The Perils of Standardized Health Care

Can healthcare delivery be standardised? This is the question, which has been bothering me this week.

The thought itself was triggered by a report in ‘Mint’ earlier this week titled ‘Government plans common healthcare standards’. (http://www.livemint.com/2010/08/24233218/Govt-plans-common-healthcare-s.html)

While the report portrays the benefits of standardization of care with millions of patients receiving standard care prescribed by the government thus saving them from being shortchanged by unscrupulous doctors and mercenary hospitals, there is also a flip (and a more real) side of the argument that we must understand.

While the government pushes through the Healthcare Standardization agenda, one wonders how can the delivery of healthcare be standardized across all medical facilities in the country? Every individual is different, reacts differently to treatments, the doctors are required to take decisions based on their experience and training and not on the basis of a set of guidelines decided upon by the government. If I was to fall sick, I would want my doctor to treat me based on his knowledge and experience and do what he feels is the best for me rather than stick to a standard set of guidelines mandated by the government. All doctors and medical establishment should have one guiding principle – the interest of the patient must be supreme and if there is a situation of uncertainty, I would want my doctor/hospital to always err on the side of caution.

Also, the healthcare delivery model in the country is hugely diversified. In its current form with poor regulation and monitoring it just does not lend itself to any standardization of care.The government-run tertiary care hospitals in large cities are filthy and over-crowded with patients and over-worked and under-paid doctors. The government run district hospitals as well as Primary Health Centres are even worse off with out dated equipment, poorly trained doctors, who often do not even show up for work. The private healthcare is dominated by secondary care establishments (usually called nursing homes), which have 10-50 beds and are usually owned by a doctor or a group of doctors. These are mostly mom and pop establishments, where owner doctors reign supreme and are answerable to none. Quality of care in these establishment is of dubious standard and these are neither properly regulated nor monitored vis-a-vis outcomes or treatment protocols. Christian missionaries and other charitable institution also run a large number of hospitals and now we have a nascent category of corporate style hospitals coming up in large cities offering cutting edge care. My point-all these hospitals are differently equipped, have differing goals (for profit, non-profit, govt. owned etc.), have vastly different resources at their disposal, have different cultures and widely varying medical expertise available to each of them. How on earth can they all provide standardised, similar quality care to their patients?

Last December my father underwent a prostate surgery in a hospital in Delhi. Elderly men usually require this surgery at some point in time in their lives. Now, while I researched the treatment options for him and took surgeon’s opinions I discovered that we had several options. Our surgeon felt that the best and the safest alternative for him would be a laser surgery involving a cutting edge holmium laser. Now, this option is not available at most of the hospitals even in a city like Delhi, thus it can safely be ruled out from the ‘standardised treatment guidelines’ that are being framed by the government. In a situation like this, will it mean that patients like my father will be denied this option and he will have to endure the conventional surgery with its attendant risks of infection, excessive bleeding and a much longer hospital stay?

Let us now also look at the genesis of all this.

The health insurance companies (mostly state-owned) want treatment protocols for some common diseases to be standardised so that they can fix a rate for these procedures, irrespective of the hospital and the doctor one chooses to go to. For the insurance companies this will lead to a state of nirvana, as they would be required to pay a fixed lump sum to the hospitals irrespective of the bill a patient runs up. They can then squeeze the hospitals further and make greater profits. Now, I am not against profits, however the problems that I see in this arrangement is that the patient will suffer, the quality of care will go down as hospitals will try to manage the delivery of care with in the financial limits set by the insurance companies (after-all they also need to be profitable). This is clearly hazardous.

One buys a health insurance cover to ensure that in the time of need, financial constraints do not come in the way of accessing the optimum quality healthcare. The operative words here are ‘optimum quality’ and not ‘standard quality’ as mandated by the government. To equate these two will be a great folly. If the insurance companies believe certain hospitals are taking advantage of the situation by excessive billing (which I submit happens), they must put in place strict monitoring mechanisms including peer group reviews of treatment provided by the hospital. A healthcare regulator needs to be set up by the government to arbitrate between insurance companies and the hospitals. The regulator can possibly frame broad treatment guidelines, which can serve as references in case a dispute arises between a patient, the hospital and the insurer.

Standardizing treatment protocols in a healthcare environment as complicated and as unregulated as ours is a dangerous and mostly an impractical idea. We need to first standardize our healthcare delivery systems before even thinking about standardizing treatment protocols. Paying hospitals based on these standardized treatment protocols because it makes health insurance companies profitable is inviting hospitals to cut corners. Once this happens, it will lead to serious erosion in the quality of care and even more importantly a big trust deficit between patients and hospitals will emerge.

That would really be the ultimate irony, for if a patient does not trust his doctor or hospital, he really would have nowhere to go.

The Government's Apathy to Healthcare in India

The Union budegt presented last month by the finance minister, Pranab Mukherjee, is hugely disappointing for the healthcare sector in the country. For many years now people associated with healthcare in the country have been waiting for big-ticket reforms in the sector, but the government has been turning a deaf ear. This year too, the story is no different.

The healthcare services in the country are not only woefully inadequate but also unevenly distributed. The healthcare industry, which is hugely dependent on private enterprise is just not attracting enough investments. Setting up and managing a hospital till it breaks even and makes money requires huge upfront investments. Presently, India has 860 beds for a million people, way below the WHO's norm of 3960 beds for a million people. Studies by E&Y and KPMG have indicated that India needs to add 100000 beds per year for the next 20 years to reach close to this figure. This alone entails a spend of Rs. 50000 Cr. per annum. Compare this with what the government proposes to spend on healthcare in the next financial year, Rs. 22300 Cr. While this is 14% more than what the government spent last year, this amount is clearly insufficient.

