Wednesday, May 31, 2017

Winds of change - 15

(This is the fifteenth part of a short story which is entirely a work of fiction.)

During their weekly reviews, they saw the same trend continuing. Numbers kept dipping. At the beginning of the third month, however, the numbers were quite alarming. The nephrology department as a whole became loss-making. Patient satisfaction ratings remained about the same. Dr. Som and Manav were very nervous. They were losing the only opportunity they had to make this work. They had a meeting where they brainstormed how they could fix things. They rolled out a patient-referral scheme for patients. If an existing patient referred another patient, he or she would get a one time referral incentive. They also decided to roll back the drop in dialysis prices. This would help improve the profitability of the department.

Patients were very upset with the rollback of the dialysis price decrease. They argued with the staff that they were promised that the drop would be there for at least three months. Why this change, they questioned? The satisfaction numbers plummeted as a result of this. Dr. Som and Manav thought that if the hospital numbers cold be improved, they could explain that away.

At the end of the three month pilot, Dr. Som and Manav reviewed all the numbers in detail. The hospital numbers did not improve at all. The nephrology department’s revenues and profitability both went down even further. The reasons were unclear. The patient satisfaction numbers were also lower than before. They thought through the plan of action. Dr. Som told Manav that this kind of plan needed at least one year of piloting. Three months was too short. Manav could sense the desperation in his voice. A meeting was called with Vasudha to discuss the results of the pilot. Vasudha got the other members of the Administration team in as well. Manav presented the numbers and in his conclusion said that they should pilot this for one year because three months was too short for such a radical change.

The other members voiced their opposition to continuing the pilot any longer. Manav argued that news about the change in prices took time to spread and patients would get to know in some more time. One of the Administrators pointed out that if this was true, at least the patient satisfaction numbers should have shown an increase. Manav said patients would generally be cautious while giving too much good feedback too soon. They would wait to see if this was sustained. No one in the room seemed to agree. If anything, they argued, patients would give good feedback to ensure that the hospital kept the prices low.

Vasudha heard everyone out. Dr. Som was quiet throughout. Vasudha concluded the meeting saying she would discuss with Dr. Som and then decide by the next day.

That evening, Vasudha asked Sheshu just one question, “What would you do if you were in my place?”

Sheshu replied, “Continue the pilot for a year.”

“You’re not being truthful Sheshu. I know this project is close to your heart. But we need to be practical. I promise you we will revisit this in thee years when our financials are more stable. We’re just too shaky right now. I listened to you and despite my doubts, agreed to the pilot. But the numbers speak for themselves.”

“Ok, shelve it then.”

“Is it our decision?”

“Does it make a difference?”

“Yes, of course, it does.”

Sheshu was silent.

Vasudha sent an email to the team asking for the pilot to be rolled back and everything to move back to how it was three months back. She had to do what was right for the hospital. Despite loving Sheshu deeply, she had to decide based on what her duty as head of the hospital was. She needed to balance the multiple roles she played in her life. She needed to separate her personal life from her professional life, however difficult that may have been.

Tuesday, May 30, 2017

Winds of change - 14

(This is the fourteenth part of a short story which is entirely a work of fiction.)

Manav worked until late that night and got all the numbers and the survey questions ready by the next morning.

Dr. Som and he discussed the numbers, made a few tweaks here and there. They decided to run the numbers by Vasudha. Dr. Som sent the file to Vasudha who said they looked good and that they should roll it out as soon as possible.

Dr. Som and Manav felt they should explain the move to the doctors in the department and get their thoughts as well. So, they had a meeting with the doctors where they went over each of the points. They took pains to assuage any concerns the doctors might have on any of the aspects of the plan. The doctors seemed to be on board. However, by the end of the day, doctors in the other departments got to know of this. Some of the senior doctors went to speak to Vasudha. The main concern they had was that having different rules for different departments was not the right thing to do. They were wondering how inter-departmental referrals would work? For example, if they referred patients to the nephrology department, would they get their referral fee? Vasudha said that would not be the case. Anything pertaining to the nephrology department would now work as per the rules of the pilot. The doctors were against such a partial implementation. Vasudha convinced them to give the pilot three months of time.

Dr. Som and Manav decided that the plan would be rolled out on the first of the following month, about two weeks away. This would give enough time for the other departments to gear up for implementation. They put up notices on the board informing the patients about the changed tariff. They made it very clear that this was for a period of three months only. The patients were pleasantly surprised. For the first time, they had seen prices actually go down for services at a hospital, even if only temporarily.

