It’s been pointed out that when it comes to capitalism, there are often many cases where the poor can teach the rich a thing or 2. In the past, we profiled private education available even in slums. A few weeks ago, the Economist had a great article about the innovative entrepreneurship that’s starting to deliver healthcare to millions of previous unserved desis.
As the patient was chatting away, Vivek Jawali and his team had nearly completed his complex heart bypass. Because such “beating heart” surgery causes little pain and does not require general anaesthesia or blood thinners, patients are back on their feet much faster than usual. This approach, pioneered by Wockhardt, an Indian hospital chain, has proved so safe and successful that medical tourists come to Bangalore from all over the world.This is just one of many innovations in health care that have been devised in India. Its entrepreneurs are channelling the country’s rich technological and medical talent towards frugal approaches that have much to teach the rich world’s bloated health-care systems.
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p>There are hundreds of ways to slice and dice “innovation” but one of favorites buckets stuff into 2 broad categories –
- product innovation – new, consumer visible products / services… new microchips… new features… Because it often literally results in new things on store shelves, product innovation tends to be highly consumer visible. In the medical arena, this would be new drugs, procedures & devices.
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process innovation – the delivery pipeline for getting stuff to the consumer. This means backoffice things ranging from more efficient factories to new retail vehicles like Wal-Mart, Amazon.com and so on. Process innovation is far less consumer visible but has a tremendous role in the long run. It’s also, alas, far less politically visible.
Note that just the already “socialized” portion of US health spending equals total health spending in many other countries altogether.
In the broad economy, new “value” is generally driven through product innovation while new “efficiency” / “lower cost” tends to come from the process side. Both are crucial for raising living standards in the long run although process innovation just doesn’t generate the same sex appeal.
Through this lens, a classic criticism of the US’s healthcare environment is that the “process” side of delivery (docs, hospitals, insurance co’s, medicare) is comparatively rigid, while the “product” side is incredibly fluid & competitive ? yesterday’s hot startup can quickly become today’s BosSci. The result is tremendous innovation in creating new drugs and treatments but comparatively less in finding innovative ways to deliver these products & reduce costs.
Folks in the Desh, on the other hand, are quite explicitly investing in process improvement and often eschewing the the latest & greatest from the product side –
…Unlike the hidebound health systems of the rich world, he says, “in our country’s patient-centric health system you must innovate.” This does not mean adopting every fancy new piece of equipment. Over the years he has rejected surgical robots and “keyhole surgery” kit because the costs did not justify the benefits. Instead, he has looked for tools and techniques that spare resources and improve outcomes.
And, as with nearly all process improvements, the race for marketshare forces a benefits trickledown & learning curve ascent –
…For years India’s private-health providers, such as Apollo Hospitals, focused on the affluent upper classes, but they are now racing down the pyramid…His model involves building no-frills hospitals using standardised designs, connected like spokes to a hub that can handle more complex ailments...Monitor estimates that its operating theatres accommodate 22-27 procedures a week, compared with four to six in other private clinics. LifeSpring’s doctors perform four times as many operations a month as their counterparts do elsewhere–and, crucially, get better results as a result of high volumes and specialisation.
..Aravind’s founders use a tiered pricing structure that charges wealthier patients more (for example, for fancy meals or air-conditioned rooms), letting the firm cross-subsidise free care for the poorest.
Aravind also benefits from its scale. Its staff screen over 2.7m patients a year via clinics in remote areas, referring 285,000 of them for surgery at its hospitals. International experts vouch that the care is good, not least because Aravind’s doctors perform so many more operations than they would in the West that they become expert.
Will the benefits of a more decentralized, entrepreneurial delivery model find their way to the US? Alas, current political winds seem to be blowing in the opposite direction –> towards even more centralized & nationalized delivery processes in the name of reducing costs and improving coverage.
While the idea of decentralized, entrepreneurial model sounds awesome to me, i have to wonder why we haven’t seen progress towards that end here in the states. Our national culture is very entrepreneurial, so what has suffocated this innovation if it was the answer? Regulation?
Health insurance is a market failure. You’re never going to see decentralized or entrepreneurial delivery systems because most people can’t afford to pay out of pocket for the latest medical care. You need a risk pooling mechanism to create a market for new products. Even now the US healthcare system is dominated by just a handful of insurance companies. That is neither decentralized nor entrepreneurial. There is no extra virtue in centralizing something under a corporate bureaucracy rather than a governmental one.
The only reason India can get away with making the delivery cheaper is because Americans are subsidizing the R&D on the front end to create the new products in the first place. The Euros get the best of both worlds. Good access to care through a universal system AND good access to new technology through American incentive structures.
