Healthcare in 'Real India'

The Healthcare Services as we know it and most of what  I have been writing on this blog I must confess applies to the metropolitan India, largely comprising of a  handful of large cities. The real India, which still  continues to reside in smaller cities and villages has  very poor access to good quality healthcare. In rural India the healthcare services are almost non existent.

My mother who lives in Lucknow, which is a the capital of the most populous Indian state Uttar Pradesh often needs to travel to Delhi for her cardiac care needs.  Lucknow is a large city with over 7 million people. It has a famous medical college the King George's Medical College as well as a Post Graduate Medical Institute named after Sanjay Gandhi. These institutes are owned by the government and have great facilities, but they are like any other government institute, filthy, overcrowded, staffed with callous and poorly paid doctors and medical personnel.

In the realm of private healthcare there are motley nursing homes, which are poorly equipped and run by mercenary doctors. Most of them provide a basic level of care and God forbid if one needs anything more than that, one needs to head for Delhi 500 kms away.

If such is the state of affairs in a city like Lucknow one can imagine the kind of facilities that one can expect in other smaller towns in moffusil India.

This has often made me wonder about the great opportunity that this affords. With increasing affluence and heightened awareness about health issues in smaller towns I would expect a lot of patients to flock to corporate hospitals, which promise better care. 

A model of  private healthcare with Primary Health Centres in villages and small towns, secondary care hospitals in district headquarters and larger tertiary healthcare centres in large cities all linked together, can be constructed as a viable business model. The rural and the semi urban centres should be able to funnel a large number of people to secondary and tertiary care hospitals thus helping them access superior quality care.

These hospitals can be set up as budget hospitals, with emphasis on higher quality medical care, good hygiene and infection control and less of imported marble and fancy fixtures. The hospitals should be designed less for luxury and high on functionality.

Medical schools in India churn out thousands of graduates every year. Many of them choose to move to bigger cities like Delhi or Mumbai but many prefer to work in smaller cities usually the cities and towns where they grew up and went to medical school. These doctors can be employed in these hospitals at competitive salaries, and afforded growth and career opportunities across the network of Primary, Secondary and Tertiary healthcare centres. The nursing and paramedical staff is fairly easily available and with proper training can be employed in the hospitals. 

Healthcare system like this, which target millions living in small town India can generate immense amount of revenues. The pricing of course would be the key. I would reckon that healthcare services in these hospitals can easily be priced at less than what the present day nursing homes charge. And the care can be far superior. These hospitals would be high volume thin margin businesses, with built in synergies through sharing of equipment, people and processes. 

Moreover with increasing penetration of health insurance, price as a decisive factor is gradually disappearing. The hospitals can also encourage people to buy health insurance and avail of cashless services at the hospitals. Managed healthcare programs can also be introduced, covering individuals and communities through group insurance schemes. The hospital can support schemes, which allow people to contribute a small sum regularly to a healthcare fund, from where money can be withdrawn during the times of need.

All this and more is possible  if one was to start looking at small town India and aim to make ones fortune from the proverbial 'bottom of the pyramid'. In India the base of the pyramid is huge and the opportunity mammoth. It is high time someone bet on it.

The Opacity in a Hospital

As a consumer of healthcare services and also as a keen observer of the drama that unfolds in a hospital everyday, I have often wondered at the extent of opacity that I see around me. A hospital is usually as transparent as a black hole. Ironically most hospital swear by the maxim of 'complete transparency'. This is rarely true.

Try getting a straight answer from a hospital executive or a doctor and you will straightaway run into a wall.  They are just not programmed to answer straight. Many a times, I would accept that it may not be feasible or advisable for a doctor to be completely transparent. However, there are times when a doctor must look the patient in the eye and say as it is.

Delivering bad news is never easy. It takes a lot of character and compassion to tell another individual that he is terminally sick. However, not telling or beating around the bush, while doing so is far worse. Than there is the matter of giving hope to those diagnosed with a rare condition, telling them that, while they are gravely ill, they need to put up a fight and the doctors, the hospital and everybody else responsible for their care will walk with them every step of the way.  I would like to believe that the ability to communicate and connect with the patients is a wonderful gift to have and it makes for some very happy patients.  

There are those tricky stuations as well, when something unexpected happens. A patient with a great prognosis suddenly collapses, a patient doing well after a complicated surgery falls pray to a rampaging infection, a completely unexpected problem arises in the OR, a terrible mistake is made somewhere. In hospitals, things happen, errors can not be completely ruled out, and unfortunately it is mostly the patient who pays the price. The treating surgeon/doctor is the one, who has to do the explaining and he usually finds himself in dire straits. After all, it is not easy to own up ones mistakes and admit that a loss of life could have been averted, if things were done differently. Here, most doctors and hospitals lie their way out of trouble.

In India it works often enough. The attendants of the patient are far too disturbed to mull over what went wrong, their sense of loss is so overwhelming that they hardly have the presence of mind to question anyone. Indians are a fatalistic people, and attribute much of what happens in their lives, death included, to the mysterious workings of fate. The doctors and surgeons are looked upon with a great deal of respect and an unexpected outcome is rarely blamed on the doctor's incompetence.  Often, medical folks tend to answer difficult questions in jargon or offer obtuse explanations, which are difficult to comprehend but appear to exonerate them from any culpability.

