Lessons from the Corona Virus

The Corona Virus pandemic has been ravaging the world like no other in living memory. The disease, really something as innocuous as a viral flu has disrupted life like never before. Millions of people the world over are locked into their homes, not daring to step out lest they catch the virus and end up in a hospital or even in an early grave. The developed world with showcase medical facilities is the worst hit. Italy, Spain, France and the UK are struggling to get their act together against the marauding virus. Prince Charles and even the British Prime Minister are reported to be nursing mild Corona Virus infections. The US is likely to overtake everyone in this ghastly tragedy. The US President, an unstable and tempestuous man at the best of times, believes that if they end up with deaths in the range of 150000 to 200000 people, he would consider that as success in his efforts at controlling the virus.

The economists are already talking about a global recession. Most businesses are shuttered, the Olympics have been postponed to the next year and no one knows when will all this end. The international and even domestic travel is at a standstill, airlines are expected to go bust in a matter of months, the hospitality industry is in the doldrums and there isn’t a single economic activity anywhere in the world, which is not impacted.

The medical systems, the very best that mankind has been able to put together are teetering at the edge. Hospitals in the most developed parts of the world have run out of ideas. They just do not know how to cope anymore, as thousands of people are dying everyday. The doctors and the nurses and all the gadgetry, which is an inevitable part of hospitals today have no answers to the unending blood-lust of the virus.

Imagine, all this mayhem is caused by just a virus, which isn’t even considered a living organism. Mankind, in-spite of all its knowledge, skills and computing prowess remains so fragile as to be threatened by nothing more than a few cells of DNA or RNA. The virus is a timely reminder of our inherent fragility, it should make humankind a lot more humble and respectful for other forms of life on the planet.

The virus has also exposed all our differences and fault lines as completely false. The virus does not respect nobility, royalty or cares for Prime Ministers or Presidents or their spouses. It does not care for geographic or national boundaries. It needs no passports or visas to cross these. It has scant respect for the religions of the world, or their mighty leaders preaching lofty sermons to their fawning followers. It cares little about people’s stations in life, their affluence can’t save them from its ravages, their knowledge and education is no consideration in the inexorable march of the virus. It attacks all humans and spares all life, which isn’t human. As we cower behind the four walls of our homes, all the life on earth must be laughing at us silly.

The virus has also laid bare our limitations as mankind, as a species that considers itself above all others in the world. It has punctured our pride as the ”masters of the Universe”. While we are capable of destroying the planet and all the life on it many times over, we still do not know how to save ourselves from something as low a life as a virus. While we have traveled to the edge of the known Universe, we have no idea how to deal with what a virus does to our own bodies. As we scramble to save ourselves from the virus, we realize that we have nowhere to go except our own homes.

One day, the virus will surely fade away, some brilliant scientist laboring in a far-off lab will soon enough master it and render mankind immune to its depredations. Or it will just mutate into something friendlier. Mankind will perhaps regain its swagger and disdain for all the other life on the planet. Yet, deep in its heart, it would remember what it was to be a prisoner of a virus for a few months.

Hopefully, it will also serve as a lesson in humility too for we are after-all not as indestructible as we have always thought us to be.

The views expressed are personal

A case for an Indian Bumrungrad

Bumrungrad International Hospital in the Thai capital, Bangkok is easily the world’s leading hospital for international patients. It has been a beacon for patients across the world for over two decades now. The hospital treated over 1.1 mn patients in 2018 with over half of them being foreigners from 190 countries. The hospital has a reputation for great medical care along with excellent international patient services customized to the needs of their global patients.

Indian hospitals too receive hundreds of thousands of international patients from different parts of the world every year. Max Healthcare, in New Delhi, where I happen to work received over 70000 patients from over 100 countries last year. Yet, we do not have a hospital in the country that can really be called a super-magnet for International patients. For most Indian hospitals, International patients are just a tiny sliver of the patients that they take care of. Unlike, a Bumrungrad Hospital, Indian hospitals are designed to cater to local patients and the international patients that they receive, while important, are rarely an area of great focus.