The National Rural Health Mission, the flagship government programme for providing healthcare services in rural areas is riddled with inefficiencies. The government-run Primary Healthcare Centres are usually understaffed, ill-equipped and provide the most basic level of healthcare. Rural and semi urban India also needs good professionally managed secondary and tertiary care hospitals, which provide reasonably good quality healthcare at affordable rates. It seems that the government does not have the will power or the resources to usher in healthcare reforms.

Amazingly, the private sector entrepreneurs are willing to step in and bridge the gap. All they need is a little help from the government in the form of tax holidays, duty reduction or abolition of duties on medical devices, easy availability of funding from government institutions at soft rates, longer payback periods and land at concessional rates. The government should also set up a regulatory body, a watchdog, which will keep an eye on hospitals being set up through this mechanism. The watchdog is critical as it will establish guidelines for setting up the hospitals, monitor progress, ensure quality through regular audits, lay down a fair pricing mechanism and in general ensure that the private sector, while availing of government policy benefits delivers on the promise of efficient, good quality and easily accessible care.

This is really not too difficult to achieve. Look at how private participation has revolutionized telecommunications in our country. Today India has more than half a billion mobile phone connections, the tariffs are the lowest in the world and even remote, far-flung and fairly inaccessible areas are connected (I had my phone working in the Nubra valley in Laddakh). The phones generally work, the services are efficient and the private sector companies, who had the foresight to start early are making profits. Some are even planning to go global and compete with the best in the world. The TRAI, which is the government watchdog is seen as an impartial and fairly efficient body, doing its job of advising the government on policy matters and ensuring compliance and a level playing field amongst all the operators.

No country can progress and aspire to be an economic superpower unless its citizens have access to good quality healthcare services. Considering India's size and a population of over a billion people, (the majority living in rural areas), it is imperative that the government kick-start reforms in this critical area sooner than later. If no significant policy initiatives have been announced this year, can the healthcare industry bodies (like those associated with CII and FICCI) lobby with the government, initiate debate and fuel informed discussion amongst all stake holders so that public opinion can be rallied in favour of these reforms.

Healthcare services impact the health of the nation. It is time all the healthcare stakeholders including the government sat together to prepare the blueprint for the next generation healthcare services for the country. This is very important because, unless we have robust, universally accessible, reasonably priced healthcare services for our citizens, all our claims about being an economic superpower will remain hollow and truly meaningless.

The Silly Question of RoI in Healthcare Marketing

The other day I was with Dr. Jadhav who heads the Marketing function at the well known Narayan Hrudayalaya in Bangalore. Dr. Jadhav was keen to use radio for his hospital’s communication needs and I was hoping to persuade him to advertise with Fever 104, the radio station owned by The Hindustan Times, my current employers. Narayan Hrudayalaya, which is a well-known cardiac hospital thanks to the famous Dr. Devi Shetty and his pioneering initiatives, has recently started a Cancer Centre as well as a Multi Speciality hospital and wanted to promote these. The aim of the communication was to tell the citizens of Bangalore about these services available at Narayan Hrudayalaya and to drive ‘footfalls’.

While I discussed the plans with Dr. Jadhav, I could not help but notice his concern about the RoI on his marketing spends. Dr. Jadhav was very clear that if he spent Rs. 100, he needed 3 times the sum in revenue, which could be directly attributed to this activity. I could easily relate to this because this is exactly the kind of expectations the management teams had of me, when I headed the Marketing function at Max Healthcare and Artemis Health Institute.

I wish calculating RoI on healthcare spends was this easy. While there are many websites, which help one calculate RoI on marketing spends using complex formulae and spreadsheets involving the lifetime value of a customer, the cost of capital and what have you, I believe quite often the best way forward is a subjective gut feel and patience.

Measuring the success of a healthcare marketing campaign by merely counting the number of queries/walk ins generated in the hospital OPD is a great folly. The hospital business is unlike any other business and one must remember that exciting marketing communication alone will not lead to people walking in to check out the services of the hospital. This can happen for a new restaurant or a movie theatre, but for someone to visit a hospital he must have a pressing need.

Tactical communication involving discounts, freebies and the like should be handled with care. I am not sure I would prefer to go to hospital for cardiac surgery because there is a discount being offered on the surgery, or I would like to go under the knife at a particular time just because the hospital is offering a deal. Come to think of it, I would be downright suspicious of the hospital if it tries to hustle me into a medical procedure by making a commercial offer.

Marketing spends in a hospital must be looked upon as an investment in the hospital brand and the values it stands for. The customers should be informed about the services of the hospital, the experience and training of its doctors, the robustness of its systems and processes and above all the promise of the experience the hospital hopes to deliver to its customers. It can highlight its ease of access, competitive pricing vis-a-vis other hospitals and superior services. The hospital must showcase medical excellence, send out stories of success against great odds and constantly remind its customers what it truly stands for. It needs to communicate all or some of these over time before it should even attempt to measure the RoI.

A hospital’s brand equity is built over many years and much as hospital marketers would like to hurry this up, there are just no shortcuts. A hospital must set aside a small sum of money (7% of sales in the first years tapering to 2-3% in later years) year on year to spend on connecting with its patients and the local communities it hopes to serve. It should diligently spend this money informing, educating and reinforcing its brand values.

A few years later, the hospital will find itself buzzing with patients and no one would really be interested in the RoI on marketing spends.

Indian Healthcare 2010

Here is a list of 10 things one would like to see happen in healthcare services arena in India in the New Year.

1. Healthcare Service providers should move faster towards recognising the patient as a customer and focusing on delivering ‘Total Patient Care’. This would include better medical care as well as much superior levels of hospital services. Hospitals need to invest heavily in people and process improvements to achieve the goal of ‘Total Patient Care’.

2. Investment in the hospital brand. Most hospitals in India are chary of investing in the brand and whatever little marketing communication that happens is purely tactical, meant to drive traffic or communicate the commencement of a new service or the addition of another doctor. This must change. Hospitals must find a credible and differentiated positioning in the consumer’s mind and move quickly to occupy it.

