Dakshas: An Aggregator in Health-CareTowards Universal Access to Safe Surgery

Concept Paper Introduction

Opportunity to Serve

Dakshas Model

Status

At Scale

Going Forwards

Role of CSR Funding

Role of Technology

Projections

Introduction:

Dakshas is a group of orthopaedic surgeons, working towards Universal Access to

Safe Surgery. Based on our experience, we believe it is possible to deliver ethical and

affordable elective surgery to all economic classes, with current resources, via a

healthcare aggregator.

This aggregator could choose to enter the market as a social enterprise serving BPL

and lower middle class. The immediate impact would be to effectively address all the

lacunae identified in the National Health Policy, 2015, especially preventing

'catastrophic' medical expenditure faced by economically challenged sections. Such

expenditure either pushes them into poverty and/or morbidity due to withdrawal from

medical care. Their financial constraints would be rendered irrelevant, in a sustainable

and scalable fashion.

The long-term consequence would be to bring in novel referral systems and asset

utilization practices across geography and health-care specialties, so that ethical and

affordable healthcare would also be profitable.

Opportunity to Serve:

According to a recent publication in Lancet, healthcare bills forced 55 million

Indians into poverty in the year 2011-12. Despite all that is being done, out-of-pocket

expenditure increased by 3.6% in the last decade (2004-14); 25% of the population

remains under-covered.

While the current investment environment promotes building bigger hospitals and

health-cities, this does not translate into innovative, cost-effective and ethical

healthcare delivery. Hospital investments, whose break-even period is 6 years, are

treated as real-estate development, where a profitable exit is always available. This

reduces the drive towards process innovation in healthcare delivery. Rather

questionable practices are used to shorten the break-even period.

Such investment practices are also contrary to the global trend to curb hospital

infrastructure. 70% of surgery in US occurs in ambulatory care centres. UK GP's have

warned their hospitals to shrink or shut. Singapore provides 50% of maid's salary, if the

maid is trained to take care of chronically ill patients at home.

The result of these macro-factors in India is a redundancy of health-care resources,

confirmed by our last 24+ months work experience in charitable surgical services.

Another important revelation is that there exists a 'human funnel', eager to connect

these redundancies to those that need them, at miniscule costs, if a credible conduit

mediates it. Dakshas could be that conduit. Dakshas can demonstrate a model that can

afford to be ethical and profitable at the same time, leading to a paradigm shift in

healthcare delivery.

Dakshas Model: Ability to Deliver at Zero

Dakshas has ringed these redundant generic resources around the marginalized

patient and plugged gaps with its own assets, all glued together with documented

processes.

Excess Resources available at Low Cost:

1. Functional charitable hospitals that lack in strategy for the current healthcare

environment.

2. Excess surgeon time, redundant due to inefficient referral systems.

3. Community embedded organizations with unmatched brand credibility, as

channel partners into the community and

4. Under-utilized State/Public insurance because very few providers meet target

costs.

Certain core competencies enable Dakshas to access these resources. The same will

be consciously incorporated into its culture as it scales up.

1. Managerial framework would adopt Code of Medical Ethics as non-negotiable

bench-marks, so we always remain a ‘social enterprise’ that would never pass its

costs to society.

2. Customers' customer: We don’t see ourselves as providers of healthcare. We

believe we are our customer's customer, implying any unreasonable prices are

passed right back to the provider in any economy. Reducing our customer's

burden, through ethical and efficient healthcare delivery, will only reduce our

own liabilities as individual consumers.

3. Trust: Built & Borrowed: Dakshas’ intent to enable Universal Access to Safe

surgery, free of financial constraints, has found resonance with

a. Long standing and credible Community Embedded Non-Profit

Organizations that provide credibility and free access to their communities.

b. Citizen's network: philanthropic citizens and civil society groups, which help

plug gaps in networking, skill-sets and resources.

c. Governmental Healthcare Hierarchies which not only provide low-cost in-

roads to marginalized populations, but also the will to overcome obstacles.