International patients travelling to India often have needs, which are very different from local patients. For many, visiting a hospital in a far-off country is a big leap of faith and they often rely on the services of healthcare facilitators (HCFs), which are intermediaries representing hospitals in different countries. The HCFs often interact with these patients before they board the flight for their medical destination. The HCFs connect them with local doctors and the hospitals, help them get a medical opinion for their afflictions, advise them and help them make appropriate choices regarding their treatment. They also help arrange tickets, often pick-up patients from the airports and make their arrangements for their stay. While the HCFs need to professionalize and become more organized, the hospitals too need to build a full suite of concierge services for international patients. Since most Indian hospitals consider International patients as just an ”add-on”, the international patient services do not get as much attention as they should.

It is time, we looked at setting up hospitals, which consider mainstreaming international patient services. This would essentially mean that the hospital should fundamentally be designed to cater to the requirements of International patients. The infrastructure would typically include plush International patient lounges, exclusive international patient registration and admission desks staffed with executives with appropriate language skills and a full services concierge desk to assist the patients for any need. that they may have. The hospital will also need signage in multiple languages, medically trained interpreters available 24×7 to assist clinicians when they wish to communicate with their patients and a maybe global choice of cuisine.

The international patient experience as distinct from the medical services being offered by the hospital has to be truly world-class. The foreign patients should be made to feel comfortable and at home right from the moment they step out of the airport. India will be able to draw a significantly larger chunk of International patients if we are able to elevate the international patient experience to the highest possible level. A business case for such a hospital can easily be made. However, apart from capital and investments, this will also require a change in the mindset of the hospital promoters and their key executives. That is perhaps the bigger challenge.

Serving International patients allows the country to earn precious foreign exchange and is considered as export of services. With relatively low costs and world-class medical outcomes, Indian hospitals have tremendous competitive advantage. They must not squander it away with what might today be called as a half-hearted effort.

It is time we built a Bumrungrad Hospital of our own!!!!

The views expressed are personal

A Letter to the Finance Minister

Dear Madam Finance Minister,

I must start by acknowledging the very difficult task that you have in front of you. Preparing the Union Budget this year, in times of such economic turmoil, is far from easy. Ordinary people of the country have huge expectations from the budget and I know, it is almost impossible to meet everyone’s aspirations. I am also sure economists and self-styled pundits of all hues must be offering you gratuitous advise on how to aim for greater growth, generate employment, rein in the burgeoning deficit and balance the budget. I am no expert in these matters and hence will refrain from adding to the chorus. My sole purpose in writing to you is to draw your attention to the healthcare sector and the urgent support it needs from the government.

As you might be aware, the National Health Policy of the Government of India itself has committed government spending on healthcare at 2.5% of our GDP. Currently, the government spends a measly 1% of the GDP on healthcare. This isn’t getting us anywhere at all. The health of the citizens of the country and their access to good quality healthcare you would accept is of paramount importance. Even a small increase in the allocation for healthcare can go a long way in improving public healthcare infrastructure particularly in the far flung regions of our country and in the area of primary healthcare.

The government had announced the world’s largest healthcare insurance scheme called Ayushman Bharat a couple of years ago. The scheme was envisaged to provide an insurance cover of INR 500000 to over 500 mn poor people. The scheme is indeed ambitious in its scope but does suffer from lack of funding. The insurance companies (mostly government owned) have been arm-twisted to accept extremely low premiums and private hospitals are being asked to support the scheme even though it is almost impossible for them to provide good quality healthcare at the government mandated price-points. Ayushman Bharat, which is designed to provide access to healthcare to the poorest of our poor needs proper funding and government support. I trust, this will be right on the top of your agenda, while looking at competing demands for funds from other government welfare schemes.

The private sector provides the bulk of healthcare to the citizens of our country. In the last couple of years the private healthcare players have had a tough time with respect to the regulatory environment mandating price capping for medical devices like stents, joints and life-saving cancer drugs. While, this has helped the common man in making healthcare more affordable, the hospitals have seen their slim margins shrink further. It would greatly help if the government was to include healthcare sector in the ambit of infrastructure sector. This will allow private sector hospitals to raise funds at low costs, which will go a long way in shoring up their sagging profits, which in turn will kick-off fresh investments in new capacity, technology and new jobs.

To attract private sector healthcare investments in smaller cities and towns in India, you must consider offering incentives and subsidies to private healthcare players. They will be able to partner with the government in setting up ”low cost” hospitals, readily accessible to most of our citizens at attractive price points. This will lead to investments and job creation, locally something that the government will be delighted with.