So why not look for ways to decentralize health insurance & make it more entrepreneural? For starters, it’s current tax law that makes health insurance a B2B market (e.g. something your employer buys for you) rather than a B2C market (something you buy for yourself like car insurance). You don’t worry about losing your auto insurance when you lose your job…
Litigation is another problem. Patient outcome is all that matters, so why bother with process.
I’ve had mixed, but mostly positive healthcare experiences after I moved to India from the US. I think the biggest advantage in India is that (at least in the good hospitals), there is always an escalation path to get good care, especially if you are willing to pay a little extra and be nice to people.
In the US, it always felt like I was dealing with a nameless, faceless system that didn’t understand a word that came out of my mouth.
I should have gone for law.
One of the first things that we can do is DOUBLE THE NUMBER OF MEDICAL STUDENTS WHO GRADUATE EACH YEAR from 18,000 to 36,000.
In a 2003 study Dean Baker, who is co-director of the Center for Economic and Policy Research, estimates that by adding roughly 100,000 physicians to our current pool of about 760,000, we could pull doctors’ salaries down from an average of $203,000 to somewhere between $74,000 and $126,000. For the average middle-class American family of four he reckons that would lead to savings of $2,200 to $3,700 per year
One argument against increasing the number of MDs in the USA is this: The USA (~2.0 MDs per 1000 people) has more MDs per capita than other developed nations, like Japan (~2.5/1000) and UK (~2.3/1000). However, even these 2 countries have shortages of MDs! By suggesting that we’re better off than the Japanese is like a lung cancer patient bragging to a pancreatic cancer patient that he/she is healthier than the pancreatic patient ,when in fact, they BOTH are sick! Moreover, about 25% of our MDs are foreign born. This means that we really only PRODUCE 1.87 MDs per 1000 people, which is much less than Japan (which doesn’t ‘import’ MDs) and UK (which does ‘import’ them).
While the AAMC has called for a 15-20% increase in current numbers of graduating physicians in the US, there are considerable challenges in carrying out this task. My university is in the midst of one such expansion and every teaching and learning resource at every level of the medical education process is strained (e.g, skilled human resources, support staff, clerkship (clinical) placements, physical space especially for small-group sessions, lab space, clinical case:student ratio, clinical preceptor:student ratio, etc.) To add to the challenge is the looming strict accreditation process…
It seems like, here too, India is seizing the day.
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8 · Malathi on July 27, 2009 06:26 PM · Direct link While the AAMC has called for a 15-20% increase in current numbers of graduating physicians in the US, there are considerable challenges in carrying out this task. My university is in the midst of one such expansion and every teaching and learning resource at every level of the medical education process is strained (e.g, skilled human resources, support staff, clerkship (clinical) placements, physical space especially for small-group sessions, lab space, clinical case:student ratio, clinical preceptor:student ratio, etc.) To add to the challenge is the looming strict accreditation process…
Malathi, Tell me which school does NOT feel strained? Moreover, tell me which corporation, businessmen, scientist, truck-driver, etc. who doesn’t feel that they need more resources. It’s simply human nature to not think that you have enough, or that you need more.
The medical schools in the USA are no different than any other organization in that they don’t feel they can’t find enough good people and funding. Absolutely every organization would feel the same, I’m sure. If the medical schools are cramped and under-resourced here, than I’m sure that the situation is 5 times worse in the Caribbeans or India, where many of our finest comes from.
It is not the money. In our case, we have the funds, the political will (push actually) and Faculty level leadership. We just don’t have enough clinical cases. Given our catchment area population, there are only so many patients from the real world–therfore, only so many hospitals, so many wards, so many outpatient clinics and so many practitioners. For example, there are only so many trauma surgeries seen in a year; ‘X’ number of residents and ‘Y’ number of students need to see them; and 52 weeks in a calendar year before ‘X’ and ‘Y’ will have to rotate through the trauma ward. Only so many clinicians can devote their time to teaching in between taking care of their patients. There is a whole body of literature on PubMed. Search using keywords ‘medical class expansion.’ My own group has a paper coming out on this topic soon.
Personally, I think US and Canada will continue to rely on International Medical Graduates whose education is for the most part subsidized by other governments. So, personally, I believe some sort of partnership and exchange between educational institutions (even if they are for-profit institutions) in countries like India will minimize the crisis to health human resource in other countries. Partnership will also ensure that North American standards of accreditation can be met and students’ future and career (read ‘repatriation’) need not be left to chance alone. With its huge population base, Indian institutions have access to people seeking primary or tertiary healthcare.
The deeply tragic story, in the news column today, of the little Indian girl who committed suicide so that her organs could be used by her father and brother makes a mockery of this “India Shining” deceit.
India has proportionally fewer doctors than even Pakistan, which in turn is below the world average in this department. Nothing here to thump your chest over.