One quick mention of the November issue of the Harvard Business Review, since the December issue is already out - the "Globe" feature is on practices at innovative Indian hospitals to deliver world-class health care affordably. What struck me most in this article is that, although the authors - Vijay Govindarajan and Ravi Ramamurti, respectively of Dartmouth and Northeastern University - begin with a modest "India might be the last place on earth where you'd expect to find health care innovation," the hub-and-spoke model it describes is eerily similar to the system strategy guru Michael Porter and his co-author Thomas Lee advocate as one of their six recommendations to fix U.S. healthcare in the previous (October) HBR issue. (I wrote about Porter's and Lee's proposal here.)
In a hub-and-spoke configuration, high-quality talent and specialized equipment are concentrated in urban hubs, while spoke facilities are "arrayed around the hubs to reach underserved patients in far-flung towns and villages." The idea is for the spokes to serve not as mini-hubs but as gateways providing diagnosis, routing treatment and follow-up care. Porter and Lee also advocate a better use of resources by addressing equipment duplication. The authors of the present article, however, do point out significant cultural differences between the U.S. and Indian models that might make the Indian model difficult to implement. For instance, "even when Western hospitals consolidate, their aim is to gain market power rather than to lower costs."
A key element supporting the hub-and-spoke is the increasing use of telemedicine. According to the authors, the concentration of the difficult cases in the hubs has the following effects:
- Attracting and retaining doctors seeking to improve their skills rapidly.
- Developing and continually updating treatment protocols that reduce errors.
- Creating specialists in relativel rare subspecialties of medicine.
- Promoting innovation that suits local conditions.
Furthermore, general physicians are encouraged to become specialists (and specialists to become super-specialists). The hospitals make significant use of support staff, from paramedics to nurses, to help make physicians more effective. They have also implemented new procedures "to decrease the amount of time it takes to move one patient out of the operating theater and bring in the next one."
The authors also make the fascinating point that in the U.S. (operating in a fee-for-service model), the goal is to maximize the number of procedures conducted, while the goal in India is to maximize the number of patients treated. The Indian hospitals are also frugal in their operations, for instance preferring in some cases to operate diagnostic equipment on a pay-per-use basis rather than owning it outright. This all contributes to an Indian healthcare system where the specific hospitals considered (most definitely best-in-class types) have quality measures -- e.g., survival rates for breast cancer -- similar to the measures in their American counterparts. They also argue that, while physicians' salaries are often cited in the U.S. as the root of many healthcare problems, lower wages in India do not contribute to lower costs as much as one would think.
The HBR article serves more broadly as a summary of a research project spearheaded by Govindarajan and Ramamurti, which aims at better understanding "how some Indian hospitals are able to provide world-class health care at ultralow cost." Excellent read.