'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.