Healthcare insurance penetration in India is abysmally low. Most people are either uninsured or under-insured. This makes quality healthcare completely inaccessible to a very large number of our citizens. It would be very useful if the government was to consider making healthcare insurance mandatory for all private sector employees with the responsibility of providing a suitable cover with the employer. This should be mandated for all Small and Medium sector organisations as well thus dramatically increasing the number of people covered under healthcare insurance. While, we are at this, may I also point out that the Central Government Health Scheme (CGHS), which covers millions of serving and retired government employees is in dire financial straits and owes millions of dollars to private healthcare providers, who are now increasingly constrained to refuse services to CGHS beneficiaries by opting out from the CGHS panel. You must consider funding CGHS and other similar government schemes adequately so that their beneficiaries continue to receive adequate healthcare.

The export of healthcare services from India popularly called Medical Value Travel (MVT) has the potential to earn billions of dollars of foreign exchange for the country. Indian healthcare service providers have tremendous advantages. They deliver quality healthcare at very low costs. We have the potential of attracting people from all across the world to India for medical care. Last year, at Max Healthcare, where I work, saw patients from over 110 countries. The opportunity is immense. However, we do need some help from the government in marketing India as world-class destination for inexpensive healthcare. The previous government had set up a board to promote wellness and medical value travel to India. For the last few years, it is lying defunct. It would be very useful to revive this board with adequate funding, infrastructure and a clarity of vision to help promote India and its healthcare prowess across the globe. Tax breaks and incentives to private healthcare players investing in MVT will also go a long way in attracting foreign patients.

Finally, I must draw your attention to technology, which is changing the landscape of healthcare delivery across geographies. India has an excellent penetration of mobile telephony and we can deliver and address a lot of healthcare concerns of our citizens using technology. A mobile phone can be used to capture healthcare data remotely, images can be sent and analysed, AI applications can be used to report and diagnose smartly. The world is increasingly moving in this direction. My request to you would be to set aside a small sum of money and create a mechanism, which encourages entrepreneurs to invest in these technologies helping deliver healthcare to our people living in far-flung areas of the country with limited access to healthcare.

Madam, the health of its citizens has to be a major priority for any forward looking government. I am sure, you will be addressing some of these concerns in you budget proposals. We are eagerly waiting to hear from you.

The views expressed are personal

What Makes a Hospital Great

We are finally on the last day of the year and the decade too. This is usually a time for reflection and I too have been thinking about my good fortune in never having been admitted to a hospital so far. God has indeed been kind and merciful. However, while I have been able to avoid a visit to the hospital so far, I have spent most of my working life and almost all of the last 10 years roaming the corridors of hospitals all over the world. This has been a great privilege for someone who isn’t even a clinician. I have been a part of teams trying to create wonderful hospitals that patients would love to come to. This quest continues with the realization that patients do not love to go to any hospital, whatsoever. They go there under the force of circumstances and are keen to return home as soon as possible.

So, what would constitute a hospital that one wouldn’t mind going to if the situation so demanded? Here are some thoughts.

The first and foremost is the obvious. The hospital must have great clinical expertise. This essentially means that the hospital should have a great set of clinicians well trained and experienced in their areas of medicine. It should also be equipped with some of the best medical gadgetry to allow the medical wizards to treat patients safely and to the best of their ability. This is relatively easy to achieve. The really difficult part is to get the great clinicians and the nurses and everybody else who delivers care to work together in the best and abiding interest of each patient. It takes years for a team to tango together. Large, successful hospitals are busy places, filled with thousands of patients demanding attention and care round the clock. For most patients a hospital visit or a surgery is perhaps a once in a lifetime experience. For busy clinical teams, scores of patients everyday is the norm. In all this a great hospital would be one where care and attention is lavished on each patient as she is the only one under their care that day.

Apart from providing great medical care, I would truly treasure a hospital that talks to me as a partner and treats me as an equal stakeholder in my own care. Very often this is a neglected area in most of our hospitals. Rarely, clinicians take the trouble to explain to the patients the medical conditions they have been diagnosed with, the treatment plan, the prognosis and the complications that may arise. There are many reasons for this – doctors are extremely busy juggling multiple balls all the time, do not consider this conversation as very important one, believe that patients do not have adequate medical knowledge to benefit much from this discussion and some, dare I say, are just not trained to address all the queries the patient may have. In a great hospital, medical teams must spend time with each patient, explaining and answering their questions as best as they can and with candor, empathy and respect.