The pilot began with little fanfare. Not much change was seen on the ground. Things went on like before. Dr. Som and Manav reasoned that the real impact was in the patient satisfaction survey numbers which would indicate if the number of patients would eventually increase or not. Dr. Som and Manav did some informal feedback gathering as well. There was a generally positive feedback on the new prices. Doctors were also happy because their earnings from the hospital remained intact.

Dr. Som and Manav conducted a weekly review of all the numbers including those related to patient satisfaction. For the first few weeks, there was no change at all in any of the numbers. At the  beginning of the second month however, hospital revenues from the department began going down. The profit from the department also dipped. Dr. Som and Manav were worried. They tried to analyse the reasons behind this. Manav dug deeper and found that the new patients added for dialysis had dropped. He also noticed that the revenues from investigations from the department had also dropped.  He discussed his findings with Dr. Som. He told Dr. Som that it was likely that other doctors in the department were referring cases elsewhere. That way they would get their fixed income from Narayana Hospital and get a referral on these cases from other places.

Dr. Som called a meeting of the doctors of the department. He discussed the findings with them. Each of them sounded surprised. They assured Dr. Som that none of the cases were going outside. They thought this could be a temporary thing and that things would pick up once other patients got to know. Dr. Som and Manav agreed.

Monday, May 29, 2017

Winds of change - 13

(This is the thirteenth part of a short story which is entirely a work of fiction.)

The next day, both Dr. Som and Vasudha called a meeting of the Administrative team in the conference room. Vasudha told the team that they have decided to do a pilot of the plan. They would try the plan in one department of the hospital for three months and see the results. At the end of the pilot, they would take a call based on the results. The results would include the results of a patient satisfaction survey. This would be necessary as three months would not be sufficient to assess the full impact of the plan.

Vasudha asked the team which department they thought would be ideal for this pilot? Everyone came up with different suggestions based on different reasons. Dr. Som said, “Let’s start with Nephrology.” “Yes”, Vasudha agreed, “let’s start with Nephrology.”

“Manav will lead the pilot implementation and we will have monthly review meetings to discuss the progress.”

“Sure ma’am.” Manav was happy at being given this responsibility.

The meeting ended. Dr. Som walked up to Manav and told him, “Looking forward to working with you Manav.” “Same here, sir”, said Manav. “Come to my cabin. Let’s get started right away.”

Dr. Som was excited as they entered his cabin. He went over to the white board that was put up on one of the walls and wrote the high level plan:

1. High fixed salary for doctors
2. No incentives for investigations and prescriptions
3. No targets for investigations
4. No referral fees to refer to other consultations
5. OP and IP investigations and drugs to be charged at the same rates
6. Medical Representatives to send all new product details to a common email id which would be screened by a Vigilance Committee
7. Outcomes of the patients being treated to be tracked electronically and monitored closely
8. Patients to take a satisfaction survey at the end of their visit

“Sir, this is quite radical, to be honest with you.”

“I know Manav. That is why it is important that we have to make it work. For how long are we going to continue like this? Currently I feel like I have sold my soul to the devil. Someone needs to make a beginning. What I am trying to prove using this model is that doctors and hospitals will both gain at the end of the day. Patients of course will gain. But even doctors and hospitals will be able to make as much money as they do currently and they need not feel guilty about it.”

“Let’s hope we are able to make it work, sir.”

“We don’t have a choice Manav. I want you to get me the payouts to all the doctors in the Nephrology department in the last twelve months. Then also get me a summary of investigations prescribed by doctors and the revenue by investigation per month for the last twelve months. Also send me number of dialysis sessions and payout on that account. We can use these numbers as a baseline and work from there.”

Manav had all this data in his laptop. He opened his laptop and showed the data one by one to Dr. Som.

“Now do this Manav. Come up with the average payout to each doctor, add 10% to that and make that the fixed salary for the doctors from next month. Remove the referral fee from all investigations and procedures including dialysis and come up with a new nephrology tariff keeping the profit to the hospital the same. Also come up with a patient survey on about 3-4 parameters which is very easy to take and captures the most important points related to pricing, time with doctor, NPS and comments.”

“Got it, sir”, said Manav as he noted all these. “Give me time till tomorrow morning, sir.”

