Doctors Jumping Borders

In the lanes of Manikonda, one of Hyderabad’s IT-powered suburbs, commercial strips hollowed out by the lockdown are slowly returning to life. The most ubiquitous of the new class of businesses coming to occupy parts of these empty shopping complexes are clinics. LED boards announce new diagnostic centres and polyclinics, multispeciality practices and old-fashioned physicians. Several medical facilities are under various stages of construction. Buildings with ‘To Let’ signs for their driveways and ground floors indicate a preference for banks and clinics. It is the best of times, it is the worst of times.

The past six months have disrupted private healthcare in new and unforeseen ways. On the one hand, Practo and other digital healthcare companies have got physicians to go online and turned the business of diagnostics on its head by aggregating freelance phlebotomists based on their location. On the other, the resource shift from secondary and tertiary care to emergency medicine and Covid management has resulted in a large class of general physicians, specialists in areas relatively unaffected by the virus, and surgeons whose livelihood largely depends on elective procedures, suddenly finding themselves out of work, underpaid or labelled non-performers. Some have found new opportunities in the crisis. “At least a dozen new clinics have sprung up in Manikonda in the past four months. Rents are low, and physicians without postgraduate degrees, or doctors who have lost their jobs, have set up shop in the hope of offering affordable secondary care,” says Dr Venkatesh Billakanti, a general practitioner who runs Relief Clinic, a two-year-old multispeciality venture in the area. There has been a surge in the number of paediatric and gynaecology OPD cases at his clinic, he says. “We have seen a trend where patients with minor or routine complaints prefer teleconsults or visit small outpatient setups rather than risk catching the virus at a large hospital. We do not see Covid cases now, but patients who know I see Covid patients at Continental Hospitals, where I am a consultant, are wary of coming to the clinic.”

For well over a decade now, large, so-called corporate hospitals have dominated secondary and tertiary private healthcare and added high-end quaternary specialities to their stable of services. To the smaller hospitals, the independent doctors and the family physicians who had already been eclipsed by glass-and-marble facades and five-star comfort, the Covid crisis has dealt a double blow. But there may yet be a silver lining.

Amidst allegations of overcharging by major hospitals, doctors have spoken out about exploitative practices, questionable ethics, and poor working conditions. Some have joined smaller hospitals or braved the odds to start up. “Some of India’s largest hospital chains are trying to force doctors to accept pay-per-service rates, essentially turning healthcare into a gig economy,” says a senior gastroenterologist at a large Bengaluru multispeciality hospital who was summarily taken off payroll and asked to consult for a fraction of the salary she was drawing. In late May, the 53-year-old decided to practise online for the first time, and now sees 10-20 patients a day on video. “I feel used. I helped the hospital build the department. Now it is time to build my own brand. I can afford to take a pay cut, but somewhere, there is a loss of dignity. And that is not acceptable to most senior doctors,” she says. “I have no intention of settling into the fringes.” In the early stages of setting up a virtual gastroenterology practice along with three former colleagues, two of them from Chennai, she sounds excited, and a little scared.

The pandemic runs like a dark thread through my conversations with a young cardiologist at a hospital in Hyderabad who was demoted to paramedic duty, an overworked nephrologist from Chennai who has been demanding a permanent increase in pay apart from the incentive he received for Covid duty for three months, and an ENT specialist who lost her position as head of the department at an upcoming hospital in Calicut and took a 75 per cent pay cut to join a clinic. Reshmi (last name withheld), 36, says she blames no one for the situation. “The hospital was new and could not afford to pay our salaries. All departments except paediatrics and gynaecology were shut down,” she says. At the ENT clinic, there are few walk-ins despite the fact that it is a preferred referral clinic for many small centres from peripheral towns. “There have been three procedures in the entire month of October so far. But something is better than doing nothing,” she says.

Doctors have to find innovative ways of keeping themselves relevant, says Dr Karan Shetty, 35, speaking to Open at the end of a long working day at his new clinic in Jayanagar, south Bengaluru. “I had four surgeries and OPD,” says the plastic, reconstructive and aesthetic surgeon whose spectrum of work ranges from cleft lip surgery and burns to leg and face reconstruction and cosmetic procedures. As work ground to a halt at the hospitals he was consulting at, Dr Shetty turned to his longstanding dream of setting up a surgical centre. “You don’t need an ICU setup for most minor surgeries and cosmetic procedures like liposuction. An outpatient surgical facility could fill the gap in the market that has opened due to the high cost of procedures at corporate hospitals and the fear of contracting the virus there,” he says. With orthopaedic, diabetic foot and wound and gynaecology consultants sharing the 2,000-sq-ft space with Dr Shetty, Tara Healthcare, named for his mother, has seen over 200 patients in the past month and performed 20 surgeries. He has invested Rs 45 lakh in the venture and is hopeful the concept will take off. “Right now, we are riding the surge in interest in botox fillers, liposuction, breast augmentation and other cosmetic procedures. Women now have the opportunity to heal in the privacy of their home,” he says. What made him go independent at a time of uncertainty? “I could have waited it out but I didn’t want to. I am at a stage in my career where I am climbing the ladder. I didn’t want to miss work.”

“There are two sides to how the past half-year has affected doctors—and hospitals. OPD and non-Covid admissions fell by over 60 per cent, but handling Covid patients has helped prove that we can provide quality critical care that is also affordable,” says Dr V Suriraju, MD and CEO of Regal Hospitals in Thanisandra, Bengaluru. “As a 100-bedded multispeciality hospital, we have been able to survive with five full-time doctors because we always had 35-40 Covid patients at any given time. As we emerge from Covid, we must make use of the goodwill we have earned to cement our position in the industry.”