There is something else that as a patient I rarely get to see or know but is absolutely critical for my well-being. This is the effort and investment a hospital makes in ensuring patient safety. Hospitals are inherently dangerous places teeming with germs and instruments, which are used for jabbing, invading and cutting open patients. Of course, all this is done in a controlled and highly sanitized environment, yet chances of someone slipping somewhere, making a grave and maybe an inadvertent error is always round the corner. The trick is in trying to eliminate these errors as far as possible through technology and stringent process controls. Ultimately, patient safety is an organization wide effort to establish a culture, which looks at learning from mistakes all the time. Great hospitals are obsessive about patient safety and treat even the smallest transgressions with utmost seriousness. To them nothing is more important than ensuring that the patient comes to no harm in the hospital.

Everything else to me in a hospital is a given. I would expect the hospital to be clean, the food to be of decent quality and served on time, the air-conditioning to be working well, the nurses to be responsive and the staff pleasant. I would greatly value efficiency in a hospital and wouldn’t like to wait endlessly for things to get done. I do expect the hospital to transparently charge me for its services and make a reasonable profit for its share-holders. A great hospital is also one, which does all of this effortlessly and as a matter of course.

As the new decade begins, I would certainly hope not to land up in a hospital in the next 10 years too. Yet, if it becomes unavoidable, I would certainly want to be in a hospital, which does all of the above rather well.

Here is wishing all of you a wonderful new year, filled with good health, happiness and much joy.

The views expressed are personal

On Medical Errors and Negligence

Medical professionals like everybody else are prone to errors. These errors are pretty much an essential part of being human. No one is infallible and therefore to expect our clinicians to be free from mistakes is foolishness. In the case of medical professionals, however the consequences of a medical error can be horrendous. A small error can leave a patient in a wheel-chair for life or can lead to life threatening complications and even death. A recently published report by John Hopkins University School of Medicine estimated medical errors to be the third largest cause of death in the US accounting for a little over 250000 deaths in a year. In India, these numbers are difficult to estimate. Business Standard quoted a Harvard study in Oct 2018, estimating that a staggering 5 mn lives are lost to medical errors annually in India.

Medical negligence on the other hand implies that an adverse medical outcome occurred because a clinician or a care-giver failed to adhere to well-established standards of care. This happens because the care givers were too casual in their approach, did not take their onerous responsibilities seriously, failed to adhere to well established medical processes and procedures or were simply careless. Often, clinicians in busy hospitals are over-burdened, are constantly multi-tasking and perennially dealing with highly stressful situations. This leads to short-cuts, a deviation from the norms and established procedures causing a catastrophic outcome. Sometimes, medical negligence can be traced to over-confidence where a clinician has supreme belief in his own abilities and becomes a little cavalier in treating patients leading to a stupid unforgivable mistake.

As patients and consumers of healthcare services it is imperative for us to understand and recognize the difference between a genuine medical error and medical negligence. Patients often tend to blame doctors for an unexpected adverse outcome, not realizing that the practice of medicine is inherently fraught with risk and an adverse outcome is always in the realms of possibility. A doctor can only try and minimize this risk by his knowledge, skills and work-ethics, he cannot eliminate it or wish it away. Medical errors can also be significantly reduced by establishing a hospital-wide culture of patient safety. The use of cutting edge technology, which warns clinicians, nurses and care-givers whenever a deviation from an established process is detected, allows clinicians to review their decisions and stop just before an error was about to happen. Many private hospitals in India now use these smart systems to prevent medical errors thus improving their medical outcomes. (At Max Healthcare, we run a program called ”Chasing Zero”, which through multiple initiatives helps weed out clinical errors. While, this program is almost invisible to patients and consumers, it is one of the most important initiatives, running silently in the background ensuring greater patient safety and better outcomes.)

Medical Negligence, of course is completely unacceptable. That a clinician or a care-giver failed to adhere to a well-established standard of care is an egregious failure and must not be countermanded or swept under the carpet. Even a single case of medical negligence is a blot and the hospitals should not shy away from accepting the mistake and taking remedial action. Sadly, many don’t, fearing a media backlash and legal liabilities.

