Wednesday, May 24, 2017

Winds of change - 8

The next morning Dr. Som got up earlier than usual. He gave a kiss to Vasudha on her forehead as she was till sleeping. “I’m leaving early. Will have breakfast at the hospital.”  Vasudha mumbled, “Hmm, what? Why? Emergency?”

“No, will explain later.”

Dr. Som had an extra bounce in his step that morning as he entered the hospital. The security guard and the sweepers were surprised to see him so early. He went to his cabin, left his things there, took his notepad and pen and took the elevator to the terrace. He called the office boy and asked him to pack up some idlis from a nearby restaurant. He ordered a coffee from the office and got to work. For the next hour or so, Dr. Som jotted down his thoughts vigorously.

At the end of an hour, he had the high level plan ready. He went back to his cabin satisfied and full of optimism for the future. He went about his daily routine - rounds, procedures, OP consults.

Over the next week, he made an elaborate plan where he dug one level deeper. He identified problems that might come up. He tried to figure out multiple solutions to each problem. He took copious notes of his entire thought process. He got new ideas as he went along. He discarded some old ones where the newer ones made more sense. He was fully immersed in this process. He worked on the plan whenever he found time.

Dr. Som knew that what he was planning was radical. This was something that he felt would shake the foundations of healthcare in the country and beyond. He realised that there would be many challenges. He was determined to overcome them. In his mind he was confident that what he was doing was the right thing.

The next morning, Dr. Som drove himself to the Swami Madhavanand Vidhya Peeth, a one hour drive from their home. Swami Keshavanand, the Head of the Ashram was revered by the the couple from the time they set their foot into Rajahmundry. They were introduced by a friend of theirs who was closely associated with the Swami. Swami Keshavanand was a very sincere and devout Sadhu who advised the Soms on various matters from a spiritual angle. He guided them from time to time. He would never interfere in the commercial aspects. That was up to the couple to figure out. Swamiji would only give them advise on how to fight their inner battles, the ones within the mind. The Corporate boardroom battles were beyond his understanding, he professed.

Dr. Som had called the Ashram the previous evening and requested a meeting with Swamiji. He got an appointment for 7 am.

Tuesday, May 23, 2017

Winds of change - 7

Dr. Som had just finished his consultations for the day. A bunch of Medical Representatives were waiting to meet him.

Medical Reps, as they are called represented the ugly underbelly of Indian healthcare. At the surface, there was nothing wrong with introducing a doctor to new products and their benefits. However, things were not that simple.  Medical Reps had to meet stringent targets set by their companies. They were encouraged to lure doctors with incentives of all kinds. These ranged from cash, a credit card which would be paid by the company, domestic and foreign holidays albeit in the name of attending conferences, fuel vouchers and some rather not so honourable arrangements. In return for these incentives, doctors had to either prescribe their drugs or use their products for procedures. Of course, these products would have been cleared by the regulatory authorities but some could be inferior to others and these incentives ensured that doctors prescribed them despite having known this.

In a world full of corruption, some doctors felt that the patient is not being harmed, so what was the problem if they made some additional money? They would have usually spent a bomb getting themselves educated. Today, many seats in Post Graduate courses can be obtained only after paying a few crores. Even doctors are human beings with needs. After years of slogging hard, weren’t they entitled to some basic privileges? Weren’t they entitled to a comfortable life?

Dr. Som saw the Medical Reps quickly, one by one. Usually, these Reps are a little discrete. They would explain the drug and then slide in a sheet that would have, without any overt branding of the company the details of the incentives. Some would be more brazen and talk about the incentive structure openly. One such person who met Dr. Som that day leaned forward after explaining the basic incentives and whispered softly, “If you use 50 catheters by the end of the quarter, we could arrange a holiday for you without ma’am at Pattaya.”

Dr. Som was red with rage. “What do you think I am? Get out right now!” He flung the brochure and the incentive sheets on the face of the bewildered Rep. “What are you waiting for? You bloody pimp. Get out right now!” Hearing the noise, Dr. Som’s office boy rushed in. “Throw him out!”, Dr. Som exclaimed. The Rep was trembling. “Sorry sir. Never again sir. Sorry sir.” The office boy ushered the Rep out. Dr. Som drank a glass of water, calmed himself down and called his secretary on the intercom. “No more Reps for today.”

Dr. Som got up and went towards the elevator. He went to the terrace of the hospital. He walked over to his favourite spot. He saw the sun setting over the resplendent Godavari. The calm waters of the river wore a golden hue due to the rays of the sun. In the distance he could see a few boats being rowed by lonely fishermen. A gentle breeze was blowing. He stood leaning against the wall and took in the fresh air and the scene that was a natural balm for his anguished mind. He closed his eyes and took a few deep breaths.