3. Develop an information resource pool that allows patients and caregivers to check out the hospital services, compare doctor’s qualifications, training, specialisation and years of experience.

4. Focus on wellness rather than illnesses. Indian hospitals are mostly about sickness and ordinary folks dread visiting hospitals. It would be a lot better if our hospitals also incorporated wellness services and promoted them aggressively. Prevention and community medicine should become critical areas of focus.

5. Develop sustainable and high quality outreach programs by seeking local community participation. I live next doors to Indraprastha Apollo Hospitals in New Delhi and I often wonder, wouldn’t it be great if this hospital ran a community health program in our area. The local community can offer space for the hospital to run and manage a small clinic with a round the clock nursing coverage and doctors (family physicians and specialists) visiting for a couple of hours everyday. Imagine, all major hospitals running maybe 5 such clinics in areas abutting them. The hospitals will not only get more patients, they will earn tremendous goodwill of the local community.

6. Use social media to create patient communities and facilitate constant exchange of thoughts and ideas. Let medical experts join in to provide guidance and keep the community interactions at an even keel. We had tried something like this at Artemis Health Institute in Gurgaon. Unfortunately it fizzled out once I moved on. More hospitals need to remain connected with their patients in a meaningful manner, even when they do not need the hospital. It is an investment in a relationship, which will pay dividends in the long term.

7. Improve Emergency services. I recall calling Apollo Hospitals once to rush an ambulance to my residence to pick up my wife who had accidently hurt herself and was bleeding profusely. I explained that I was at work and was on my way as well. I reached home before the ambulance and brought my wife to the Emergency in my car. The ambulance never reached my place because the Emergency services at the hospital kept calling my wife at our home landline phone to confirm whether she was really hurt!!!

8. Government run hospitals treating the poor are models of sloth, inefficiency and corruption. It would be great if private enterprise forges some kind of a win-win partnership with these hospitals and improves services. I am sure the savings from reducing crippling systemic inefficiencies will itself ensure decent profits for the private healthcare enterprises. The government must take initiatives in inviting a few carefully selected private healthcare organisations to participate in this experiment.

9. Health Insurance must penetrate deeper and wider. The claims processing should become less cumbersome. In this age of instant communication, hospitals and insurance companies manually fax documents, seek patient histories and look for loop holes to wriggle out of paying claims. This must end. Insurance companies and hospitals must connect with each other seamlessly and exchange information that helps patients get better service.

10. Rural and semi urban India must get its due share in the development of healthcare infrastructure. The government must encourage investments in primary and secondary care in these areas. Unless we have more and more people accessing reasonably good quality healthcare services close to where they live, the India growth story will remain a big sham.

Here is wishing everyone a happy and healthy 2010.

Pic courtesy www.muhealth.org

Indian Hospitals Need New Online Initiatives

Websites of Indian hospitals are hardly something to write home about. They are mostly poorly done, difficult to navigate and usually the information lies buried so deep that it tests ones patience to get the relevant information . The other day, it took me close to 20 minutes and numerous clicks to locate the address of a hospital from its website. I needed the address to send a Diwali card to a friend who works at the hospital and try as I might, I just did not seem to find the address of the hospital.

Almost all of the hospital websites that I am familiar with are largely static. Thus, they do not interact with patients or caregivers looking for specific information. They do not allow one to book appointments, download reports, interact with doctors taking care of ones loved ones, send good wishes or chat with the patients. They do not support e-commerce. Thus if I was an NRI living abroad and wanted to buy my parents an annual health check or if I wanted to pay their hospital bills on line, I just can not.

In the era of burgeoning medical travel and with Indian hospitals attracting a sizable chunk of patients from all over the world, this does seem strange. For some unfathomable reason, Indian hospitals have not invested too much on their websites or for that matter on online marketing per se. I believe it is high team someone woke up and used the net better.

It is indisputable that a certain kind of Indian consumer has fully embraced the e-revolution and their tribe is growing by leaps and bounds. With the broadband penetrating deeper, more and more Indian consumers will look at the internet for information, entertainment and commerce. They would seek information about doctors, medical facilities and would like to compare medical outcomes across hospitals. They would like to chat with doctors and customer experience executives in the hospital before making a choice. A hospital aspiring to attract these kind of patients must consider significant investments in their websites and in enhancing their online visibility.

The entire gamut of social media on the net can also be used by hospitals in interacting with their patients. At Artemis, we tried creating an online community of patients and caregivers, where members could post their hospital experiences, their recovery post discharge from the hospital, photographs showing their progress and interesting pieces of information on their disease and latest advancements in medicine. We also encouraged hospital doctors to interact with members of this community. Unfortunately the hospital discontinued this initiative once I left. The hospital was cutting costs and building an online community was considered too ‘long term’ for investments to continue.

The next level of online presence would require hospitals integrating their Hospital Information Systems (HIS) with their websites allowing patients and their relatives on line interactivity. This will facilitate hospitals inviting second opinions from experts anywhere in the world, keeping the patients family and relatives (who might be half way around the world) in the loop on the patient’s progress, interaction with their doctors and online payments. The big issue here is the online security of patient information. The hospitals will have to invest in a foolproof system, which guarantees authorised access to medical data. It would be a disaster if a hospital integrates its website with HIS and leaks confidential data.

With the current level of IT advancement, this and more is certainly possible. Indian hospitals have to look at these opportunities seriously and start investing. The returns would quickly follow

Service Design Prescriptions for Indraprastha Apollo Hospitals

A couple of weeks back I had written about my experiences at the Indraprastha Apollo Hospitals. Following the publication of that post, I received a call from the hospital. I must say I was very surprised. The caller was a lady who said she looked after service quality and was calling to learn more about my experiences at the hospital. While apologising for what we had to go through the hospital, she wanted more details and appeared keen to fix the problem. Subsequently I also received a call from my former colleague Usha Bannerjee, who presently heads nursing at the hospital. She too admitted that they have been having ’service’ issues and they are trying their best to rectify these.

