A Virtual Dose

An experiment that two friends began 17 years ago has taken a new form and acquired relevance. At the turn of the century, space scientist and the then Chairman, Indian Space Research Organisation (ISRO), Dr K Kasturirangan, and Dr Devi Prasad Shetty, leading cardiac surgeon and founder of Narayana Health, came up with a plan to leverage ISRO satellites to remotely provide healthcare services. Little did they know then that it would become the norm in a corona-ravaged world. "Kasturirangan wanted to revolutionise rural healthcare using telemedicine that could be made possible with an ISRO dish on a hospital roof-top linked via satellite to a small dispensary in rural areas at the other end. I ended up seeing 53,000 patients across the country then," says Dr Shetty.Teleconsultation

"We could not transfer data and I could not see blood or X-ray reports. Now, it is dramatically different, and data is on the Microsoft Azure platform," says Dr Shetty. Both he and Dr. Kasturirangan look back fondly at what they had attempted then and the new, robust form it has taken today, when Narayana gets health insights through the platform run on Azure, SQL Server and Power BI, as do some other leading hospitals. With pestilence rife and physical distance inevitable, teleconsultation is emerging as a viable healthcare delivery model. The Narayana Health City in Bangalore is alone seeing over 300 patients every day.

Ranjan Pai, Chairman, Manipal Education and Medical Group, says, "We are seeing about 250 patients online each day across our hospitals." He says the numbers may nearly double over the next few months as more follow-up consultations move online. Physicians and hospitals have been quick to adapt to the new mode of healthcare delivery. "After the recent approval of telemedicine guidelines by the Union government, teleconsultation has emerged as godsend for patients who cannot go to the hospital," says Preetha Reddy, Vice Chairperson, Apollo Hospitals.

The Big Picture

It is early days for telemedicine in India. But things might change considering that in the backdrop of lockdown and physical distancing, most private hospitals, including the major chains, are struggling. Occupancy levels are down to around 30 per cent and likely to remain there unless there is easing of the lockdown and patients return to hospitals. All hospitals have high fixed costs and are expected to report huge losses as revenues decline by at least half in major facilities and more in smaller ones in the current quarter.

In terms of business potential, there is pent-up demand as many procedures that have been postponed will have to be done. It is estimated that even if hospital occupancies rise to 50 per cent, many may be able to recover fixed costs considering the reduction in marketing, travelling and administrative costs. However, until standard revenue streams - inpatient, surgeries (including elective ones like cataract or hernia, which have got postponed), pathology/radiology tests and OPD services - pick up, the major source of revenue for hospitals will remain online consultations, remote services, emergency admissions and for some (like Apollo Hospitals) even testing and pharmacy services.

Most hospitals are talking about the need for a special financial package. The major ones like Apollo and Fortis, analysts say, may also need short-term financing, perhaps to the tune of around Rs 250 crore, in current and next quarters. Players across the board are looking at ways to conserve cash, including by reducing costs, cutting salaries of senior administrative staff, deferment of rent payments and clearance of old dues.

Remote Monitoring

Doctors expect that management of many ailments like diabetes and hypertension will shift to the online consultation mode. Many patients in urban areas are already relying on smart phones and other health tracking devices to keep tabs on things like blood pressure and sugar level. Those who have undergone heart procedures keep an eye on body weight and oxygen level in their blood using oximeters that cost around Rs 2,000. Others use glucometers for tracking blood sugar levels. Those who do not have access to these go to the clinic or diagnostic lab next door and report findings to the doctor. Because of the Covid problem, senior intensivists are also monitoring patients in the ICU using apps. Narayana Health has an app called Atma' while Apollo uses the 'Philips Remote Monitoring System.'

New Revenue Streams, Cost Structures

The changes in revenue streams and cost components have meant reworking of the business model. All elective surgeries (cataract to hernia) have been postponed and only emergency procedures are being done. Till all routine operations begin again, hospitals will have to look at doctor fees and online services. Costs for patients

are likely to increase because someone has to pay for the additional disposables that doctors need to now wear, regular sanitisaton of waiting areas and doctor rooms and compensation to additional staff needed to record body temperature of patients.

The hospitals treating Covid patients also need to pay staff extra and in times of lockdown have them picked up from home and house them separately in hospitals with suitable diet. In fact, as BT is going to print, there are reports of doctors talking of cases where patients finding themselves hit by huge hospital admission bills, in some cases as much as Rs 3 lakh or more per day. Hospitals say this cannot be generalised as Covid treatment is patient-specific and so costs vary and cannot be generalised.

Hospitals, however, feel these allegations could be some specific cases and erring hospitals need to be pulled up as it is not possible across the board. Covid treatment, they say, is patient-specific and costs vary per patient. But then, triggered by allegations of exorbitant pricing, the Maharashtra government has come out with a notification capping the price of all procedures. Hospitals apparently are talking to the state government to lift the price cap. Hospitals also need to invest more on digital infrastructure and digital health records, which may again be challenging for smaller 10, 20 or 50 bed hospitals that are struggling to get business. Also, doctors will increasingly see patients strictly by appointments, which means getting appointments with doctors will not be easy as most will be busy and seeing fewer cases as physical distancing will require OPD sections of hospitals to now accommodate fewer patients.

Treating Symptoms

While there is a clear upside in being able to avoid visiting hospitals, a preferred option for many in times of corona, the downside, say doctors, is that patients will increasingly be diagnosed on symptoms and based on what the patient tells the doctor as against what the doctor finds after a proper clinical examination of the patient.

Judging by symptoms alone can be challenging as the problem could range from a simple allergic cough to Covid, with other ailments like TB and others in between. In this model, the failure rate of treatment could be higher. As Dr. B Soma Raju at the Asian Institute to Gastroenterology, who with Dr APJ Abdul Kalam had developed the first indigenous coronary stent - Kalam-Raju stent - says, the only challenge of going online will be the quality of bandwidth. That could determine how well doctors diagnose patients.

@EKumarSharma