“Sure Manav. See you at 9 a.m tomorrow.”

Sunday, May 28, 2017

Winds of change - 12

(This is the twelfth part of a short story which is entirely a work of fiction.)

Vasudha felt bad at how she treated Sheshu’s plan. She was torn between doing something that she knew would make him genuinely happy and doing what she thought was right for the hospital. She realised that they had convinced close family and friends to invest their money in this venture. She also realised that they both had worked so hard to set up the hospital and bring it to a position that it was in today. She had a duty to the people who had invested and to themselves as well to make this a commercially successful venture. Was there a way both could be done?

Vasudha recalled what she liked about Sheshu. When she had met Sheshu for the first time, she was deeply drawn by his no-pretence, genuine demeanour. She loved him for his innocence. Here was a guy who was completely what-you-see-is-what-you-get. She had met so many attractive men during her IIM days and later, in her stint in consulting. She found most of them putting on facades. They would say things they did not believe in just to make an impression. People like to have others think about them in a certain way. They say things that reinforced the false personas they have built around themselves. Things became really complicated when the individuals themselves started believing the lies they’ve been peddling. Their lives became totally messed up at that stage.

Sheshu, on the other hand was like a sheet of glass, completely transparent. After years of living with him, she knew that he could never say something he did not believe in. Vasudha loved this vulnerability.

Vasudha wanted Sheshu to be happy. She would do something that would pacify him.

The next day, she called a meeting of the Admin Team. Along with the email requesting a meeting, she gave a high level overview of Sheshu’s plan and attached the presentation file. She asked them to review the presentation and be ready with comments before the meeting.

The team met at the Conference Room. Vasudha began the discussion. She talked about how change is the only constant in life and how they needed to adapt to the changing times. With patient-centric care becoming the latest buzzword in healthcare, maybe Narayana needed to think things afresh and come up with some new, radical ideas. The team heard her carefully. She then invited comments on the plan that she sent to them. One by one, the team pointed out problems with the plan. The objections were on the same lines as those that Vasudha had voiced to Sheshu.

One of the team members, Manav Sharma was silent. Vasudha looked towards him and asked, “Manav, you seem to be quiet. What are you thinking?”

“Ma’am, I believe this plan has its merits. The key to this plan is to ensure increased patient walk-ins which will ultimately protect the hospital’s revenue and bottomline. We all understand that our numbers eventually depend on volumes. If we come up with an intelligent marketing campaign around  this - for both doctors and patients, we can make this work. But it will not be a short term thing. We will need to be patient. In the end it can work.”

“Interesting take Manav. The question is, will we have enough time before panic sets in? Also, do you think we can do something with the government on this?”

“Government would be very interested in this model. With Aarogyasri bleeding like crazy, I am sure they would be keen to see how this model works”, Manav said.

“Ok. Thanks all of you for your inputs. Let me think about this.”

Saturday, May 27, 2017

Winds of change - 11

(This is the eleventh part of a short story which is entirely a work of fiction.)

A week had passed by since the day Dr. Som had revealed his plans to Vasudha. Dr. Som got busy in his work. Vasudha was busy with her work. Dr. Som wondered at times what was happening? He was wondering why Vasudha had not mentioned the plan at all. He decided to wait for a few more days.

Another week passed. There was still no discussion. That evening, at the dinner table, Dr. Som asked Vasudha, “Did you get a chance to think about the plan I presented the other day?”

“I actually did go through the presentation again. It is a great plan.”

Dr. Som could sense that there was a ‘but’ coming.

“But, I don’t think this is the right time to implement this.”

“Why is that?”

“Look, Sheshu, we are barely breaking even now. Implementing something this radical could be very risky. Things could become very bad.”

“What are the risks?”

“Patients will like it. That is great. Doctors will get a high fixed salary. They might be ok with it. But what about the hospital? If our equipment does not make money, how do we recover the huge costs we incurred? If doctors are not incentivised to recommend that patients get the tests done, they could potentially send those patients to other hospitals to get the tests done.”

“Why would patients go elsewhere when they can get the tests done here?”

“What if a doctor tells his patients that the test is not done here? Or they say things like the test is cheaper elsewhere? Or they could also say that another place does it better?”

“Why would they do that?”

“Oh Sheshu, you are so impractical. The moment other hospitals get to know that the doctors here are not incentivised to get tests done, they will start offering them incentives to get them done there. Is this really that difficult to figure out?”