I would like to believe that Apollo’s problems are those typical of enterprises, who have more customers that they can possibly handle. To compound matters, they are stuck with poorly trained people and processes, which make matters infinitely worse. That they are committed to better services is great. However, the problems will not go away in a hurry.

The problem of plenty in a hospital is just as bad as the problem of having very few patients. Apollo Hospitals attracts patients from across the country and pretty much from the whole world. ( I literally live in the hospital’s shadow and keep running into enrobed Arabs, staying in rented digs in Sarita Vihar, where many an enterprising landlords have converted their flats into makeshift guest houses). The sheer numbers mean that the hospital staff is unable to give enough time and attention to each patient and there is always a rush at hospital counters. Thus, the service folks at the hospital are not interested in looking after individual patients, all that they do is ensure that the patient is lobbed in another direction, away from the counter they man. This is all too common in service establishments where there are a surfeit of customers (bus and railway stations, government hospitals, etc.)

Apollo gets away with this because it is a healthcare establishment, which has some of the best known doctors working for it. The patients flock to the doctors looking for succor and inevitably get sucked into the Apollo system. The other thing that works in Apollo’s favour is the simple fact that most Indians still consider doctors and medical establishments as demi Gods and rarely challenge small service failures, lest they offend their doctors who they believe hold the power of life and death over them. I am sure if Apollo was a hotel, its customers would be a lot more demanding and a lot less forgiving of its follies.

How can Apollo improve its services. Here are a few suggestions.

The management team at Apollo Hospitals should be clear in its customer experience goals. They must set the agenda for service excellence and establish clear and measurable goals. They must also demonstrate their willingness to bring about serious change and the ability to stay the course.

Apollo needs a complete makeover in terms of service processes and their flow. While the hospital has embraced the JCI processes, they seem to be more from the perspective of getting a certificate rather than genuinely improving customer experiences. Each process needs to be carefully studied and calibrated in terms of the delivery of the right customer experience.

The hospital needs to look at its people dispassionately and put them in a matrix based on their ’service’ orientation. Any other consideration such as the number of years they have spent working in the hospital should not matter (there is no such thing as loyalty). Only those who demonstrate adequate customer orientation, empathy for patients and the willingness to go the extra mile to ensure patient satisfaction must be retained. Others, who have the potential and need training should be taken through a structured training program focussed on delivering the right customer experience. This process would lead to the elimination of a lot of employees, particularly those who have been with the hospital for long. This should be viewed as an opportunity to induct fresh talent, young and bright people more in tune with the needs of the present-day customers.

The change towards a better customer focus, will also entail a new cultural orientation. The hospital should aim to embrace a more open, customer friendly culture, which rewards team members going out of their way in delivering great customer experiences. The new culture should be transparent, encourage team play and the senior management should lead by example.

I know these prescriptions are easy to suggest. However, the real challenge lies in implementing these and managing the transition. Great customer service must be driven with great force and alignment of every individual including medical folks is a must.

For Apollo Hospitals, I reckon it is really high time they began.

The Future of Medical Education in India – The Way to Go

The Union Health Minister Ghulam Nabi Azad appears to be busy shooting the breeze by announcing vague policy changes involving setting up of Medical Colleges through private capital and in collaboration with government run district hospitals. The minister who is well known for putting his foot in the mouth, recently announced at a FICCI conference that the government is considering relaxing the norms for setting up medical colleges by the private sector. He also announced that these colleges can be affiliated with the government owned district hospitals, thus doing away with the requirement of a teaching hospital to be attached with the medical college.

The minister is seeking private equity participation in rural, backward and far-flung areas of the country. He believes that the private players can be attracted to set up medical colleges in these parts of the country by offering concessions such as access to district hospitals.

Doesn’t this sound completely hare brained?

Why would a private entity invest money in backward and far flung areas? The minister must know that what passes for District Hospitals is a sham. The hospitals are poorly equipped, have limited resources and are dens of corruption. Many are old and decrepit, some even falling apart with peeling plaster and leaking roofs. How will these private medical colleges attract students when they will be offering their students medical training in these hospitals? Will these students learn cutting edge medicine in hospitals, where high tech might mean an X-Ray machine? Why would they pay hefty fees to go to attend these medical colleges, knowing fully well what lies in store for them in the future? And if the students don’t find this proposition attractive, how will the medical colleges make money and generate a return for their investors?

India needs more doctors. According to the current planning commission estimates India needs 600000 doctors, a million nurses and more than 200000 dentists. The only way this shortage can be met is by investing in medical education. The government must find the resources to set up more medical colleges and teaching hospitals across the country. The bulk of the investment must come from the government. After all, this is an investment in the future of the health of the citizens.

The private sector can be roped in to partner in this effort, where in some of these colleges can be set up in collaboration with private players. The government can facilitate these investments by offering tax breaks, land at concessional rates, soft loans, duty concessions on buying high tech equipment, and by developing allied infrastructure like power, roads and telecom in these areas. The teaching hospitals established along with the medical school can than serve as regional/district level referral centres for far flung Primary Health Centres. The teaching hospitals can also run outreach programs, touching lives of people in remote areas through regular camps and mobile hospitals.

These state of the art medical colleges and teaching hospitals will than be able to attract bright students and dedicated faculty. Many of them will come hopefully, not from far off places but also from local areas and will be happy to serve their own communities. Thus, they will form the backbone of a medical network that will extend its reach into the farthest nooks and corners of our country, making it possible for our citizens to access high quality healthcare nearer to their homes.

The minister must find a way to make a clean break from the past, think afresh and find the resources to get this going. More importantly he needs clear thinking and resolute will to bring about the change in the way healthcare is delivered in our country.

