Transform or Perish

Dr Alok Roy, Chair, FICCI Health Services Committee, and Chairman of Medica Group of Hospitals, on the news ways of engagement for hospitals

Dr Alok Roy, FICCI Health Services Committee, EBITDA, The New Normal, Ministry of Health, Medica group of Hospitals, Rational costing solution for COVID treatment

How hospitals can bounce back from the current downturn in business, caused by the COVID-19 outbreak?
Hospitals need to transform and find new ways to engage. The ones that cannot transform would perish. Hospitals need to maintain the balance between providing treatment to COVID and non COVID patients. When COVID cases surge, hospitals have to cater more to COVID treatment than non COVID treatment, and when COVID subsides they have to cater more to non COVID patients. This see-saw between COVID and non COVID would continue for some more months.

Already, hospitals have started witnessing recovery in business and they would recover fully in the next few months. Hospitals need to realise that surgeries have only been deferred and soon the number of surgeries would be like before, and soon the business would be like before. However,  like other industries, healthcare also needs to embrace the ‘New Normal’.

Cost of care has increased due to the ‘New Normal’. Would it be the same in the future?
Hospitals would not be able to provide services at the earlier cost, given the safety measures and infrastructure changes needed now. So, obviously, the cost of care would be more than before.

Hospitals have received flak for exorbitant charges of COVID treatment. What are your views on making the treatment more affordable?
While it is true that a few private hospitals have been charging patients exorbitant sums for COVID treatment, this is not the case everywhere. At all private hospitals under the FICCI umbrella, minimal working costs have been agreed upon that allow for hospitals to continue functioning without being a burden to patients. Additionally, we have streamlined processes to distribute the costs of protective equipment across patients. Regular and repeated internal audits help prevent misuse and remove redundant costs in bills.
Capping of fees is not the answer at the level that has been ordered by some state governments. A broader understanding on the minimum possible pricing with leeway for expensive medications like Tocilizumab and extreme procedures like Extracorporeal Membrane Oxygenation will go a long way in making treatment more affordable.

FICCI has provided a rational costing solution for COVID treatment at private hospitals.  What has been the response from the Government regarding it?
We submitted the first cut of the costing strategy, which was based on hypothesis, in the month of April. The revised version, submitted in June, was worked out based on analysis of actual data of 150 cases of COVID treatment in major private hospitals.  After FICCI submitted the costing framework to the Union and State Health Ministries, many stated governments have referred to the costing solutions before deciding on the costing for COVID care.
FICCI member hospitals have pledged to adopt these cost recommendations and display it transparently on their hospital website in their endeavour to fight this war against COVID-19.

Which are the other areas that FICCI is working on regarding COVID?
We are continuously imparting training to nurses and healthcare workers. We are organising webinars. Also, we are in talks with the insurance companies trying to work on an insurance package for COVID patients that is viable to all.

What are some of the positive learning from the pandemic for the healthcare industry?
It is evident at this point that we will be living with COVID for the foreseeable future. It is prudent to adopt designs and operational processes that serve to prevent cross infections and outbreaks.

One of the biggest lessons probably is being able to reassign and refit various areas of the hospital to function differently. During the course of the last three months, general wards have been converted into ICUs, offices into donning and doffing areas, etc. This adaptability of hospital spaces has been a major lesson.

Another aspect that was brought to light during the pandemic was ventilation systems. Positive, neutral and negative pressure systems all have an important situational role to play. Operation theatres require positive laminar flow systems. Wards generally have neutral pressure. Rooms that are built for isolation in case of respiratory illnesses like COVID-19 and pulmonary tuberculosis require negative pressure. This sudden surge in requirement of negative pressure areas has highlighted the need for flexible air pressure systems. These will play a crucial role in the robust hospitals of the future.We have learnt that our brave COVID warriors have endless enthusiasm and a drive to serve. They have picked up new skills, taken on new responsibilities and flourished. We have learned how to reallocate resources to keep the system functioning smoothly. Everyone is important and everyone does their part.

What about the learnings about leveraging technology during a pandemic?
The shift to technology has been another major change that will be integral to all projects. Using electronic medical records in place of physical files, teleconsultation services in place of physical visits and webinars in place of physical conferences are some of the few changes that can be extrapolated across the board.
We moved over to an appointment only system for our OPDs which is not common in India. The advantage is being able to stagger the arrival of patients so as to enable crowd control and social distancing. Our efficient operations team monitors the areas that are a common choke point and direct patients to holding areas where they wait for their token numbers to be called out. This system has allowed us to achieve 50% of our usual footfall despite the pandemic. The patients who require routine care for chronic conditions like diabetes, hypertension, etc. are hence able to seek care. Treatment is not delayed.  This system works and is sustainable in the long run.
In what ways should the government help the private hospitals during the current pandemic?
Private hospitals have been doing everything in their power to cater to the needs of the people during this pandemic. The government needs to have faith and show solidarity.