“This must change”, he thought to himself. “I will change this.”

Monday, May 22, 2017

Winds of change - 6

The next morning, at breakfast, Vasudha suggested that they both take a weekend break. Sheshu’s eyes light up. He suddenly felt that he badly needed a break. Three years of toiling without any meaningful break whatsoever could take a toll. They both started discussing where they could go. They first thought that it cannot be too long but later felt that the team could handle stuff on their own. They did have a mature team in place. Its just that they felt too scared to let go. What if something happened? What if a crisis came up?

Starting a new business is like raising a child. For the first few years, the child needs your constant attention. After a certain point, you don’t realise that the child has become independent. You are too scared to let go. Unless you actually try, you are never sure. But you feel you cannot let go until you are sure. The Soms were in that phase with Narayana Hospital.

However, with all that had happened in the past few weeks, they both felt that if they did not take a good, meaningful break, things could become much worse. They needed to get away from it all. They needed to find each other. They loved each other so deeply. For the first time in all these years, it looked as if a slight coldness had begun developing between them.

They zeroed in on Coonoor. This little hill station close to Ooty was the perfect place for them to recharge. They had been there once briefly before starting Narayana Hospital. They had always wanted to go back there. The first trip was only a couple of days and they felt they hadn’t got enough of it.

That afternoon, Vasudha called a meeting of her most trusted advisors in the hospital. These were business graduates who had joined them early on and took care of all the administrative and financial aspects of the hospital. She announced that she would be away for a week on a holiday. She was to be disturbed only for something really urgent. Dr. Som also met a few of the hospital’s senior most doctors and told them that he was going to be away for a week.

The couple headed out the next morning. A couple of flights and a two-hour drive later they found themselves in the cool climes of Coonoor. They had booked themselves at a homestay. Though they were quite tired with the travel, they decided to take a walk before going to bed. After a long, long time, they held hands and went on a long walk. As they walked along the road, they took in the moist, cold air, free from any smoke. The silence of the night was broken only by the odd bicycle passing by. There was a gentle breeze blowing. What a good decision they had taken to go to that place!

The next few days went by. They would have a hot breakfast and then head out to the middle of town, stroll around, go on treks and return by late evening. They were disturbed only a couple of times for some work from the hospital. Other than that, they could take their minds fully off work and enjoy the time together.

The night before they were supposed to return home, during a walk, Sheshu told Vasudha that they should talk about the IP charges and resolve the issue before heading back. Vasudha nodded. Sheshu said that he understood the pressure on her and that sometimes he did become impractical due to his naivety. He suggested to her that they do an IP price of 30% above the OP price. Vasudha agreed. They smiled at each other and were very happy with the way they reached a compromise and with the way the week had gone by.

Sunday, May 21, 2017

Winds of change - 5

A few weeks later, as Dr. Som was finishing his OP consults for the day, he got an email from Vasudha. The subject was ‘Price increase’. In the email, Vasudha had forwarded the Finance department’s proposal for price increases for various procedures, investigations and other services the hospital offered. Dr. Som opened the attachment to take a look at the details.

Since the opening of the hospital, prices had never been increased. The focus was on setting up a reputation and getting a good patient base. Three years is a long time. With inflation, everything had become more expensive. Manpower costs, electricity tariffs, the prices of consumables - everything had shot up but the prices that Narayana charged for the services had remained the same. The Finance team had brought this to the notice of Vasudha in a detailed presentation. They explained that a steep price hike was essential to control the financials.

The Finance team had come up with an initial proposal which Vasudha reviewed and asked them to modify. She did not want to take any chances with the patient base. Over the last three years, they had been able to develop a loyal following and many people saw the hospital as a high quality, reasonably priced and ethical institution. Vasudha reviewed the modified price hike proposal and sent it to Sheshu for review.

Dr. Som saw the details. He understood that prices had not been changed for three years. He realised that a price hike at that point was necessary. He went over the list. He made some minor corrections at a few places. However, his eye stopped at a line towards the end of the file. The line indicated that the plan was to increase Inpatient charges for the same services by 50% more than the Outpatient charges. An example was given that to get Hemoglobin tested, an outpatient currently paid Rs. 100, while an inpatient paid Rs. 110. The plan was to increase the outpatient charges to Rs. 110 while the inpatient charges were to be increased to Rs. 165. He found that to be extraordinary. He sent an email back to Vasudha saying that he was ok with everything but he thought there was mistake in the Inpatient charges clause and asked her to get that checked and revert.