My experiences at the Indraprastha Apollo Hospitals

The other day I landed at the Indraprastha Apollo Hospitals, a stone’s throw away from my residence in New Delhi. My wife needed a test and our doctor at Max Healthcare asked us to get it done at Apollo as the equipment at Max was out of order. The moment I walked in I felt as if I was on a railway platform. The hospital was full of patients as everybody appeared to be in a mad rush. In the OPD area, the ladies at the reception were busy, chatting amongst themselves, while patients and their caregivers waited for their attention. They wore no uniforms and for some strange reason, they were also collecting cash from the patients (apparently for the doctor’s consulting charges) and handing out receipts scribbled on small chits, which did not even have the hospital’s name on it.

Strangely, I was than directed to a cash counter to pay for the tests.

Since my wife needed some injections we were asked to go to the pharmacy and buy them, bring them back to the treatment room in the OPD area, where a nurse would help us with the shots. As we wound our way back to the Pharmacy we discovered that buying medicines is a huge chore. We submitted our prescription at a counter in the pharmacy and were handed over tokens and asked to wait. There was no place where one could even stand, without being pushed around. After being jostled around for 30 mins, we managed to buy the medicines, only to discover that we also needed to buy the disposable syringes, which the doctor had forgotten to mention on the prescription. So lo and behold the charade of the tokens was repeated.

During all this I counted 18 people inside the pharmacy store and the two guys who handed me the medicines and accepted my cash kept chatting with each other in a south Indian tongue, without bothering to pay any attention to me whatsoever.

We returned to the OPD and were directed to room no. 15 for the shots. This room was locked and we were than directed to a paediatric immunisation room full of anxious parents and bawling kids. This is where my wife managed to get the shots she needed. We wasted more than an hour in all this and ran around the hospital OPD trying to get some very basic services. The staff was uniformly disinterested in us, poorly trained and too busy to attend to us. Fortunately, the test my wife needed was routine and she is in good health. I can just about imagine the plight of patients and their care givers flocking to this hospital and being shunted around by a callous system, which barely works.

And now here is what happened when I came to collect her reports two days later.

I called up the hospital to check if the reports were ready. On being informed that I could collect these by 8 PM, I agreed to stop by to pick these up. As I walked in at about quarter to 8 in the evening I discovered a security guard merrily locking up the report collection area. He directed me to take another door into the radiology reception and 5 minutes later, when I walked in I found the lights switched off, the guard had also disappeared and there was not a soul to be found. Perplexed, I walked into another adjacent room and found someone busy on the phone.

As I explained my predicament, this gentleman informed that I was late and that the staff usually left 15-20 minutes earlier than closing time! Amazed and incensed at all this I asked to be directed to someone, whom I could lodge a complaint with. Much to my disbelief I was told to approach the Emergency Medical Officer in the Emergency!

At the reception in the Emergency, I found myself explaining my situation to a young man, who was simultaneously trying to answer questions from an anxious gentleman, whose father had just been brought in with severe chest pain!!! The emergency medical officer, who was supposed to record my complaint was predictably busy with a patient and I was asked to wait. After about 30 minutes of watching the bedlam of a busy Emergency room with no one paying me the slightest attention, I raised my voice (and in the process added to the chaos) and demanded to see the highest ranking hospital official to record my complaint.

I was than informed that the Night Duty Manager will now attend to me soon. Another wait of about 15 minutes followed and yet no one showed up. I again screamed at someone and in another 10 mins a nurse walked out looking for me. She understood my problem, asked me to wait and went to fetch my reports. She returned in a while with my reports and gently admonished me for being so late and irresponsible in collecting my documents.

This is a true story of Delhi’s only JCI accredited hospital. God help us all!!!

The Apathy of Delhi Hospitals Towards the Poor

The Delhi High Court has been after private hospitals in Delhi to honour their commitments regarding the treatment of the poor, but sadly to no avail. The hospitals are just not willing to treat poor for free, a condition that they agreed to while accepting land from the government at hugely subsidised rates. In-spite of the Delhi high court directing the hospitals time and again to fill up the beds for the poor, the hospitals are dragging their feet by hiding behind every legal loophole that they can find.

For the uninitiated here is the story. As many as 38 private hospitals in the city managed to get land at subsidised rates from the government under the condition that they will treat certain number of poor patients free of cost. The list of these hospitals today read the whose who of the hospitals in the city. However, once these hospitals commenced operations, they never honoured their part of the bargain. Thus the poor continue to be unwelcome in these hospitals, while beds reserved for them either remain empty or are filled up with full paying patients. This needless to say is criminal.

The reasons for this, however are not too difficult to fathom. The business of healthcare is a capital intensive business and the cost of real estate in Delhi is a prohibitively high expense. Thus, getting land from the government at very cheap rates against a commitment of treating the poor once the hospital starts, seems to be a good way of grabbing land. I seriously doubt that any of these private hospitals had any intention of treating the poor to begin with. This was just a ploy to grab land to build the hospital.

Now with the hospital up and running they had to find excuses to wriggle out of the commitment made. Here is a sample of what the hospitals have been saying. A large 600 bed hospital sitting on prime land in south Delhi and part of the largest hospital chain in the country claims that they are unable to treat the poor because they can not find them! As per them the government needs to refer poor patients to the hospital, and since there has hardly been any government referrals, they can not fill up the beds reserved for the poor. They further claim that ‘free’ to them means a free bed and the patient has to pay for all other expenses, thus making the hospital out of reach of the poor. (Mercifully, this claim has now been thrown out of the window by the high court). Other hospitals too advance similar claims. Strangely many do not offer any reason for not filling up these beds.

A recent report in The Times of India indicates that 16 of these 38 hospitals have not even bothered to submit details of the status of their free beds to the government. Hospitals like Dharmshila Cancer Hospital and the Jaipur Golden Hospital have submitted that all their free beds are empty. The Times of India report also alludes to a nexus between the health officials of the government and these hospitals. The health officials refer their kith and kin or their political masters to these hospitals and they are treated free against the beds meant for the poor.

