What can Rural India Teach American Healthcare?

In Fiscal Policy, Health Care, Hospital, New Ideas, Personal Experience, Reform on June 10, 2012 at 2:19 pm

There’s a new television talk show in India called Satyamev Jayate which focuses on different issues that plague the country. It’s hosted by Bollywood legend Aamir Khan, star of the Oscar-nominated film Lagaan, which basically gives this show a healthy dose of star power and a committed audience.

The reason I bring up this show is because it highlighted a particularly relevant topic during one of its episodes. In the fourth show, Satyamev Jayate tried to tackle the dilapidated state of health care in India. You can find the video below, but be warned: it’s an hour long and entirely in Hindi.

For those who want a quick synopsis, during the episode a few stories were shared that revealed how broken the Indian health care system can be. Patients recounted stories of physicians who preyed on their trust, inflated their bills, and then took a cut from the payments to line their own pockets. Still others surmised collusion, where physicians would refer patients to other physicians who would also take a cut. The racket extended to the pharmaceutical industry, where pharmacists were bullied into scamming patients. All in all, ethical boundaries were flagrantly violated and few were doing anything to rectify the situation.

While there is definitely some sensationalist reporting that warrants fact checking, based on my own experiences in Indian health care, I wouldn’t be surprised if these claims were true. During my time volunteering in Anandwan, a rural Indian leprosy colony, I was an eye-witness to the struggles these rural villagers had to endure just to receive a primary care check up. When I helped treat lepers and villagers at wound-wrapping and cardiac clinics, I would ask why they came to Anandwan instead of visiting their local physicians.

Turns out there weren’t any, at least for the 5000 patients in Anandwan. They traveled from all parts of India to receive free treatment from the Amte physician family because their local physicians did not care to see, let alone touch, a leper. Stigmas against the disease ran deep; deeper than a 21st century medical education could uproot. Most lepers had incomes at or below poverty-level, so physicians may have realized the lack of money to be made from them. That may not be entirely the case, however, as Indian healthcare faces extenuating circumstances that make rural practice extremely difficult. As I wrapped the lepers’ ulcerated feet, I could feel the history of their traversals etched into the cracks and soles. Some walked for miles, while others hitched rides, all forced from homes and lives because of a curable disease they had no control over. It was sad to see and heartbreaking to hear.

It reminded me how thankful I was (and still am) for the quality of physician we have here in America. Even if our healthcare system isn’t sustainable, I’d take it over physicians who prey on my pocketbook any day.

There was one guest at the tail end of the show (around the 45 minute mark), however, whose idea I feel is worth exploring. In particular, this physician’s idea could be a viable method of helping America overcome its spiraling healthcare expenses.

Dr. Devi Shetty

Dr. Devi Shetty, a cardiothoracic surgeon, has been providing low-cost, high-quality and high-tech health care and surgery to India’s poorest populations for fractions of the analogous US cost.


Specialist hospitals and low-cost insurance schemes.

Dr. Shetty has established three hospitals in the southern state of Karnataka. Each of these hospitals specializes in one thing – cardiology, opthamology, or oncology. The vast majority of these hospitals do just their specialty and little to nothing else. The key, however, is that each of these hospitals performs surgeries en masse.

For example, Narayan Hrudayalaya (NH), the original cardiac specialist hospital opened by Dr. Shetty, performs 85 surgeries a day. It’s 42 cardiothoracic surgeons work six days a week to ensure that the low income patients get access to high-tech health care. NH houses all the latest medical technology from General Electric and other biomedical powerhouses. It’s able to afford these expensive American brands because of the high patient throughput.

All the patients NH sees are low-income or poverty level citizens who pay $15 per annum for access to NH and all its other specialty hospitals in Karnataka. That’s a complete hospital health insurance package for $15 a year.

With all this, NH still maintains a profit margin of 7.7% after taxes, as compared to the US national average of 6.9%. The average cost of open heart surgery in the US versus NH? $20,000 to $2,400. That’s nearly a tenth of the cost. With NH insurance, patients pay $1,400.

When we’re floundering in an unsustainable health care system, what can we learn from Dr. Devi Shetty and NH?

The majority of hospitals in the US are “full-service” – they tend to cater to every need a patient may have. While that certainly has its benefits, maintaining a full-service hospital would be rather expensive considering the amount of equipment needed and specialists on staff. According to Census data, in 2009 the average community hospital cost per patient per stay was approximately $10,000.

If hospitals specialized, perhaps that would reduce overhead. Only the proper equipment and certain specialists would be needed at that hospital. Of course, we would need every kind of specialty hospital from trauma to neurosurgery. The frequency of hospital specialty could be modulated in accordance with specialty need. For example, if a certain area has a considerable obese population, more cardiac or GI hospitals could be established.

I’m not advocating a dismantling of the US hospital system. That would be catastrophic considering how many ancillary fields have been built upon this model. Rather, instead of patients undergoing surgery at a general hospital, why not refer them to a single specialty hospital? General hospitals could maintain their position as primary receiving centers from which triaged patients are referred to a specialty hospital.

The insurance scheme that NH has is also interesting in that monthly fees are paid directly to the hospital. In America, we pay thousands of dollars a month to a corporation that distributes its profits to its shareholders while sporadically denying us coverage. What if we were to pay a much smaller monthly fee to a community system of specialist hospitals who reinvests profits into medical technology and facilities? We get better hospitals, better medical technology, better care, and our money goes towards its intended purpose. There’s no middle-man insurance broker to pay to deny or approve our medical procedures and pills.

One drawback to this specialty model that has been brought up often is patient volume. 85 surgeries per day, while impressive, will compromise quality of care for every patient. That is arguably true, but our quality of care has been improving. Atul Gawande‘s concept of the checklist has concretely improved surgical outcomes in every hospital implementation. Furthermore, the general health of America’s population can be considered superior to rural India’s. Thus, this specialty hospital would handle much less than 85 surgeries a day. Combined with the checklist, specialty care becomes much safer and more cost effective.

Given the state of healthcare today, a model like this seems pretty attractive. Dr. Shetty has already taken the initiative by establishing an NH-like hospital in the Bahamas, right near Florida, for American medical tourists looking for cheap procedures. While we continue to debate what’s best for hospitals today, Dr. Shetty may be one step ahead of all of us.

Comments? Concerns? Questions? Comment below or tweet me @TheBiopsy! If any hospital administrators are out there, I’d love to hear your opinions.

Edit (06/16/12): I just got hold of an article from The Economist. Looks like this author saw the same thing in Dr. Shetty as I did!

Additional Reading:

The Henry Ford of Heart Surgery – The Wall Street Journal

  1. […] society they built up over years slowly crumbles because of a disease they couldn’t control. Without home or help, these lepers come together to Anandwan, one of India’s largest colonies. Founded by Dr. Babe […]

  2. […] Interestingly, I believe if Makary’s vision were realized, full-service hospitals would become relics. As hospital data becomes transparent and patients are empowered to choose hospitals based on outcomes, I foresee hospitals becoming more businesslike by “trimming the fat”. For example, if Hospital A is fantastic at cardiac surgery, but lousy at oncology, Hospital A may decide to drop its oncology department in order to focus on providing optimal cardiac surgeries. What may ultimately unfold is some version of what Dr. Devi Shetty has accomplished with his low-cost specialist hospitals. […]

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