Is all this sound medical practice? Most of us would answer that in the negative. Is it the most convenient way out for the doctors and the hospital, I would probably answer in the affirmative but with a caveat. The hospital after every such episode must undertake to investigate the matter, fix accountability, correct the process, which led to the error and ensure that the problem never recurs. Should the hospitals offer a compensation or own up to an error, whenever an unexpected outcome happens? I would say no, simply because in the practice of medicine, negative outcomes can never be completely eliminated. 

Finally, what should the hospital do, when gross error amounting to negligence comes to light. My answer would be to own up, investigate, fix responsibility and act decisively.  Communicate directly with those hit by the tragedy, apologise and transparently share with them the corrective measures being put in place. Also ask, if there is something that the hospital can do by way of compensation. This is the most tricky and difficult part because whatever one may offer, the unexpected loss of a dear one can not be compensated.

I personally hold that appropriate communication, done in the right manner can help mitigate  even the most difficult situations. If one is honest and sincere, most people will understand and reciprocate.

Marketing Maternity Programs

Fortis La Femme, a boutique hospital for women is running a promotional campaign on a local radio station for their IVF program and the venerable Moolchand Hospital has launched 'Mother's Nest' a maternity services program targeting would be parents. A full page advertisement announcing the new program was carried in HT City a few days ago.

Fortis La Femme, which was known as Cradles earlier was a brain child of Ratan Jalan, the CEO of Apollo Health and Lifestyle Ltd. (AHLL) who was my boss, when I headed marketing at AHLL. The Cradles was set up as a franchised operation and was later bought over by Fortis. It was conceived by Mr. Jalan as a high end birthing centre and has now been repositioned a s a hospital for women, with Maternity Services being one of the several service lines.

Moolchand Hospital has of course been a fixture in Delhi's firmament for decades and is undergoing a complete makeover under the guidance of Shravan and Vibhu Talwar, the present owners. Both of them are well known to me.  

Childbirth is one happy occasion in the life of a hospital. It is the only time when one looks forward to going to a hospital. In most people's lives the arrival of a new family member is a time of unalloyed joy and hospitals try to deliver a great experience. 

In fact, many prospective parents select a hospital based on their assessment of the kind of experience they can expect. The hospitals realising this try to offer a great experience for the would be mothers as well as the enire extended family.

Many hospitals offer packages, which include regular care during the ante-natal period, a great and hassle free birthing experience during the time of the delivery and than a post natal package including infant care. The packages are designed to ensure customer lock in and the hospitals encourage both the would be parents to share the experience of preparing for the arrival of the new one.

The Marketing of these packages involve effective branding and packaging of the services and than connecting with folks planning a family. 

The million dollar question is how to identify such families and than whom to communicate with. While attempting to create effective communication for the Maternity Program we were not sure if the communication should be directed at the would be mother, father, the mother in law or the sister/sister in law who had had a baby the previous year!

I remember having long but unfortunately fruitless discussions with my team mates trying to figur this out. We even once asked our below the line Marketing agency to collect information on all the marriages being registered in Delhi so that one can start approaching couples with marketing messages on the 'joys of parenthood'. Fortunately, better sense prevailed and we gave up this exercise as impractical.

We tried associating with stores selling Maternity related products and get information from the web about people downloading maternity related information from pre defined websites. All this just did not work.

Very soon we realised that direct marketing was perhaps not as effective as we thought it would be. We quickly reverted to above the line advertising and slick branding. The Max Hospital's maternity package was called 'MaxiMum'. We created information booklets on what to expect during pregnancy, acquired videos of child birth to demystify the entire experience and also developed information on infant care. We also tried to standardise the experiences across the hospital touchpoints.

All this worked far better than the earlier direct marketing approach. Young couples planning a family would call, visit the hospital, be taken around to see the facilities for themselves and interact with their obstetricians. They were given answers to all their questions by trained executievs, handed over the literature we had developed and encouraged to enrol for the program. Customers could 'touch' and 'feel' the hospital and interact with the caregivers. They also understood that the hospital wanted to partner with them in their moment of great joy.

And in the course of all this we also discovered that India is changing and at least in urban, educated, middle class India, the decision about choosing a hospital for a childbirth is now largely a decision of the would be parents.

The Ills of Health Insurance

I have been reading posts on what ails the American  Healthcare System and how the president elect Barack  Obama wishes to attempt to fix the problems on a high  priority basis.

The more I read the more I am realising that the American Healthcare System has been crippled by an health insurance system, which has grown to an extent, where it interferes with the delivery of care. 

Health Insurance Companies need to make profits to remain afloat. The only way they can do it is by ensuring that the premiums they collect are more than the claims that they pay out. Thus, to ensure profits they have to ensure high premiums (as high as the market can bear) and try and limit claims as far as possible.  

