👍India is emerging as a hub for complex, high-end surgeries, treatment

Clipped from: https://www.business-standard.com/industry/news/india-emerges-as-a-hub-for-complex-high-end-surgeries-123042300310_1.html

India is not only performing complex surgeries but is also setting new standards of care prompting more and more people to travel to India for treatment

86-year-old Sumitra Sharma, a resident of Gaya had slipped in the washroom and fractured her left hip. With a previous history of breast cancer and angioplasty, her condition was complicated. At the time of admission at Fortis Escorts Hospital in Okhla, Sharma complained of chest pain. Investigations revealed an acute cardiac event along with old scarring and her heart was pumping at 30 per cent of full capacity. So, she went for an angiography before her orthopaedic surgery. Sharma needed surgery urgently.

A team of doctors led by Dr Kaushal Kant Mishra, director, orthopaedics and joint replacement, Fortis Escorts, Okhla, New Delhi performed a hip-ball replacement surgery in 15 minutes and 35 seconds – the shortest duration for such a surgery known so far globally. It is three minutes less than the previous world record which was also set by Dr Mishra and his team.

India is not only doing complex surgeries but is also setting new standards of care. Now more and more people are travelling to India for treatment, and corporate hospitals are investing anything between 5-8 per cent of their topline in technology upgradation.

According to a March release by the Union Health Ministry, 304,000 patients travelled to India for medical purposes in 2021 compared to 183,000 patients in 2020 (a pandemic-hit year). India now ranks 10th in the Medical Tourism Index for 2020-21 out of the 46 destinations in the world.

“Our doctors are among the best in the world, and there is no procedure that is happening in the West that cannot or does not happen here,” says Dr BS Ajaikumar, Executive Chairman of HCG. He says that at times our outcomes are better. 

“We were not publishing enough, unlike the West. But now we are catching up. Our own HCG data on 4,500 patients shows that outcomes for triple-negative breast cancer patients are equal or better than MD Anderson Cancer Center, Houston, Texas,” he said. MD Anderson is considered the gold standard in cancer care.

Ajaikumar adds that until 2005-06 the technology transfer process was slow. “Now with more private equity investment in healthcare, access to technology has increased. Knowledge transfer is almost immediate now with the internet,” he explains. Ajaikumar himself had gone to the US to train.

“When we used to hire doctors earlier, a common question used to be will we send them to the US to train? Now doctors don’t ask that anymore – they can train equally well in India,” he quips.

Corporate hospitals are estimated to spend anything between 5-8 per cent of their topline on acquiring technology, upgrading technologically, he pointed out.

Dr Ashutosh Raghuvanshi, MD and CEO of Fortis Healthcare seemed to agree. He said, “We are acquiring four orthopaedic robots and we already have seven. The profile of patients coming to our hospitals is changing – people are looking at complex, tertiary care procedures, most of them are with high-co-morbidities.” Raghuvanshi added that investments in technology would thus continue.

What kind of treatment options dominate the country also depends on its demographics. Bishnu Panigrahi, group head, medical strategy and operations, Fortis Healthcare says that in the 1950’s, around 60-65 per cent of our deaths were from communicable diseases, and now that skew has changed in the favour of non-communicable diseases like cardiac and neurological issues, cancer, organ transplants etc.

“India is fast emerging as a hub for liver transplants,” Panigrahi says. Unlike the West where most liver transplants involve deceased donors, India does a lot of live donor transplant surgeries, which are more complex.

The use of surgical robots has definitely played a part when it comes to better outcomes in complex surgeries, as the surgeon gets a clear incision, lesser blood loss, less stay in the hospital and lower chances of infection.

Robotic surgeries typically cost a lakh more than conventional surgeries, and Panigrahi says that about 20-30 per cent of patients have started to convert to robotic surgeries.

While high-end complex surgeries are definitely on the rise, most of it is still happening in large metros.

A churn is necessary here and green shoots are already visible. Dr Shekhar Salkar, Senior Surgeon, Chief Of Oncology Department, Manipal Hospital, Goa has trained at Tata Memorial Centre in Mumbai, but has gone back to his home-state as Manipal Hospital came up which offered him the opportunity to do complex surgeries in his hometown.

Salkar says that surgeons typically move to large metros to train, but if more hub-and-spoke model hospitals and large corporate hospitals come up in the tier-2 and tier-3 towns then there will be reverse migration. 

“The government also needs to step in to ensure that not only those who can afford it can get these surgeries. In Goa, the government covers every citizen with medical insurance, and this has led to a rise in cancer surgeries happening here,” he says.

Ajaikumar says that they are in the process of buying four surgical robots, and two of them will be for smaller cities like Cuttack or Vadodara.

Doctors are also returning to India from abroad. Ajaikumar says that for their Mumbai hospital, they got Dr Sachin Trivedi as head of medical oncology from Nottingham, UK where he was heading the breast cancer division. He was open to returning to India, and did not need any cajoling, Ajaikumar said.

The mix of surgeries too is changing – from predominantly cardiac procedures, now neurology, orthopaedic and oncology surgeries are on the rise.

Panigrahi explains with the Fortis example. “Earlier around 40 per cent of the surgeries were cardiac, but now that has come down to a high 20 per cent or so, while oncology surgeries are 17-18 per cent of the pie,” he says.

But do high-end, complex surgeries mean more margins for corporate hospitals?

Hospitals disagree. Dilip Jose, MD & CEO of Manipal Hospitals says, “It is not necessary that the complex surgeries have higher margins than the rest. It is true that it might cost more to a patient, but the implants, consumables and ICU stays that are usually associated with complex procedures also drive up the cost of delivery of care. As many such items are price-controlled, the overall margin available to the hospitals is not necessarily high. Examples are cardiac procedures, orthopaedics and spine surgeries etc.”

Panigrahi says that if a hospital charges a 50 per cent margin for robotic surgery, then it would become unaffordable and no one would opt for it. “So while margins are protected, the costs are worked out in a manner that it remains accessible to patients,” he says.

A senior hospital administrator said that it is not uncommon for senior doctors to charge extravagantly, but typically, for all surgeries, hospitals tend to maintain a 20-35 per cent margin. “Only recently, a heart surgery happened in Mumbai where the doctor charged Rs 20 lakh and the hospital charges were around Rs 30 lakh. So extravagant costs are not unheard of,” he said on grounds of anonymity.

Affordable prices would drive more patients from overseas to come to India too and stop Indians from going overseas.

Hospitals provide some numbers – a PET scan costs around $300 in India compared to $2500 in the US. A breast cancer procedure can happen comfortably within Rs 7 lakhs here, and if any patient needs some special medicines then at best it stretches to Rs 12 lakhs or so. In comparison, it costs Rs 45 lakh in the US.

“India has 350 mn middle-class people, which is almost equivalent to the US population. Therefore, if one is able to cater to these people alone, there is a huge market for hospitals. Investments in technology and focus on high-end surgeries are thus here to stay,” Ajaikumar adds.

• Lack of access to essential surgeries results in 4.7 mn avertable deaths in LMICs every year- Disease Control Priorities Network (2015)
• With a population of 1.4 billion people, India is the most populous LMIC whose residents bear 18.4 per cent of the global disease burden
• The Lancet says while a precise estimate remains elusive, a large portion of India’s disease burden requires surgical care
• India now has roughly 140-150 robotic surgery systems across 70,000 hospitals
• 10,000-12,000 robotic surgeries happen every year in India