Retaining doctors has been a challenge for corporate hospitals as well as mid-sized doctor-run hospitals. “About 25 per cent of doctors working in corporate hospitals may come out of this crisis detaching themselves. Although Covid has given hospitals reason to slash pay and target non-performing doctors, holding on to a cosy job albeit at lesser pay is tempting,” says Dr Jagadish Hiremath, MD, ACE Suhas Hospital, Bengaluru. His hospital decided to go non-Covid-only from October 5th, a conscious decision that has impacted business in the short run. “We have had only three patients so far, but things will turn around by November. There simply isn’t a need for that many Covid beds anymore—regular patients should have access to a safer healthcare environment. And this is where mid-sized hospitals can step up and fill a gap in the market,” he says.

“There has been a lot of movement in core Covid departments,” says Raghavendra Reddy, a 32-year-old pulmonologist who recently moved out of Century Hospitals, Hyderabad, to a smaller hospital run by the Renova Group for better pay and the opportunity to practise interventions. “Many pulmonologists have started their own individual practice aside from being attached to major hospitals. For us, this is a time to learn and to build a brand around ourselves.”

“Many of my patients have been asking if I have an independent outpatient setup,” says Dr U Vasudeva Rao, a vascular surgeon who has been associated with Manipal Hospital, Bengaluru, since 1991. “Physicians can set up a clinic but specialists like me who joined high-tech modern hospitals for access to the best diagnostic machinery cannot do independent medicine any more. The costs are prohibitive, with the initial outlay for a small clinic starting at Rs 1.5 crore,” Dr Rao, 67, says. He is clear that he doesn’t want to be chained to a single corporate hospital either. Since they are answerable to investors, large hospitals tend not to pass on benefits to experienced doctors, he says. “Our professional fee, which used to be 25 per cent of the total bill, has dwindled to about 15 per cent.” With the caseload at Manipal dropping drastically, Dr Rao saw opportunity in visiting smaller hospitals, but didn’t know who to reach out to. He rounded up five to six associates and colleagues, and together, they decided to launch a group practice, using Medisync, a private healthcare management start-up that helps connect secondary care hospitals in the market with doctors and patients, to find work. “We have worked out a system where we cover seven hospitals in Bengaluru between us. We don’t all have to do rounds at every hospital every day—we cover for one another and work as a team. The revenue sharing model, too, works out well.” he says. The basic surgical group has doctors with various levels of experience and it plans to onboard a specialist group of associates who would be brought in for consultation if a case demands it. “When things return to normal, I will continue to consult for Manipal but parallelly, I think that an independent practice and identity are essential for specialists to cultivate today,” Dr Rao says.

Medisync set out to be the Oyo of secondary hospitals in the private sector, says Dr Nagendra Swamy, the founder and chairman. He describes the two-year-old Sequoia Capital-backed company as a knowledge platform to help neighbourhood hospitals manage and market themselves better. “In India, we keep talking about the need to expand capacity in healthcare without realising that we have an underutilisation problem. Out of the 16 lakh beds in the country, eight lakh are in the private sector, and less than a lakh of them in corporate-run or large hospitals. Of the remaining seven lakh private beds, only 40 per cent are occupied at any given time. We see opportunity in strengthening this segment rather than creating new infrastructure,” says Dr Swamy, who has three decades of experience in corporate healthcare. Large multispeciality hospitals were built for tertiary care, and yet, they have cornered 60-70 per cent of the secondary care market, he says. “Neighbourhood hospitals are underutilised because they are not recognised as a brand. Just like Oyo standardised the middle-class hotel category by ensuring clean rooms and bathrooms, we help smaller hospitals by verifying doctor credentials with the Medical Council, ensuring transparent billing, appointing customer care managers to counsel patients, insisting on uniform care for all patients, and encouraging patients to seek a second opinion if they so wish. The patient can confidently walk into a Medisync hospital and expect standardised care.”

The company has onboarded eight new hospitals since Covid-19 struck—a 50 per cent growth—and introduced them to the digital market by setting up a telemedicine platform. “We have helped them find a new clientele in this time of crisis. We now set up 400-500 digital appointments in a day,” Dr Swamy says. Medisync has 300 doctors onboard, most of them specialists. It is also helping surgeons by offering transparent pricing to patients and bringing down costs. “We are trying to restore the family doctor culture across our hospitals. The Covid-19 phase is an opportunity for the private healthcare market to reorganise.”
There has never been a better time for doctors to make themselves valuable, says Dr Sonal Asthana, an organ transplant surgeon at Aster CMI Hospital, Hebbal, Bengaluru. He is excited about how the leap in the adoption of telemedicine and teleradiology within a short period of time has changed the way doctors practise. “Even in super-specialities, 70-80 per cent of the work is follow-up, and most of this has moved online. Although there is a short-term pain element, I think this forced acceleration of healthcare reform is good for patients and doctors in the long run. Doctors are more accessible now, dead time has been eliminated, and costs will come down eventually. Many doctors now have time to think about the direction they would like to take when things normalise,” Dr Asthana says.

Aster focused on retaining doctors at a time when most hospitals, large and small, were delivering pay cuts ranging from 25 to 70 per cent. “Hospitals will always need qualified specialists and specialists will need high-quality infrastructure, but post-Covid, this symbiotic relationship could change in many ways. Hospitals would try to consolidate the gains from the past few months, and groups of doctors would branch out to set up aggregate practices. One thing is for certain: patients will be better off.”

“As hard as it is to run a hospital today, with administration getting increasingly complicated, smaller, doctor-run hospitals that survive the crisis could emerge as net gainers,” says Dr Anil Agadi, whose 44-year-old hospital, started by his father in the heart of Bengaluru, has refused to go corporate. “With fewer people able to afford corporate healthcare post-Covid, and specialists like Dr Rao making time for visits to small hospitals, there is hope.”

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