4. Healthcare domain expertise that helps streamline services to target populations

and customize

a. Market Segment

b. Service Design

5. Business Tools to leverage

a. Partners' spare capacities

b. Remain a cost-driven and lean organization.

Dakshas' Assets:

1. Documented processes to bring in standardization, quality assurance and scale to

operations

2. Equipment and Instrumentation, unavailable in charitable hospitals

3. Operation Theatre Staff trained to assist new surgical techniques

4. Sterilization of theatre instruments to ensure perfect quality control

5. Dakshas Support Group: philanthropic individuals, from diverse backgrounds,

who plug gaps in networking, skill-sets and finances.

Status:

Dakshas has a pilot project at a charitable clinic, Vivekananda Health Centre at

Ramakrishna Math, Hyderabad. Dakshas’ physiotherapist run the clinic 8am to 5 pm, 6

days a week, seeing approximately 1000 patients a month. While patients are charged

a nominal Rs.10-20/- towards centre’s expenses, Dakshas provides free service.

Dakshas’ physiotherapist, along with six general physicians at the centre, follow a

standardized primary orthopaedic screening and treatment protocol, which enables

them to treat 95% of orthopaedic patients at primary level. 5% of patients are referred

to the Dakshas’ orthopaedic surgeon at the centre, through pre-defined referral points.

Most of these are treated conservatively by the orthopaedic surgeon.

Only 1% of the 1000 patients per month require surgery. The surgeries are offered

free to the patient, via the Government Arogyashri or RSBY scheme, at charitable or

trust hospitals like Mahavir Hospital or Durgabai Deshmukh Hospital. Other surgeries,

not covered by Arogyashri, are offered at a low-cost community hospital, MEDS

Hospital, for out-of-pocket patients, irrespective of their paying capacity and

Arogyashri schemes limitations.

Selected patients are provided a blanket financial cover for any treatment

component (diagnostic tests, blood transfusions, surgical implants) or even the whole

surgical treatment. Assistance is provided based on the financial need. Free groceries

for family of four are also be provided, up to a period of 3 months, while patient

recuperates.

The extreme reduction in cost of healthcare delivery also allows Dakshas to extend it

support to those patients who may develop post-operative complications. The

incidence of these is miniscule (minor complications 1-3%, major 0.1 %) as anywhere in

the world. Dakshas has been able to provide financial free treatment support to those

patients who happen to go through a difficult recuperation period.

The total spectrum of skills-sets deployed in these operations are as follows:

1. Community Centre:

a. Dakshas’ Physiotherapist:

Screen patient history,

Counselling,

Physiotherapy,

Dressings,

Plaster/splint application,

Post-operative rehabilitation and

Overall coordination.

b. General practitioner:

Thorough history as required,

Conduct clinical examination,

Prescribe medication and investigations.

Wound management and suturing when feasible.

Post-operative care.

c. Orthopaedic Surgeon at Charitable Clinic:

Back-up Centre services during working hours over phone or

video-conference, including

reviewing history, clinical pictures, investigations,

radiology/imaging,

discussion with physiotherapist and/or general

physician and

refine medication/investigations.

Evaluate patients with red-flags, or at patient request, twice

daily (morning & evening)

Carry out conservative treatment for 4 of 5 referrals

Surgical counselling for 1% of patients

Post-operative follow-up

2. Hospital Team:

a. Orthopaedic Surgeon at Hospital: Co-ordinate and provide comprehensive

peri-operative surgical treatment.

b. Hospital Ward Nurse: Perioperative care. Pre-operative surgical profile,

coordination consultant and in-patient care

c. Dakshas’ Theatre Nurse:

Intra-operative Care.

OT set-up,

Floor nurse,

Dakshas’ Equipment and Instrument management

Sterilization at Dakshas’ base unit

Following this structure give Dakshas’ the unique advantage of not only owning its

own referral network, but also the ability to deliver very low cost post-operative care

and rehabilitation through the same peripheral centres. It is also possible to bridge the

last mile and establish a home-care network in centres supporting a substantial post-

operative population.