“I agree that this could be a problem. But this will only be in the short term. In the long term, patients will figure the truth out and then they would insist that they get the tests done here. Trust me on this. We might have to take a short term hit.”

“That is why I am saying that we cannot take a chance now. Do you think we can bear the impact of a short term hit?”

“Yes, of course we can, provided we are doing the right thing.”

“Sheshu, you don’t understand the financial implications. Please, please leave this to me. You please focus on the medical part of running the hospital and leave my responsibility to me.”

Sheshu could not understand what problem she could have. He did not say another word. He quietly finished his dinner and then went to bed. He could not sleep however. He thought about what Vasudha said. He tried to look at it from her point of view. He could not justify her stand however. He started thinking that all she cared for was money. How different she was from the girl he knew from about ten years back. They had met at a mutual family friend’s wedding. They started talking at the event and hit it off instantly. They dated for a while before realising that they were deeply in love. There was no resistance from the families. It was a very happy marriage. They shared similar interests and values. They were not the party-going type at all. They much rather spent time with their families, going on long walks and had a deep interest in spirituality.

Sheshu felt that the last three years of struggling with Narayana Hospital had taken its toll on Vasudha. She now desperately wanted to succeed financially. But was financial success the only measure of success? Wasn’t there more to life than money? These thoughts lulled him to sleep.

Friday, May 26, 2017

Winds of change - 10

(This is the tenth part of a short story which is entirely a work of fiction.)

Dr. Som did not have a good feeling about this discussion. He sensed the negativity around this from Swamiji’s voice. He put those thoughts behind and started thinking about how the entire healthcare system could change. Every revolution begins with a small step. The entire commercial nature of healthcare was something that bothered him right from the days he began practising. He however felt compelled to go with the flow rather than to try and change anything radically. He did feel a tinge of guilt when he went on his first sponsored trip from a pharmaceutical company. He also accepted handouts  from companies on prescription targets with a sense of embarrassment. He would justify these to himself in one way or another. ‘Everyone takes this’, ‘I am only prescribing when necessary’, ‘Nothing wrong in going on trips’.

As Dr. Som walked into Vasudha’s cabin, he found her in a good mood. He was a little relieved. He could do without any additional obstacles. He sat in front of her and opened his laptop. He wasn’t very good with presentations but wanted the whole pitch to come across as well-thought. It also helped him give structure to the discussion.

Vasudha was surprised when she saw him start a presentation. “Wow, this must really be something important. You have actually put together a presentation.”

“Yes, actually. I also figured you could use this to review later or when you wanted to discuss with others.”

Sheshu started the presentation with his experience of dealing with pharmaceutical companies. He explained how embarrassed he would be to accept doles from them. He said that even though he would never prescribe anything unnecessarily or prescribe something that is not genuinely good, he was sure there could be other, more commercial-minded doctors who would not mind doing such things. He had a slide that asked a question, “Is there a way doctors can be compensated in a manner where these incentives could be completely avoided and yet the doctor made enough money to lead a comfortable life?”

Sheshu then detailed the specific contours of his plan. He called for a fixed, high remuneration for doctors based on their degree and experience. He added a variable component that was based on the clinical outcomes of the patients the doctor treated. The plan removed all incentives for pharmaceutical prescriptions and investigations. Another thing which he proposed was to charge for all procedures and investigations for patients admitted to the hospital at the same rate as when they were out-patients.

The plan banked on the hospital improving its reputation by reducing the cost of treatment to the patient and improving outcomes due to these measures and improving the volume of patients treated. This would offset the loss incurred due to a reduction in the volume of investigations per patient. He had also put some proposed remuneration numbers for some of the specialties. He also detailed on how the variable component would be calculated for those specialties. The presentation was silent on how this would impact the hospital but he added, “In the long run, the hospital would benefit due to a much better reputation and better financials - but it would all be very ethically done.”

Vasudha listened carefully to the entire presentation. At the end of it, Sheshu asked her if she had any questions. She shook her head and said, “I need some time to digest this. Can you email a copy of the presentation to me?”


Thursday, May 25, 2017

Winds of change - 9

(This is the ninth part of a short story which is entirely a work of fiction.)