While all this has been going on for many years, some public spirited Non Governmental Organisations have moved the courts. The high court has made all the right noises but justice is yet to be done. While the cases against these hospitals meander in our courts, the poor, as always continue to suffer silently.

Pic courtesy http://www.flickr.com/photos/9019392@N08/552358084/

So much for my ‘Indian Hospital Experience’

While trawling the net I came across a blog (http://www.travelblog.org/Asia/India/National-Capital-Territory/Delhi/blog-440604.html) about the travails of an American, getting treated for a mole/wart/skin cancer in New Delhi. The experience narrated in this post is exactly the kind of stuff we do not want. I am amazed at some of the narration and the stereotyping this does of the Indian doctors and medical system.

The blog has a semi mad sardarji (sikh) as a doctor who speaks and understands no English, laughs at his own jokes in Hindi and does not understand the difference between a mole and a pimple. The doctor has never heard of the United States and knows America, a country whose citizens are rich and ripe for fleecing. The doctor prescribes lotions and creams for treating the mole, which are not available at his own pharmacy and the patient (the author) walks out, having parted with Rs. 500 and nothing to show for it. Astoundingly, this gentleman returns to the clinic of the mad sardarji, encounters a ‘wildeyed’ patient on a wheelchair, and asks the doctor to burn off the offending mole in the emergency room next door.

Can you really believe this? A dermatologist who knows no English, does not know what the US is, prescribes lotions for treating moles and does strange surgery in his ER. All this in Delhi. To me this sounds stranger than fiction.

One can not study medicine in India unless one knows English as the language of instruction in medical schools across the country is English. I refuse to believe that there exists a dermatologist, who can’t differentiate between a pimple and a mole and if I ever encountered, will I let him treat me not once but twice! Come to think of it, will I let someone operate on me if their was a serious language barrier, when I am not sure if the doctor/surgeon understands the problem. If I agree to all this, than it is me who is playing with fire and taking completely unacceptable risks.

I am willing to grant that the author might have been lured to a quack’s place by someone. However, his complete gullibility and his willingness to try out this kind of treatment, which one would instinctively recoil from appears to be a product of his imagination. This as I said earlier only reinforces Indian stereotypes of a land of great mystery, faith healing, strange medical practices and half crazy doctors.

I am sure this makes for great reading back home.

However, what it also does is that it mocks at the great advances India has made in medicine. It paints a very distorted picture of Indian healthcare. India has some of the most modern hospitals and qualified medical personnel, which attract thousands of foreign patients every year. While, there is no denying that there are quacks and the like who exist, not going to a qualified dermatologist for the removal of a mole and continuing with the treatment of a doctor/quack who does not understand ones language will be considered foolhardy anywhere in the world.

Let us have none of this kind of crap.

Pic courtesy http://www.flickr.com/photos/robotalphabet/2693142482/

The Dilemma of Single Speciality Hospitals

A recent cover story in Business World highlights the growing influence of Single Speciality Hospitals (SSH) in India. I read the story carefully. First and foremost, I was delighted to see a cover on healthcare in Business World. It is not often that the business of healthcare gets prominence in a widely circulated and highly respected business weekly. That, BW decided to do this story is a testimony to the growing importance of the private healthcare sector, which is something to cheer about.

SSH’s make good business sense at least in some specialities. The investment required is low compared to a large Multi Speciality Hospital (MSH), funds can be accessed through PE firms and financial institutions, the hospital can be set up quickly and if one ropes in a well known medical luminary of that particular field, it is not too difficult to fill up the beds. Once the operations stabilise, one can consider franchising or expanding by setting up super specialised centres in large multi speciality hospitals. Specialities like Ophthalmology, Dentistry, Obs and Gynaecology (remember the neighbourhood mother and child centre) have always had Single Speciality Hospitals and clinics. The trend is now towards large SSH for Oncology, Urology and even Day Care Surgeries.

These hospitals are presently being set up by eminent doctors, who are partly putting in their own money and getting PE funds and financial institutions to invest in their ventures. Thus these SSH’s are hugely dependent on the goodwill and equity of the owner-doctor. Also one is not sure, how capable these hospitals are of attracting the best medical talent and thus providing high standards of care to patients. Typically, in a doctor owned SSH set up, it is rare to find other doctors of similar or higher capabilities than the owner. The fear of always being eclipsed by the owner-doctor drives other talented doctors to MSHs, where the canvas is bigger and the environment less claustrophobic.

From a consumers perspective SSH’s are a huge dilemma.

My father, now in his seventies suffers from an enlarged prostate. This is a problem that most elderly men are likely to have. Like most people he is terrified of surgery and has been on medication for the last few years. However, we know that surgery can only be postponed for a while and sooner than later he will have to go under the knife. Now should I choose a RG Stone Clinic, which is a well known SSH for Urology, or do we go to the multi speciality Max Hospital. While RG Stone may have better and more advanced equipment for the treatment of his condition (some fancy lasers), I am not sure they are equipped to handle complications, which may happen. The last thing one would want to deal with is an emergency requiring shifting him to a larger hospital after the surgery.

Also, I am not sure about the credentials of the doctors in RG Stone clinic. On the other hand MSHs like Max and Fortis and Apollo are well established brand names, have systems and processes (Apollo is JCI accredited and the others are in the process of accrediatation) and some of the most well known surgeons in the city are associated with these hospitals. From a cost perspective RG Stone might be cheaper, but if the patient is fully covered by health insurance (as my father is), expenses are the least of ones concerns.

Thus, in a situation like this, I will be inclined to go to the bigger MSH and I would reckon most of you will do the same.