Within a minute, Vasudha responded saying that it was correct and that was the plan. Dr. Som responded to the email, “Let us discuss.”

Vasudha came over to Dr. Som’s cabin. She told him that they did not have too much scope in OP prices because the competition was getting tough. IP prices were the only area they could be a little more ambitious. Sheshu countered, “It is unfair to charge so much higher for IP cases.”

Vasudha was getting impatient. “The whole world does this Sheshu. What is wrong with this? When someone is admitted in the hospital, they do not have any other option but to get their investigations and procedures done here. We can and should charge more! For OP, they can go anywhere else so it is important to keep prices low and attract more patients.”

“That inflates the bill artificially. When the patient sees his hospital admission bill, they would feel cheated. They can always go to other hospitals the next time because of this. In the long run, we lose their business.”

“It does not work that way Sheshu. All other hospitals do the same thing. Everyone does this.”

“Exactly. Just because everyone does this does not mean we should do this. It is wrong to charge more for IP just because they don’t have any option.”

“It’s not that alone. IP cases need more care because patients are inherently more sick when they are admitted.”

“Taking a Hemoglobin sample involves exactly the same effort whether it is IP or OP”

“The sample has to be collected by visiting the ward or the room. That requires more effort.”

“Not 50% more effort as OP.”

“Sheshu, every single hospital in the country charges more for IP. That’s where everyone makes their money. Why should we be any different?”

“We started this hospital to be different. Not to take the easy way out. We were doing fairly well in comfortable jobs. We did this to do something challenging.”

“We have too many challenges already Sheshu. We cannot take on more.” Vasudha stormed out of Sheshu’s cabin.

Saturday, May 20, 2017

Winds of change - 4

“May I come in, sir?” The Procurement Manager from the Inventory department asked Dr. Som.

From time to time, the Inventory Department would try to procure, at lower costs, consumables for procedures and various drugs that were used within the hospital. That way, the hospital could make  slightly higher profits without increasing the cost to the patients. However, there was always a risk of unscrupulous manufacturers trying to push some inferior quality products in the guise of reducing costs. To avoid this, Dr. Som had put a process in place where the Head of Department of each specialty would take ownership of the quality of the products being used or prescribed by the department.

The Procurement Manager had come to him that morning to introduce a lower cost catheter that was used to start dialysis on a patient who needed it urgently. Dr. Som took a look at the catheter. He asked the usual questions.

“Have we used products from this company before?”

“Yes sir. We use their Foley’s Catheters.”

“Any feedback gathered from other hospitals or doctors?”

“No sir, they are introducing this for the first time.”

“What is the price benefit?”

“About 15% sir.”

“I don’t think we should take a chance on a new product for 15%.”

“Sir, maybe we can try a few pieces. If it does not work well, we can refuse?”

“No. Catheters are sensitive products. If something goes wrong, it can be very bad.”

“Ok, sir.”

Within half an hour, Dr. Som got a call from Vasudha. Vasudha asked why he rejected the catheter? Dr. Som explained that this was new to the market and wondered why they should be the guinea pigs. Let someone else try it and and then we can think about it.

Vasudha argued with him about how they need to encourage new manufacturers who are no different from them. She asked Dr. Som how patients had to try Narayana Hospital in the early days for them to even begin being trusted. If everyone would wait for others to try them out, how would they ever begin to succeed? Dr. Som said that trying someone new for catheters was very risky. He was not going to sign off on this. She could do as she pleased as CEO.

Vasudha hung up. She asked the Procurement Manager to go ahead and get some catheters for the hospital to try out.

Dr. Som, however, refused to try those catheters in procedures he did. He allowed other doctors to use them but gave strict instructions to his team not to give him those catheters to use.

Dr. Som kept an eye out on any reports of issues faced with that brand of catheter. Nothing at all was reported. After a few weeks, Vasudha asked Dr. Som if they could change the brand of the catheter to the new one since no reports of issues were found. Dr. Som could not find any reason to refuse. He sheepishly agreed.

Friday, May 19, 2017

Winds of change - 3

“You did it again?”, Vasudha asked.

“He was extremely poor. No money for dialysis either. He will go to an Aarogyasri centre and get dialysis. It was only the jugular charge that I waived off!”, Dr. Som responded.

“Exactly my point! If he is anyway not continuing with us, why did you have to waive off the jugular cost?”

“Come on Vasudha. You know how it is.”