At current level of operations, these would consume 30% of normal working hours,

except for the physiotherapist (100% utilization per centre). If two more

physiotherapists and sets of physiotherapy equipment are provided, 100% utilization is

expected of the Dakshas’ Theatre Nurse and Orthopaedic Surgeon, creating a self-

sustaining and scalable unit.

Communication between the hub and spokes could be easily conducted through any

of the economical mobile platform at practically miniscule increase in cost.

At Scale:At its obtainable scale and scope, Dakshas could

1. Ensure under-utilized resources in the system would be accessed at minimal costs

2. Become self-sustainable, if operated at 100%.

3. Allow proper division of labour, so that surgeon can focus on patients that really need

that level of expertise and surgery.

[4.] Potentially expand with internal accruals, after 100%, to deliver elective orthopaedic

surgery across geographies, limited only by personnel availability.

4.[5.] Growth would also come from economies of scope across every other surgical

specialty, achieving Universal Access to Safe Surgery in elective cases.

5.[6.] Open multiple revenue streams by occupying a pivotal position across the value

chain

6.[7.] Most importantly establish collaborative relationships with existing providers,

tipping the sector towards ethical and affordable healthcare delivery.

Going Forwards:

The missing link is the capital required to fund the team while the model comes into

effect. It will probably take 3-6 months for a centre to reach its capacity. Even if all the

patients are operated under the Arogyashri scheme, at minimal government prescribed

surgical packages, a team could deliver a modest 15-20% return, and will be self-

sustaining and expanding. Of course, further infusion of capital after 100% with shorten

the growth period.

Three physiotherapists at three such centres in Hyderabad, backed by one theatre

nurse and orthopaedic surgeon, managed through a central office, would be able to

provide free orthopaedic care for approximately 2000 2600 patients free of cost. The

impact at such scale would be immense:

1. Prove an ethical and affordable healthcare delivery model, capable of expanding

across geography and to other surgical specialties

2. Provide enough traction to change how healthcare is practiced across the sector,

enabling and facilitating ethical behaviour among surgeons, diagnostic centres

and hospitals

3. Provide viable channels to the lower middle class, who are largely uninsured and

currently unsupported by the government schemes.

4. Compensate where Arogyashri coverage is inadequate, as Dakshas could fund the

occasional short-falls through its philanthropic networks.

Further expansion could be rapidly achieved by funding replication of these primary

centres, spoked to a charitable hospital hub across the State and then cities across

India, effectively covering non-emergency healthcare requirements of the urban poor.

The ripple effect of reaching such a scale would set the ball-rolling. Yet, Dakshas

would usher a non-competitive, collaborative model, ultimately triggering large scale

efficiency and cost effectiveness into the healthcare sector. The existing players could

collaborate via Dakshas, as a new channel for service delivery, without compromising

on their bottom line.

Role of CSR Funding: Dakshas’ ‘Money to QALY’ ProgramHealthcare Promotion tied to Disease Treatment at Miniscule Costs.

While the model relies heavily on government funded public insurance, like

Arogyashri or RSBY, there may be patients who fall out of this net:

1. When their condition or procedure is not covered

2. When they are lower middle class and not covered under such schemes

Dakshas hopes to structure a perpetual fund to support such contingency, through

health promotion among the corporate sector. As part of this program, corporate

employees will be taken through a 12-month healthy lifestyle transformation program

to help them earn QALY (Quality Adjusted Life Years).

The lifestyle transformation program has the support of some very credible not-for

profit partners:

1. Nutrition: National Institute of Nutrition, Hyderabad

2. Stress Management: Vivekananda Institute of Human Excellence,

Ramakrishna Math, Hyderabad

[3.] Intentional Physical Activity: Dakshas is in talks with a Hyderabad Runners, a

Marathon marathon Runner’s runners Ggroup, who conduct the Hyderabad

Marathon. based out of Hyderabad

It is hoped that the blue-print of this program and its impact will be published as a

scientific study in a peer-reviewed medical journal by mid-next year, setting out the

bench-mark for such interventions on a country-wide scaleacross India.

In turn, corporate sector will be encouraged to deploy its CSR funds for disease

treatment of those patients who fall out of the social net. In this manner, Dakshas will

become a conduit through which health will flow both ways, while resources flow

from haves to have-nots.