Dr. Som reached the Ashram by 6:45 a.m. He first went to the temple within the Ashram. Every time he visited the temple, he felt extremely peaceful. Made out of pure white marble, open on three sides, it gave him a feeling of space, of tranquility and of a calmness that he could go to whenever his mind was agitated. The idol of Lord Krishna inside the Garbha Griha was enchanting. He spent a few minutes in quiet contemplation ending it with a prayer to the Lord to guide him on this important mission.

Dr. Som left the temple and made his way to Swamiji’s dwelling. As he reached, he saw Swamiji was sitting and writing something. He went and paid his respects to Swamiji and sat down in front of him. “Radhe Krishna, Radhe Krishna”, Swamiji greeted him. “So, what brings you here today, Sheshadri?”

Dr. Som enquired about his health and well-being and then explained his plan in detail. Swamiji heard him very attentively throughout. He stopped him several times to understand the plan better.

“So, what do you think of the idea, Swamiji?”

“Who can find fault with this plan Sheshadri? This is how healthcare in this country and everywhere in the world should be. The primary goal of any doctor or medical institution should be the well-being of the patients. However, these days it has become just another business and a lot of corrupt practices have crept in. While no one can argue that your plan aims to remove the ills of these corrupt practices, you have to think it through. I’m not sure if you realise that the problems in implementing this will be huge.”

“I’m aware of that Swamiji. But someone has to make a beginning. I cannot just let things be the way they are. I feel suffocated at times staying quiet in these circumstances.”

“I am not asking you to let things be. But before you begin any battle, you need to be aware of the challenge that lies ahead. There is no point in beginning the battle if you do not have the resources to fight to the end, irrespective of the result. I don’t want you to think this is going to be easy.”

“I’m aware that this is going to be difficult.”

“I think you are underestimating the difficulty. You tend to be an idealist Sheshadri. Have you discussed this with Vasudha?”

“Not yet.”

“I thought as much. Talk to her about it. Get her thoughts.”

“I will, Swamiji. But what is your gut feel?”

“As I said, Sheshadri, no one can find fault with the intention behind this plan. But I am worried about the implementation. I am worried about the challenges you will face. I am worried about whether you will get support from those you need.”

“I am sure Vasudha will support me. I wish she would have come with me today. What problem could she have with this? Despite some initial problems, in the end the hospital is going to do well commercially as well, right?”

“As I said, talk to her. Get her thoughts.”

“Sure Swamiji. I will do that. I just wanted your blessings before I begin this important project.”

“You always have my blessings Sheshadri. You know that!”

Sheshadri got up and touched Swamiji’s feet.

“Radhe Krishna, Radhe Krishna!”

Wednesday, May 24, 2017

Winds of change - 8

(This is the eighth part of a short story which is entirely a work of fiction.)

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

(This is the seventh part of a short story which is entirely a work of fiction.)

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

(This is the sixth part of a short story which is entirely a work of fiction.)

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

(This is the fifth part of a short story which is entirely a work of fiction.)

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

(This is the fourth part of a short story which is entirely a work of fiction.)

“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

(This is the third part of a short story which is entirely a work of fiction.)

“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

(This is the second part of a short story which is entirely a work of fiction.)

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.

Wednesday, May 17, 2017

Winds of change - 1

(This is the first part of a short story which is entirely a work of fiction.)

It was nearing 9 o’clock. Vasudha Som was winding up her work. She wondered if Sheshu was done for the day. It had been a tiring day. She was dying to get back home. She called his extension.

“Are you done?”

“Just about. 5 minutes?”

“Sure. See you at the lobby.”

She picked up her bag and headed towards the lobby. She went towards the notice board kept in the lobby. She saw the poster about their new Master Health Checkup and wondered if they could create flyers and distribute them as newspaper inserts. People must get to know about this. Her eye caught Seshu walking towards her.

They both headed towards the entrance. Sheshu called the driver and asked him to bring the car to the entrance of the hospital. As they were getting into the car, Sheshu got a call on his cell phone. He was needed back in the ICU. The 64 year old patient from Polavaram was deteriorating.

“Shit! I need to go to the ICU. You get dropped home and send Murali back.”

Vasudha nodded and acknowledged.

Dr. Sheshadri Som, Chairman and Chief Medical Officer of Narayana Hospital rushed back to the ICU.

Along with Vasudha, his wife of seven years, who was an MBA from IIM Bangalore, Dr. Som had setup Narayana Hospital about three years back. She took on the role of CEO. It quickly became one of Rajahmundry’s top hospitals. It was a 250 bedded hospital and had some really good doctors who helped establish this as the go-to destination for quality healthcare in the region.