Health Insurance companies in a bid to limit claims often try their utmost to wriggle out of their policy commitments citing fine print regarding what is covered (and what is not) and asking for endless information regarding the disease and the treatment plan. All this has led to a system, where the focus is less on the disease and the care needed and more on getting the nod from the insurance companies. This is a pernicious system.

Another way of limiting claims is offering insurance covers to only those who are relatively healthy and have a lesser probability of getting hospitalised. This can be done by refusing coverage outright to people with existing diseases, or by refusing to offer insurance covers beyond a certain age. This kind of 'favourable selection' ironically eliminates the most vulnerable, who have a much higher need for insurance cover.

Another method of reducing claims is by questioning every item of cost that a hospital incurs in delivering care. Insurance companies also do not hesitate in questioning the judgement of the treating doctors and second guessing him. Thus, hospitals are required to use only certain kind of prosthesis, stents, joints, medicines et al, which allows the insurance companies to maximise their profits. Thus it may happen that the care that you and I get is remote controlled by a desk bound doctor, working for the insurance company.  Thus,  insurance companies in the role of payors dictate what kind and what quality of care we get. Scary isn't it.

I would hardly want to point out the adversarial relationship that exists between a hospital and an insurance company. The hospital as a business entity, would like to maximise its profits and so would the insurance companies. A big chunk of the hospital profits are controlled by the revenue that that they generate from their insured patients. This is directly controlled by the insurance companies, who would like to minimise their payouts to the hospitals thus impacting the hospital's revenues and profitability. This is a vicious cycle.

The fallout of all this relentless chase for higher profits, is the kind of chaos one is witnessing in the US healthcare system today. While big hospitals and bigger insurance companies fight their battles, the small consumer is caught in the middle. 

Their are no easy solutions here. However, we in India, while welcoming an increased penetration of insurance must be cognizant of what this may ultimately lead to. We do not want to go the US way.

The need of the hour here is to set up a regulatory body, which regulates both healthcare as well as health insurance. It should set out the rules of engagement, put in place a mechanism for monitoring all the players, ensure that they adhere to these set of rules and it should be empowered to act and penalise those who stray. 

At the end of the day, healthcare services are far too important and vital for all of us and they must not be allowed to become a prisoner of profit hungry hospitals or insurance companies.

The Idea of a Healthcare Resource Centre

Having worked in hospitals in Delhi for many years I am often required to help out friends and relatives when someone in their family needs medical attention. I am supposed to be the guy who can recommend a specialist, fix an appointment, advise on the choice of a hospital, help folks seek a second opinion and in general be the knowledgeable person around for matters medical. 

This has often made me wonder if there is a need and possibly a business opportunity in developing a large resource base of information and knowledge, which most people can access with ease and use without worrying about the reliability and authenticity of the information.  

What will be this Resource Base ?

A reservoir of authentic medical information about medical professionals, hospitals, nursing homes, specialised centres, nursing services,  homecare services, old age homes everything and anything that one can conceivably need. It will also have a database of information about medical conditions, their causes, symptoms, treatment modalities and prevention advice, all in a language that a layman would not find too taxing.

How Can this be Done ?

India is a vast country and to create a resource base of this kind for the entire country will be a herculean task. However one can begin small by starting with a pilot project in a city like Delhi. The information regarding medical facilities can be sourced directly from various hospitals and nursing homes or from the Ministry of Health and Municipal authorities , who register these facilities with them. The key to success for something like this is that the hospitals, the doctors and all stakeholders in the healthcare domain must come together to support such an initiative and provide accurate information willingly and without the fear of it being misused in any manner. Thus those behind this initiative must be completely unbiased and have the highest level of professional integrity. This Utopian vision, even to me appears to be far cry from reality. Thus I would recommend that the government set up an independent regulator much on the lines of IRDA (the insurance regulator in India), which can then set up a body to device ways and means of creating this resource centre.

The Revenue Model

The Revenue Model can be based on certain services being paid for on an annual subscription fee. Thus for example if someone wants to know about cardiologists in Delhi, the information, which is a list of cardiologists with their contact details can be accessed without any charge. However, if someone wants a comparative opinion about the cardiologists or wants to see comments or access a blog about them or wants to interact with people treated by a particular cardiologist, then they can pay a small fee to access this information.

Advertising can be another stream of revenue. Various hospitals and medical services provider can be allowed to advertise on the site in an area clearly marked as advertising. Since the site will be attracting eyeballs from people seeking medical advice, they can be considered as potential customers for these hospitals and I am sure they would love to advertise on a topical site like this.

Regular newsletter, analysis of disease groups and other insightful reports can be another source of revenue. Hospital Ratings done in an unbiased manner and based on consistent medical and non medical parameters can be an additional source of revenue. 

Who should fund this?

This effort must be made through a private-public partnership with Ministry of Health and private equity pooling their resources together and running it as a 'for profit' enterprise.  The government must play a role as this resource centre has social relevance and can be construed as a public service. Private entrepreneurs need to get involved to ensure efficiency, transparency and high standards of quality. The government apart from partly funding the venture must follow a hands off policy in the day to day running of the enterprise. It should act as a neutral umpire setting the rules of the game and ensuring that everybody plays by them.