Role of Technology: Technology would enable three broad processes:

1. Patient screening, surgery and rehabilitation

2. Capacity aggregation

3. Match the patient to spare capacity

The virtual and fragmented nature of the operations will be tied together, effectively

unravelling the current hospital processes and re-wrap them around Dakshas.

This would include, but not be restricted to:

1. Converge across hardware and software platforms, various media and languages

2. Appointment and accessibility

[3.] Support consultation information access for decision making, referral and follow-up

3.[4.] Take over surgical planning as project execution

4.[5.] Provide relevant business intelligence for future directions

Projections

Currently, Dakshas’ runs an three orthopaedic unit Bone and Joint in a charity Charity

cClinics with a capacity to screen and provide primary (out-patient) orthopaedic

treatment to 132600 patients per month at Rs.6.73 per patient. It is expected the

population served may need 240-60 surgeries per month, on average.

Dakshas at one center:

While resource utilization is currently 100% for physiotherapist, the orthopaedic

surgeon and OT nurse would be engaged 30% of time.

Poor patients who need surgery would be covered by Government Public Health

Insurance, like Arogyashri, and/or Sharma Family Charitable Trust’s CSR ‘Money to

QALY’ Program. Those patients who have no cover what-so-ever would be encouraged

to bear cost of laboratory tests, medicine and consumables alone.

While resource utilization is 100% for physiotherapist, each clinic engages the

orthopaedic surgeon and OT nurse 30% of their time.

IfAs surgery is required for 1-2% of the patients per centre, 3 such centres could are

be supported by a single orthopedician-OT nurse team.

A lower number of surgery per month would simply mean more such centres could

be tied to the orthopedician-OT nurse.

Poor patients who need surgery would be covered by Government Public Health

Insurance, like Arogyashri, and/or Sharma Family Charitable Trust’s CSR ‘Money to

QALY’ Program. Those patients who have no cover what-so-ever would be encouraged

to bear cost of laboratory tests, medicine and consumables alone.

Fixed Costs per Sub-Unit (3 centres)

The fixed costs to support 3 peripheral centres, tied to an orthopedician-OT nurse,

would be depreciated over 3-5 years, would be:

Profit & LossImpact:

At its base unit of function- 1 hub with orthopaedic surgeon- OT nurse, supporting 3

physiotherapists at peripheral centres, the following P&L finances could be projected,

at current salary, equipment costs, virtual office charges and Arogyashri Packages

(State of Telangana).

Dependencies & Other costs:

1. A physiotherapist, with one year work experience, needs approximately 1

month of training to adapt to the system.

2. A centre takes approximately 3 months to mature its patient flow

[3.] Dakshas already has threeone physiotherapists-orthopedician-OT nurse

working in tandem.

[4.] Another physiotherapist is expected to complete join training in May ’17 and

start a new centre by 1st AprilJune.

[5.] Starting May 2017, the The enterprise can grow exponentially, subject to

availability of such centres, human resources and surgical requirement.

3.[6.] A cloud-based medical records system would be required after 3rd month of

operations, to streamline information and decision making.

4.[7.] Ability to hire managerial expertise, preferably with a medical background

and 2 years of experience, could cut down the time to scale by 50%.

Risk Management

The risks in the model would largely be based on lesser number of patients opting for

surgery through the system.

If the number of patients requiring surgery per centre is less than expected, more

centres could be attached to the same orthopedician-ot nurse team-office support, so

the escalation of cost would be limited to

a. Fixed Cost of Physiotherapy Equipment: Rs. 70,000/- (per centre),

depreciated over 3 years, or Rs.2000/ month.

b. Salary of Physiotherapist: Rs.13000/ month

Therefore, the model would still become self-sustainingreak even If even if only 6

patients per centre require or opt for surgery per month.

In such a scenario, as many as 10-11 centres could be tied to one orthopedician-OT

nurse team, providing comprehensive orthopaedic care to as many as 13,000 patients

at Rs.6.73 per patient.

However, the break-even period would be longer, as time will be taken to develop

these centres.