“He could have got it done under Aarogyasri. He was going there anyway.”

“I know. But I just felt sorry for him. I just felt compelled to do something for him.”

“You don’t understand, do you? We have taken money from tons of people who expect some decent returns from their investment. We have invested our life’s savings in this hospital. We have spent three years working day and night to make this work. This is not a charity for God’s sake!”

“We’re doing pretty well Vasudha. We are about to break even.”

“Break even? Is that all you want? What about our dreams? What about returns to the investors? How much longer do you want to slog without taking a single break? Don’t you want to start a family? Don’t you want to give our kids a good education? Don’t you want to enjoy the fruits of our labour? Is breaking even all you care about?”

“Vasudha, it’s not that bad at all. I think you are over-reacting.”

“Yeah, right. I am the one who is over reacting. You’re the one who turns this hospital into a charity by seeing one poor patient. And no, don’t make me the villain here. I am all for helping people. But how many are you going to help?”

“Vasudha, I think once in a way, by doing this, we can at least feel that we have helped someone. I agree that we cannot help everyone. But what is the harm in reminding ourselves about the misery that exists all around us and feeling a little better by helping a few people. Its not like we have changed our policies to change the way this hospital functions, right?”

“I don’t deny that. But we cannot get distracted from our main goal of making this hospital commercially successful. And we owe that to our investors, damn it! How would they react if they got to know that we are treating patients free of charge?”

“Not ‘patients’, Vasudha. Just one patient.”

These were tough calls. While medicine was a noble profession, one could argue that doctors are also entitled to a good life. After all the years of hard work and all the toiling, what was wrong if they made a little money for themselves and got themselves some luxuries? At the same time, in a country like India, where a large part of the population had little or no access to quality healthcare and those that did, had to bear all the expenses out of pocket, moral dilemmas like this kept presenting themselves regularly.

Regularly seeing patients succumb to diseases that could have been easily cured but for want of resources made even the softest of hearts hard. For the first few years, you felt bad, you kept thinking of what could have been done better. But after a point, you resign to the fact that these things happen. You get over one patient and move on to the next. There’s not much time for grief.

Thursday, May 18, 2017

Winds of change - 2

It was a tough life but neither of them complained. Both of them found their work extremely satisfying and intellectually stimulating. The hospital was beginning to do well financially as well. They could see that their efforts were bearing fruit. Having your own hospital, catering to hundreds of patients every month and making some money in the end gave them a sense of achievement, of having done something, of drafting a success story that few could boast of.

Dr. Som saw close to fifty patients every day. People came from Rajahmundry and towns and villages close by. He understood the plight of some of the poorer patients. They barely had money for the commute. The hospital was not yet empanelled with the state government’s health insurance scheme, Aarogyasri. Despite that, due to the superior quality of care, many patients came here even though they could barely afford the cost.

Dr. Som was sympathetic to them. He appreciated the fact that they came to him even though they could have gone to another hospital that was empanelled under Aarogyasri and got treated free of cost. Sometimes, he waived off part of the treatment cost for those who could not afford it but needed the quality of care Narayana Hospital offered.

A patient had come to see him from Samarlakota one afternoon, a place about 50 kilometres away. He was in bad shape. He needed dialysis urgently. It was a case of late detection of kidney disease. For years, the symptoms had been building up. As is often the case in places with inadequate medical facilities and awareness, people realise they have kidney disease when it is too late to do anything to save and preserve kidney function.

Dr. Som told the patient that he would need to get a temporary access for dialysis until a permanent one - an arteriovenous fistula was made. He would need dialysis immediately. He was asked about the cost of the entire treatment. Dr. Som told him that the initial cost would be about five thousand rupees including the temporary access and one session of dialysis. The permanent access would cost about Rupees 7,500 but he could get it all done free of cost under the Aarogyasri scheme if he went to a hospital that covered it.

The patient chose to get the temporary access and the first session of dialysis done at Narayana as he was in a bad shape and did not want to prolong the agony by going elsewhere at this stage. Dr. Som put in a catheter in the jugular vein that would enable the patient to get a dialysis session immediately. Dr. Som decided to waive off the charges of the temporary access and charge only for the dialysis. He made a note to that effect in his file and sent the patient's wife to the billing section.

In the meantime, he started preparing for the minor procedure which was typically done in the dialysis unit itself.

By the end of the day the patient had undergone his first dialysis session.

Dr. Som was in his chamber when he got a call over the intercom from Vasudha. Vasudha wanted to come over to discuss something. Dr. Som knew what was coming. He called her over.