospital in dire and difficult circumstances is often akin to walking a tight rope. The message runs the risk of being perceived as either too commercial (this hospital seems to be hoping that I fall sick and land at its doorsteps), too glib (it trivialise something as serious as my health and well being) or just too smart or plain dumb.

Here are some lessons that I learnt, while handling communications for large hospitals.  

The Customer is Not a Moron

Healthcare Marketers tend to assume that the customer knows nothing. They believe that healthcare and medicine are way too esoteric and difficult for a non medico to comprehend. We often forget that this is not about a tumour or a disease, it is all about a human being, an individual who is sick. There is no one who knows his problems better than the individual suffering from the illness and he is quite capable of making intelligent choices that he believes the are best for him. As healthcare marketers, we must respect this.

Talking Down to the Customer Never Helps

Many a times I have come across communication, which is downright patronising. It talks down to the customer rather than engage with him in any meaningful dialogue. I believe a good piece of marketing communication must appeal to a customer at a sublime level, it should make a subtle point rather than being in your face and loud. And yes one can be subtle and yet appealing.

Too much is always too little

In a hospital, virtually everybody and their uncles are expert marketers. A cardiac services ad will require inputs from cardiologists, cardiac surgeons, hospital leadership team, medical superintendent, the COO, the CEO and pretty much everybody else who works in the hospital. And all of them will want the ad to include something or the other, which in their opinion is important about the hospital and must be communicated. The brand team will be buried under an avalanche of opinions, which must be included in the ad. Leaving any of that will typically upset one or the other doctors, leading to an ugly situation. In all this the customer will generally come last. 

It Must always be about the Customer

It unfortunately very rarely is. The communication is more often than not about the hospital, the doctors, the equipments, the technology, the systems,... The breast clinic is not about the breast surgeon or the mammography machine, it must be about early detection and comprehensive care. Everything else including the doctors are just means to that end.

In India, healthcare marketing communications is in its infancy. I am sure as we see more corporate hospitals and greater marketing talent moving into healthcare, the transition from the hospital being the center piece to the customer becoming the focus of communication will commence.

The sooner the better for all.

Pic courtesy www.flickr.com

Should their be Money Back Guarantees in Healthcare?

I know I run the risk of being shot by friends and colleagues for even suggesting something like a ‘moneyback guarantee’ in medicine. I am aware of all the usual arguments about why it cannot be done and why my understanding of issues in medicine is so limited.  Let me begin by capturing some of these arguements.

Medicine is a profession, which involves huge risks. Our understanding of how the body works and heals is limited. All the advances in medicine that we have witnessed in the past decades, while incredible do not still allow us to say with certainty that what works for John will also work for Joe assuming they have similar problems and are being treated by the same doctor. Each individual is different, and he responds to medicine in a different way. Moreover, medicine is an inexact science, the outcomes are dependent on too many factors beyond the control of the doctor and that it is next to impossible to predict a successful outcome. 

I agree with all this, except the fact that outcomes cannot be predicted with any degree of success. They can be. Cardiac Surgeons blithely talk about a success rate of more than 98%  for something as delicate as bypass surgery and surgeries involving the prostate, gall bladder and hernias have a close to 100% success rate. I also know of Orthopaedic and Spine Surgeons, who pride themselves in success rates of over 98%. These are facts that can easily be ascertained and documented.

If we know that the mortality or complications rate for a particular surgery in a particular hospital is in excess of say 98% than I see no reason why a moneyback guarantee can not be issued. The hospital stands to loose the fee earned in just 2% of the cases averaged out over a period of let us say a year. Financially this makes complete sense.

Surgeons and clinicians regularly communicate these risk factors to individual patients. My mother needed a bypass surgery last year. The surgeon we went to had a more than 98% success rate with this kind of surgery and he told us so. That really helped my mother, who was extremely worried about being under the knife. Now why can’t this be communicated to a wider audience and also put some money where one’s mouth is?

Let us also consider what the promise of a moneyback guarantee tells me - the customer. First and foremost it establishes the point that the hospital has complete faith in the abilities of its surgeons and doctors, it is willing to wager its money on a successful outcome. The moneyback guarantee also tells a patient that the hospital is absolutely confident of its systems and processes, nursing care and infection control protocols. Above all it makes the point that the hospital is willing partner in sharing my risk at least to a certain extent.

Imagine, what a powerful tool a promise like this can be in the hands of skilled marketers. The promise smacks of supreme confidence and provides a powerful reassurance to patients. It makes the hospital standout from everyone else as unique. It inspires trust amongst customers. It sounds honest and makes the hospital look like a partner in the process of care for the patients.

I do believe that the time for limited money back guarantees in healthcare has arrived. All it requires is a bit of courage from a surgeon and a hospital to stand up and go for it.  

 

The image is courtesy www.flickr.com

Should Doctors Advertise?

Advertising has traditionally been a strict no no amongst the medical fraternity. It has always been considered infra-dig. A doctor's face peering down from a bill board or staring you in the face from the pages of your favourite magazine does make one feel a little uncomfortable. We have all been brought up to look on the medical profession as something noble and with a strong orientation towards service to humanity.