And here is than the lesson for the SSH’s. They need to establish themselves as a far superior option in their chosen speciality. They need to invest in the brand, move away from the perception of being owner-doctor driven centres, hire the best talent by offering a great work environment and competitive salaries and establish systems and care protocols comparable to the best in the business.

SSH’s must convince me, the consumer, that they really are super experts, before I can seriously consider entrusting them with my care.

Marketing With In

Here is an interesting exercise that I recommend hospital marketers to try out with their colleagues in the hospital. Select a group of 30 individuals working in the hospital, preferably those who handle customers. Include in the group a few medical folks, doctors, nurses, front office executives, billing executives, F&B personnel and a few guys from housekeeping. Ask them simple questions on what the hospital brand means to them.

You would be surprised with the variety of answers you are likely to get.

All marketers try and look for a unique customer proposition for their hospitals, one which they believe the hospital delivers to its customers. The proposition is carefully selected after many a long ‘brain storming’ sessions involving the hospital’s leadership team, the branding and communications experts from advertising agencies pitching for the lucrative account. After these hectic sessions what often emerges is a positioning statement, which is than condensed into the hospital baseline, which is than incorporated in the logo of the hospital. It is in essence the consumer promise, which than is communicated to the external world in right earnest. However, what they fail to do is communicate this promise with the same vigour and zeal with customer facing employees, who are actually tasked with delivering this promise.

Let me take examples from two hospitals, where I used to work.

Artemis Health Institute in Gurgaon says that it is all about the ‘art of healthcare’. Max Healthcare similarly professes to be ‘caring for you …for life’. Artemis believes that its services are differentiated from other hospitals because it focuses on the softer side of medicine. The arguement is that the best infrastructure and world class medical faculty is a given, and easy to replicate. What really distinguishes this hospital from others is not what it delivers but how it delivers. Similarly Max Healthcare is all about superlative care, what the hospital calls ‘patient centric care’. It prides itself in delivering great patient care at all customer touchpoints and at every patient interaction.

Now these are indeed lofty goals. I would even go ahead and aver that when these hospitals were being conceived and set up, the founding teams did believe in these ideals. The hospital communication program was designed to put across these differentiations and a fair amount of energy and effort was expanded in developing communication, which helped establish the hospital’s core values. However, and here is the nub of the matter, these hospitals just did not do enough to communicate these values to their own folks down the line who were actually supposed to deliver these sterling objectives.

In the initial days of commencing operations the hospitals did make an effort to train people in handling and treating patients as customers. However, the initial enthusiasm waned soon enough, competition poached many a well trained individuals and somewhere in the hurly burly of running large hospitals the idealism of the past gave way to an all pervading cynicism. Training individuals in the ideals and core beliefs of the hospital became a chore and the trainers too lost their passion.Thus the marketing promise, the all important differentiator remains only in the minds of resolute brand managers who faithfully continue to reproduce these lines with the hospital logos and the colours.

Unfortunately, this is true of most hospitals I know. A brand promise must be delivered unerringly and all the time. For, which hospitals must spend time and serious effort in keeping the promise alive amongst those who are supposed to deliver it a million times everyday.

Pic courtesy www.flickr.com

The Healthcare Opportunity in India

Everybody acknowledges that the healthcare industry in India has a lot going for it. Patients from across the world are looking at state of the art Indian hospitals for cheap and quality care. The doctors and the nurses are considered to be one of the best in the world, their is abundant supply of good quality medical talent, health insurance is penetrating deeper and the market is predicted to grow substantially.

A quick look at the numbers tell the story. Healthcare is presently a USD 35 bn industry and is expected to grow to USD 75 bn by 2012. A Confederation of Indian Industry report says that investments worth USD 50bn are required annually for the next 20 years to meet the growing demand. India will need 3.1 mn additional beds (presently 1.1 mn) by 2018

While the sector has seen substantial investments in the last year, they are but a drop in the ocean. The healthcare sector has not really seen the kind of action that one would expect considering the opportunities.

The country has just a handful of players who have any significant presence in the market. These include the Apollo Hospitals Group, Fortis Healthcare, Max Healthcare, Wockhardt Hospitals, Manipal Hospitals and Columbia Asia. Out of these only Apollo and Fortis has a significant pan India presence. Wockhardt is largely present in the west and south India, Max is located only in Delhi and the National Capital region and Manipal Hiospitals has presence only in South India.The expansion plans of some of these are in the ‘go slow’ mode. Manipal’s hospital in Delhi, which was earlier slated to commence operations is no where near completion, Max’ hospitals expansion in East and South Delhi are yet to commence operations. New entrants including Reliance are still testing the waters. Sahara group has recently commenced operations at their first hospital in Lucknow, while the plans for many more are still pretty much on paper. Artemis Health Sciences, which had announced ambitious plans for 10 hospitals by 2015 is still struggling with its first venture in Gurgaon and plans for the other hospitals are on hold. Wockhardt is in the doldrums as its parent, the eponymous pharma company is in a financial mess and has reportedly put its hospitals business up for sale.

Strangely, not many foreign hospital chains has as yet finalised their plans to enter the country. Healthcare consulting firms have done studies for some likely entrants but nothing concrete has come of it as yet. Columbia Asia is the onlyforeign hospital chain, which is making steady investments and following a well thought through strategy of establishing its presence in tier 2 towns in India.

It appears that amongst the foreign players the reluctance to invest in India largely stems form the fear of the unknown. Everyone is waiting and watching for an opportune moment. The lack of a proper regulatory environment and an uncertain health insurance play is also acting as dampners.

However, I also believe that for wanna be investors, whether Indian Corporates or foreign players, the time is just about right to make that foray. It is being widely acknowledged that the worst of the economic downturn in India is behind us, a new government is set to take charge in less than 15 days from now and healthcare is bound to be on its priority agenda.

Pretty much like the telecom sector, I believe that the time has come for the healthcare sector to break the shackles and herald the next wave of transformation, which will fundamentally change the way most Indians access healthcare today.