From a patient’s perspective, being a victim of either a medical error or medical negligence is terrible. Patient’s go to the hospitals in search of a cure and an enhanced quality of life. To emerge from a bout of hospitalization in a worse condition is a tragedy. It is hardly a consolation to know that the medical error was either ”unforeseen” or ”unavoidable” and a result of human fallibility. These patients have to learn to live in altered circumstances and daily face up to the new reality of their diminished lives.

It is thus imperative for hospitals to continue to invest in technologies, which help avoid medical errors. The hospital leadership teams should continuously work towards creating a culture which respects and honors professionals who are always vigilant, all the time looking over their shoulders and going out of their way to help ensure minimal medical errors. There can’t be anything more important in a hospital than patient safety.

If we have to err, let us always err on the side of caution.

The views expressed are personal

The World Medical Tourism and Global Healthcare Congress – A Tame Affair.

The 12th edition of the World Medical Tourism and Global Healthcare Congress was quite a tame affair. The meeting was held earlier this month in Abu Dhabi, UAE. Compared to some of the events in the past, this was in many ways a damp squib.

However, first all that was good about the event.

The organizers, The Medical Travel Association (MTA) had changed the format this year and made it a more business to business (b to b) event and had restricted access to only people who were actually connected to healthcare and medical travel. This in itself is not a bad thing to do as it brought greater focus to the business aspects of the meet and eliminated frivolous visitors who would just visit the exhibition out of plain curiosity. The organizers had also cut out the song and dance and the hoopla, which was a part of the earlier events. Thus, the event had a more business feel to it and all our meetings were with serious and relevant people who had good reasons to be at the event.

The event also attracted buyers from a large number of countries. From the perspective of Indian hospitals, many people came from countries, which are relatively new and fairly unknown to Indian hospitals. These were clearly opportunities and I am sure many hospitals and healthcare facilitators (HCF) from India would have benefited from these interactions. I was quite surprised to see large delegations from China, Russia and South Korea and we had good meetings with them.

Now the not so good, which frankly outweighed the good.

The entire event appeared to have been sold to the Abu Dhabi’s, Department of Health. The MTA must have made tonnes of money, however the credibility of the event was seriously compromised. Thus, the inaugural day only had escorted visits to various Abu Dhabi hospitals aspiring to attract patients from various parts of the world. Buyers and hospitals participating from other parts of the world were not invited (they are after-all competition) on these tours.

The plenary session the next day was an extended advertisement for Abu Dhabi medical tourism and the medical infrastructure, which has come up there. The speakers including the CEO of Cleveland Clinic in Abu Dhabi had no insights to share except highlighting the facilities and services they offered to patients wanting to travel to Abu Dhabi. This is hardly the stuff of serious global conferences. While, I understand the commercial nature of these events, the organizers usually aim for a balance between sponsor’s propaganda and genuine high value content. Sadly, in this conference the organizers did not even pretend to be not a mouth-piece of their sponsors.

The rest of the conference content too was quite lack-luster. Most of the sessions and the speakers were predictable and were happy to plug in for Abu Dhabi, Department of Health. In one session involving a benefits manager from a US company, the interviewer wanted to know if they would be interested in sending their US employees to Abu Dhabi for medical treatment!!! No wonder, I counted 5 people in the hall listening to this conversation.

Most of the buyers were those whose travel and stay has been paid for by the MTA. This was perhaps a desperate bid to get them to the event and ensure that they visited the Abu Dhabi hospitals and also met the sellers (mostly hospitals from different parts of the world). In my view quite a few of these were non-serious buyers who had been flown in to make up the numbers. A rather sad state of affairs.

In conclusion, the conference was high on hype and low on substance and content. From a b to b perspective and purely as a platform for meeting new buyers from different parts of the world, it scored reasonably well. However, from the perspective of enhancing knowledge, offering newer insights on what is happening in the world of Medical Value Travel (MVT) and showcasing the best in the MVT, the conference was quite a disappointment.

The views are expressed are personal.

Medical Value Travel in India-A promise yet to be fulfilled.