However in today's times I am not sure this argument really holds. If a doctor chooses to advertise his skills and does it honestly without taking recourse to exaggeration and hyperbole, is there anything really wrong with it? If a doctor has unique skills and training, which helps him get better results, than isn't advertising these, allow consumers of healthcare make better informed choices? Why do we have to look upon this particular doctor as 'too commercial'?  

It is also believed that doctors who spend a lot of money on advertising will eventually recover these from hapless patients. There is no evidence of this and to believe that just because a doctor chooses to build his practice by advertising, he will also resort to unethical practices (to make money to pay for the advertising) is wrong. If a doctor is keen on cutting corners to make a fast buck, he will do so anyhow.

I  do believe that it is important for doctors to connect with consumers. They must inform the society they serve about their skills, training and experience. Advertising can be a strong and powerful tool to do this.

The big question really here is what kind of advertising should doctors undertake to attract more patients. I believe the ads should be honest and truthful. They should not make promises, which are misleading and difficult to believe. The advertising should largely stick to facts. It may be wrong to say that 'I am the best/most skilled cardiac surgeon in town'. However, the same point can be made by stating that 'I have done 10000 cardiac surgeries in the past 10 years with a success rate of 99%'. Consumers are not morons, they will get the message.

A separate regulatory body might be required to ensure that doctor's advertising is fair and makes truthful and verifiable claims. This can be an independent body created by medical community with representatives from the world of advertising, media and aware members of the society. The society can develop a 'code of ethical communication' for all doctors to follow, while advertising their services. The media can stipulate that they will accept ads only if cleared by this body.

I do hold that the time has come when doctors were allowed to advertise their services. Not only will this help doctors attract more patients, it will also help consumers choose their doctors better. 

The pics are from www.flickr.com

Outreach Programs - Lessons for Healthcare Marketers

Outreach Programs are essential weapons in the armoury of a healthcare marketer. The programs are widely used for creating awareness about the hospital's services amongst people, who live in communities away from the hospital. Quite often these programs also serve as screening services for more serious disorders and the hospital naturally hopes to attract some of the patients requiring higher end diagnostics and treatment to its doors.

Very often the communities served by the outreach programs are either rural or semiurban, where the availability of good quality, modern healthcare is very limited. These communities too hugely benefit from these outreach programs as they get access to good quality healthcare services.    

Inspite of a win win situation both for the hospitals as well as the far flung communities served by a hospital's outreach program there are not too many real success stories of outreach programs. Good intentions rarely translate into effective and successful programs.

Artemis Health Institute (AHI) based in Gurgaon in the National Capital Region of Delhi last year instituted an outreach program which involved the cardiology teams. The program comprised of weekly outpatient clinics by cardiologists at Sohna, Rewari and Bhiwadi, semi urban communities all located with in a radius of 50 kms from the hospital. The three locations were carefully chosen as they are well connected to the hospital (the driving time less than 90 mins)  and there are no qualified local cardiologists. The population of the towns is about half a million each.

The program has been running for more than a year now with less than satisfactory results. Everybody agrees that the opportunity is huge. Yet there is really very little to show for it on the ground.

The lessons learnt are simple yet profound.

A community outreach program can be a success only if the doctors involved un the program are completely committed to it. At Artemis it was always a challenge to get the doctors to go. The doctors felt that going out in the 'field' and seeing patients at an outreach clinic, (which would typically run from a local ill equipped but popular hospital) was beneath their dignity. Some believed that it just served no purpose as patients seen at these clinics were too poor to go to private and expensive hospitals like AHI. 

Some would complaint that there is no point in traveling so far unless there are enough patients. This was like the proverbial chicken and egg. Patients will come if the doctors show up regularly and on time. A no show also destroyed the relationship with the local hospital as their credibility suffers as well. At Artemis we never could convince our senior doctors that this was worth their time and effort.

An outreach program must be an integral part of the Marketing Program of the Hospital and the hospital must spend the money needed to popularise the program. At Artemis the clinic was advertised with the help of local ads, handbills and banners. However, there were always severe budegtary constraints. The money was never enough.

Consistency of the program is essential. It is imperative that as far as possible the outreach clinic be run by a single physician. This enables the local population to forge a relationship with the doctor, whom he knows he can meet every week. At Artemis this was rare. Though the clinics were assigned to a senior physician, he seldom went. Sending someone else usually a junior greenhorn served no purpose. The patients could see through his inexperience.

Time is essential for the success of the program. It is quite unfair to expect that the program will deliver a large number of patients in a hurry.  A level of trust must develop between the doctor and the local folks, before patients turn up at the door of the hospital. In my estimation a minimum of 6 months of regular effort is a must. At Artemis we were always in a rush.

The Local partner is important. The local partner must be selected with care. His expectations from the program should be ascertained and a fit between the hospital and the local partner should be evaluated. The local partner wants an association with a bigger tertiary care hospital as it adds to its own prestige, At the same time he hates being pushed around by the big hospital. At Artemis we tried hard to get the fit right. I would like to believe we succeeded more often than we failed.

I also know of far more successful programs initiated by the doctors themselves usually in communities where they have their own roots. Dr. Anil Bhan a cardiac surgeon ran a successful program in Srinagar, Kashmir for many years. That however must be the subject of another post.

The image is from www.flickr.com

The author was till recently the Head of Sales and Marketing at Artemis Health Institute, Gurgaon