Pricing Healthcare Services

The pricing of services in a hospital is perhaps one of the most complex and difficult exercise undertaken by the hospital managers. Pricing is  usually a Marketing function in most industries and the final call would usually rest with the Marketing chief. However, in hospitals this seldom happens. Pricing issues are generally discussed and debated in the executive committees and the leadership teams, views are sought from senior medical leaders and usually a consensus is arrived at. l,

Many hospitals follow a ‘market based’ pricing model, which simply means they comb through the pricing policies of their competitors, get pricing data from various labs and other diagnostic centres through their referral sales teams and establish their pricing either basis a premium or a discount from their chosen competitors.

Very few hospitals have a ‘cost plus’ pricing system. Developing an accurate costing of all medical procedures is next to impossible. This is simply because the medical consumables used vary from doctor to doctor and also depend on the complexity, age and general condition of the patient. The cost is also invariably a function of the training and competence of the concerned doctors and medical staff attending on the patient. Thus the cost of a bypass surgery may vary dramatically depending on the condition of the patient, the competence of the surgeon and his team and co-morbidities like diabetes.

The calculation of a price is usually based on a ’surgeon’s fee’. On top of this is added the cost of anaesthetic gases, the anesthetist’s fee, an OT fee and OT consumables. The surgeon’s fee is usually checked with the hospital’s surgeons and if it is Rs. X, the fee for surgery inclusive of gases, anaesthetist’s fee and the OT charges usually adds up to Rs. 2X. 

The patient on top of this is charged room rent depending on his choice of the hospital room, the cost of medicines and room/ward consumables and all diagnostics. The hospital also charges exorbitant consultant’s visiting fee every time he/she visits a patient in the hospital. (Some hospitals like Artemis cap this to a maximum of two chargeable visits). Strangely all hospitals charge a premium on all services if a patient chooses a single or higher category rooms. This simply means that if one opts for a single room one pays higher for everything, the surgeons fee, the cost of surgery and diagnostic tests. Most people do not know this and believe that the hospitals charge a premium only on room rent. Many would consider this a pernicious practice simply because a surgeon’s skill and time, which are the determinants of his fee has nothing to do with the room category a patient is in.  

Some hospitals like Max Hospitals create price bands for surgeries based on their complexity and average duration. Thus all surgeries in a particular band has the same basic surgeon’s fee. On top of it is added everything else.

Healthcare Pricing in India is still very unscientific and subjective. This is a far cry from the pricing models prevalent in the US, where ICD and other scientifically designed parameters help assess the cost of a procedure and patient billing. Health Insurance companies have been able to push through accurate and scientific billing procedures.

The need for a better system for patient billing in hospitals is acute. The government must establish a regulatory body to help fix the basic billing rules for all hospitals. The hospitals should than be allowed to price themselves as they wish keeping in mind their expenses etc. I would reckon once insurance companies gain prominence as payors, they would start dictating their terms to the hospitals.

And that would be a different story altogether.

Compulsory Rural Postings After MBBS

The Hindustan Times reported a few weeks ago that the Union Health Minister Dr. Anbumani Ramdoss has announced that young medical graduates, fresh out of medical schools will now have to mandatorily serve one year in rural and semi-urban centres in India.

Dr. Ramdoss believes that this will help in augmenting healthcare services in these parts of the country. It is well known that in the Indian hinterlands the availabilty of healthcare services is pathetic.  In villages, where more than 66% of India lives, it is rare to find a qualified doctor. In semi-urban centres too modern, good quality and reliable healthcare is largely unavailable.    

The government has set up a network of Primary Healthcare Centres in the rural areas. However, these centres are mostly crumbling buildings with poor or non existant medical infrastructure. The doctors posted in these back of the beyond places are mostly conspicuous by their absence. District Hospitals established in all district head quarters are also in a bad shape. The medical infrastructure is poor, doctors are poorly paid and are mostly buried under an avalanche of patients. 

While good quality healthcare remains out of the reach of most Indians living in rural and semi-urban India, their does seem to be a crying need for qualified doctors. However, I am not sure if a compulsory posting of young doctors is the solution.

The minister must recognise that young doctors passing out of India's medical colleges aspire to a career in medicine, which can afford them a modern and comfortable life. They see their peers passing out of fancy business schools choosing high profile careers in business . A doctor toils much harder-many years at the medical school to earn a grduate degree, followed by a gruelling post graduate course and than the struggle for a job in an intensely competitive medical world. Now to send them for one more year to the inhospitable Primary Healthcare Centres and District Hospitals appear to be cruel.

Moreover, one is not sure how competent fresh medical school graduates are and what quality of care will they be able to deliver in ill equipped and distant rural and semi urban medical centres, where they might have to work unsupervised. While, they may be much better than what we have today (assorted quacks), they will hardly be able to do justice to the demands of their profession.

While the minister might argue that since medical education in India is largely subsidised by the government and therefore it has a right to ask these young graduates to spend one year of their professional life working for the government in far flung inaccessible areas, this would hardly cut any ice. By the same logic shouldn't engineers, business and science graduates passing out of government owned colleges and Universities be also required to serve in remote areas. This can never work.

I do believe that there are no easy answers here. It will take many years for good quality healthcare services to 'trickle down' to these remote rural areas. For the moment, the government must provide roads and communication infrastructure, which allows patients to be quickly transported to urban centres, where relatively better healthcare is available. The government must offer incentives such as an option for subsidised post graduate education, health insurance and guaranteed employment for doctors, who choose to serve a year or more in rural hospitals. 

Last but not the least the government must improve its healthcare infrastructure. It must invest in better equipped facilities, ensure better hygiene and provide a better professional work environment. It can even experiment by involving private players in a model which guarantees minimum returns on private capital and the franchisee will guarantee far better and more efficient care.

At the end of the day, the government must try and attract young doctors rather than force them into rural postings.