The choice was between setting up a hospital in one of the Tier 1 cities like Hyderabad or picking a smaller place like Rajahmundry which had only a few good hospitals. After a lot of consideration, they picked Rajahmundry because they felt that the bigger cities had enough options and they would end up being one among the many options for patients. In Rajahmundry, they could bring good care to people who had fewer options. Also, Rajahmundry was Dr. Som’s home town. He wanted to do something in this region.

Dr. Som gave up his job at one of Hyderabad’s top corporate hospitals where he was a Nephrologist. Vasudha quit her job as Strategy Consultant at a consulting firm in Hyderabad. The couple chose not to have kids until they settled down. The decision to quit high-paying jobs and plunge into a future, uncertain and risky was not easy by any means. Friends and family dissuaded them. Both of them however, had an itch to do something from scratch. They felt that if they did not venture out at that time, it would never happen. The biggest advantage was, if things did not work out, they could always return to regular jobs.

They finally took the plunge, raised some money from their family and friends, put in their own savings and started the hospital in April 2012. They got some good doctors to join the team. To help manage the hospital well on the administrative side, they got some good MBAs with experience in healthcare to join them.

Dr. Som got home after midnight. Vasudha was working on some Excel files with revenue figures of the month. They had dinner together and went to bed. By 8 am, the next morning, they were both at the hospital back to work.

Tuesday, May 16, 2017

Winds of change, a short story coming from tomorrow

Dr. Sheshadri Som was Chairman and Chief Medical Officer of Narayana Hospital. Vasudha Som, his wife was Chief Executive Officer. Together they set up the hospital to bring quality care to Rajahmundry and areas close by.

Like anyone else in healthcare, they encounter challenges, both operational and ethical from time to time. Life takes an unexpected turn at one point. This spurs the winds of change in the hospital.

Read the 29 part story starting tomorrow and see how the Soms revolutionise healthcare delivery in their hospital and then eventually beyond.

Wednesday, May 10, 2017

Why I started dreading my non-dialysis nights

I posted recently about how I looked forward to my non-dialysis days. That has changed quickly. I have started dreading the nights due to the numbness in the left hand.  I am able to sleep only for a few hours and then wake up with severe numbness in the fingers of my left hand. I sit up for a bit and the numbness gets better. Then I try to sleep again. Within 30-40 minutes it returns. I do this a few times and then give up. This morning I gave up at around 4 am. Last Tuesday night, it was 3 am.

Luckily I have a diagnosis. I saw a vascular surgeon a few days back and he is convinced that it is Steal Syndrome. The fistula in my left arm is not allowing enough blood to flow to the hand due to which the hand feels numb.

The plan is to take a vein from the lower left thigh and bypass the fistula to give supply directly to the hand. This needs to be done under general anesthesia. My parents are going to be out of town the rest of the month. I am planning to get this surgery done in the first week of June.

I also went to see the orthopedic doctor a few days back to discuss the worsening pain the left knee. He asked me to repeat the MRI which showed that the inflammation was getting worse. He has suggested that we get a procedure done called an Arthroscopy where they will remove the synovial fluid and send it for analysis. This will tell us what exactly the reason is for the inflammation. It could be rheumatoid arthritis, Tuberculosis or something called Pigmented villonodular synovitis (PVNS).

Once the cause is established, the treatment can be planned. This will also be done after the first week of June.

To my mind, the numbness is the bigger problem and I am really looking forward to it being resolved. I will keep you posted.

Thursday, May 4, 2017

Why this dichotomy?

It’s late evening
The body is tired, the joints ache
He’s in no mood for more
He’s had enough
His eyelids droop

How has his day been?
He reflects and nods with satisfaction
Not spectacular, not uneventful
Could have been better
But for things beyond his control

He is ready to sleep
As the birds head home
As darkness envelopes the sky
Nothing more to do
Nothing more to look forward to

He looks around him
People are still in their mornings
Or afternoons
With lots more to do
With lots to look forward to

Why then has night fallen?
Why then is it time to sleep?
Isn’t there an answer?
Will someone not question?
Why this unfair ending to the day?

Life is not fair, not just
Not equal to all
Some have bright days
Others have clouds
Why this difference, why this dichotomy?