The allocation for healthcare in the government stimulus feels inadequate. A larger allocation would help cover expenditure towards training, protective equipment, infrastructural changes and salaries. Fiscal support in terms of clearing long standing claims and line of credit would also go a long way. While it is clear that the government works with the best of intentions at heart, attempts to cap fees for various hospital procedures and bed charges are counter-productive. Fee caps are not sustainable for private hospitals and would result in a decrease in access to health for the masses.

Coming to Medica, when did the group start preparing for the pandemic? What were the initial steps taken to modify your operations to meet the current crisis?

COVID-19 was first declared a global health emergency towards the end of January 2020 by the World Health Organization. At this point countries across the globe had started noticing a handful of cases sprouting up. Medica kept a close eye on these developments and began preparing defense systems as early as the first week of February.
It began with setting up handwashing stations at all entry points along with non-contact thermal scanning stations. Thereafter, a fever clinic was set up outside the main building to assess and risk stratify patients who were febrile, thereby protecting healthcare workers and the non-COVID cohort of patients.

As the number of COVID positive patients grew in the city, we felt that our skilled healthcare workers, state-of-the-art ICUs and more than adequate oxygen support systems (High Flow Nasal Oxygen devices/Mechanical Ventilators/ Extracorporeal Membrane Oxygenation devices) would be wasted if we didn’t serve the people. This led to wards being reassigned to serve as COVID wards and ICUs. New oxygen and dialysis lines were put in, Negative pressure spaces were created in a day or two and technology was used to the hilt.

Additionally, tele-consulations have been promoted to reduce OPD crowding. When physical OPDs are essential, they are done so only by appointment so as to enable social distancing.

How is MEDICA catering to the COVID
We have had many patients with COVID-19/SARS CoV-2, who have been successfully treated on ECMO and have gone back to their usual life,  healthy. As advised by Principal Secretary, Health & Family Welfare, we have acquired a 52-bed hotel near to MEDICA hospital to accommodate mildly symptomatic, asymptomatic patients or those who do not have home quarantine facilities. These cases will be watched closely by medical faculties of MEDICA.
We have increased the numbers of beds for treatment of COVID-19 patients to 112, in tune to the wishes of Government of West Bengal.  We are also adding another 38 beds to treat suspected patients. We have reduced the cost of COVID testing further to Rs 2,250, PPE kits to Rs 1,000 and doctors’ consultation at Rs 1,000 per day.
We are also moving forward and starting Plasma Convalescent Therapy for moderate to severe patients for early and smooth recovery.

How are the hospitals functioning amidst the crisis and what precautions has the group taken to reduce the risk of transmission in its hospitals?
At Medica, we felt it would be unwise to forget about the whole gamut of non-COVID conditions, in our intense fight against COVID. Hence, we sought to keep our doors open to both groups of patients. With this as the goal, strict measures were required to reduce the risk of transmission in the hospitals.

Healthcare workers and patients undergo screening (via a scoring tool), a thermal scan and are asked to wash their hands with soap and water prior to entering the hospital. All hospital visits are now only by appointment so as to preventing crowding in our clinics or testing areas. Social distancing is being maintained all across the hospital by demarcating spots on the floor where patients must stand, blocking out chairs and by removing and rearranging chairs.

Other major changes have been with respect to infrastructure. Negative pressure systems have been installed. Wards have been reassigned to function as ICUs, COVID positive areas and COVID suspected areas.
Social distancing, wearing of masks and hourly hand hygiene have been integrated into nor

mal functioning of the hospital. Being cautious and developing systems based on the notion that every person entering the system is COVID positive has kept our patients and healthcare workers safe.

How the upcoming projects of Medica been impacted?
The pandemic has hit all healthcare delivery institutions with low earnings and a severely depressed EBITDA. In this situation, arranging for funds for the growth of the group looks very difficult. Hence, all upcoming projects will be either shelved or delayed.

How are you integrating operational efficiencies and lean approaches for upcoming projects, post COVID?
The hospital designing will undergo a sea change in the post COVID world. At Medica, once we start any new projects, we will have longer general wards with separate Air Handling Units (AHUs).
Air conditioning system from now onwards will have suction at the bottom rather than at the top, among many other changes that will follow suit. Another important aspect shall be the pressure interchangeability, meaning wards or rooms shall have the option to be converted into positive or negative pressure as required. Natural lights’ in patients areas has been a standard feature in every Medica hospital and that shall remain so going forward as well.

What steps has the group taken to remain sustainable when revenue has dipped substantially?
The first step to remain sustainable has been to put in place various safety measures to prevent outbreaks and cross infections. Next, we have restarted OPDs and surgeries on a large scale. At this point, we are not looking to make a profit. We aim to serve while making enough to keep the doors open. With this in mind, we are able to serve the masses at justifiable and sustainable