For at least the last 10 years one has been hearing about the Medical Value Travel (MVT) market in India touching a whooping USD 5bn, 8bn or even 10 bn by 2020. These are breath-taking estimates provided by venerable consulting firms from almost 10 years ago. These had been quoted ad-nauseum by all manner of people (including, I must confess, myself) as the potential of MVT in India in presentations made to likely investors, foreign governments and indeed overseas hospitals with the potential to send patients to India. Many analysts have cited it as the next big thing after India’s dominance in exporting software to all parts of the world. It has been touted as the real big thing about to hit our shores.

Sadly, the reality has turned out to be a little different. The big wave hasn’t really reached our shores. The MVT business including those flowing into sectors like travel and hospitality would today be well under USD 2 Bn.

So, what worked and what didn’t and more importantly what needs to be done?

In my view what has largely worked for MVT in India has been the outstanding medical services and world class outcomes that our clinical teams continue to generate. The commitment of the clinicians, private investments in additional beds, equipment and technology has helped deliver cutting-edge care to thousands of patients who continue to travel to India in search of better health. Increased competition among private hospitals have also ensured that pricing hasn’t gone through the roof and India still is by far the least expensive destination for high-end medical care.

Medical outcomes and care are just one part of what patients look for when they wish to travel abroad for healthcare. Sadly, we have not done as well in almost everything else.

The government of India is still not very friendly towards medical travelers. In many countries the Indian missions have archaic rules for issuing medical visas, often the patients themselves have to spend time in long queues outside the embassies to apply for visas and touts merrily ply their trade. The International airports even in major Indian cities do not have adequate facilities to receive sick patients. While, immigration counters for people traveling on medical visas have come up, a lot more can be done at the airports to ensure greater comfort for weary travelers who are also sick, often seriously.

Even those private hospitals in India who are teeming with thousands of international patients have very scratchy patient services. Almost every aspect of non-medical services is neglected. The interpreters are few and of dubious quality, patient concierge services do not exist and hardly any hospital makes the effort to serve the patient’s preferred cuisine. Information regarding the treatment plan, medical risks involved, and prognosis is usually scarce, and patients must depend on unreliable sources such as clinician’s secretary and other assistants to get whatever information they can get.

The biggest bugbear of all remains the unreliability of patient estimates. Healthcare is an inexact science, it is almost impossible to predict with great accuracy the course a patient may take in a hospital. However, hospitals wishing to treat international patients must come up with fixed price packages for at least the most commonly done procedures and surgeries and ensure that the bills of foreign patients do not escalate.

To make matters infinitely worse, often the patients are assisted by the so-called Healthcare Facilitators (HCF’s) who are still largely individuals (and not well organised institutional service providers) looking after ”their” patients. Most of them have the right intention to assist the patients during their stay in India, however they are seriously hampered by a lack of organised resources and well-established processes. Sadly, some are plain opportunists, who dump patients in hospitals, which pay the maximum commissions and disappear thereafter. There is a crying need and a great opportunity for medical concierge services providers to set shop and look after foreign patients in need of assistance. The established hospitals must also encourage and support the emerging organised players in this space.

MVT in India (also healthcare in general) remains unregulated. It is extremely important that the government urgently creates an independent regulatory body, which works closely with MVT stake-holders to set up rules for all those involved in medical value travel. These will include airlines, hospitals, hotels, spas, ayurveda centres and HCFs. Quality standards need to be developed and implemented in all the aspects of MVT. Accreditation norms must be a lot more stringent and command greater respect.

The other big problem that remains unaddressed is the sheer lack of information and knowledge about modern India and its medical capabilities. Most people abroad have preset notions of India being largely an over-crowded nation of over a billion people mostly mired in crushing poverty and squalor. This is clearly a uni-dimensional and dated narrative completely at variance with reality. All stake holders in MVT in India including the government and private healthcare providers must join hands to work towards dispelling this notion about India. A campaign like ‘’Incredible India’’ is sorely needed.

Essentially, MVT in India has not done as well as expected because of a lack of vision on the part of key stakeholders namely the private hospitals, the government and the HCF’s. All three need to seriously introspect. The hospitals and the HCFs need to look beyond just the next patient and invest in better infrastructure, better systems and processes, better quality people and a greater commitment to overseas patients. The government needs to create a regulatory and supportive environment, which allows them to function well and with greater efficiency.

This can’t be too difficult.

All it requires is greater alignment, focus and commitment among all MVT stakeholders.

The views expressed are personal