Hospitals raise tech bet as India emerges as hub for complex surgeries

Experts say corporate hospitals are estimated to spend anything from 5 to 8 per cent of their top line on acquiring and upgrading technology

Eighty-six-year-old Sumitra Sharma, a resident of Gaya, had slipped in the washroom and fractured her left hip. With a previous history of breast cancer and angioplasty, her condition was complicated. At the time of admission to Fortis Escorts Hospital in Okhla, Sharma complained of chest pain. Investigations revealed an acute cardiac, along with old scarring, and her heart was pumping at 30 per cent of full capacity. She went for an angiography before her orthopaedic surgery.

A team of doctors, led by Dr Kaushal Kant Mishra, director, orthopaedics and joint replacement, Fortis Escorts, Okhla, New Delhi, performed a hip-ball replacement surgery in 15 minutes and 35 seconds — the shortest duration for such a surgery known so far globally. It is three minutes less than the previous world record — also set by Dr Mishra and his team.

India is not only doing complex surgeries but is also setting new standards of care. More and more patients are travelling to India for treatment, and corporate hospitals are investing anywhere between 5 per cent and 8 per cent of their top line in a technology upgrade.

According to a March release by the Ministry of Health, 304,000 patients travelled to India for medical reasons in 2021, compared to 183,000 patients in 2020 (a pandemic-hit year). India ranks 10th in the Medical Tourism Index for 2020-21 of the 46 destinations in the world.

“Our doctors are among the best in the world. There is no procedure that cannot or does not happen here,” says Dr B S Ajaikumar, executive chairman, HCG.

“We were not publishing enough, unlike the West. But we are getting there. Our own HCG data on 4,500 patients shows that the outcomes for triple-negative breast cancer patients are equal to or better than MD Anderson Cancer Center in Houston,” he says. MD Anderson is considered the gold standard in cancer care.

Ajaikumar adds that until 2005-06, the technology transfer process was slow.

“With more private equity investment in health care, access to technology has increased. Knowledge transfer is almost immediate,” he explains. Ajaikumar himself had gone to the US to train.

“When we used to hire doctors earlier, a common question used to be: ‘Will we send them to the US to train?’ Now doctors don’t ask that anymore — they can train in India,” he says.

Corporate hospitals are estimated to spend anywhere between 5 per cent and 8 per cent of their top line on acquiring technology and upgrading technologically, he points out.

Dr Ashutosh Raghuvanshi, managing director (MD) and chief executive officer (CEO), Fortis Healthcare, concurs.

“We are acquiring four orthopaedic robots and already have seven. The profile of patients is changing — they are looking at complex, tertiary care procedures, most of them with high comorbidities,” he says.

The kind of treatment options that dominate the country also depends upon its demographics.

Bishnu Panigrahi, group head, medical strategy and operations, Fortis Healthcare, says that in the 1950s, 60-65 per cent of patient deaths were from communicable diseases. That skew has changed in favour of non-communicable diseases like cardiac and neurological issues, cancer, organ transplants, etc.

“India is fast emerging as a hub for liver transplants,” says Panigrahi. Unlike the West, where most liver transplants involve dead donors, India does a lot of live donor transplant surgeries.

The use of surgical robots has played a part when it comes to better outcomes in complex surgeries since the surgeon gets a clear incision, less blood loss, reduced stay in hospitals, and lower chances of infection.

Robotic surgeries typically cost upwards of a lakh, as opposed to conventional surgeries. Panigrahi says 20-30 per cent of patients have started to opt for robotic surgeries.

While high-end complex surgeries are on the rise, most of them are still concentrated in the larger metros.

Dr Shekhar Salkar, senior surgeon, chief of oncology, Manipal Hospitals, Goa, has trained at the Tata Memorial Centre in Mumbai but has gone back to his home state. Manipal Hospitals offered him the opportunity to do complex surgeries in his hometown.

Salkar says that surgeons typically move to large metros to train, but if more hub-and-spoke model hospitals and large corporate hospitals come up in tier II and III towns, there will be reverse migration. 

Ajaikumar says that they are in the process of buying four surgical robots, and two of them will be for smaller cities like Cuttack and Vadodara.

Doctors are also returning to India from abroad. Ajaikumar says that for their Mumbai hospital, they got Dr Sachin Trivedi as head of medical oncology from Nottingham, UK where he was heading the breast cancer division. He was open to returning to India, and needed no cajoling, says Ajaikumar.

The mix of surgeries, too, is changing — from predominantly cardiac procedures, now neurology, orthopaedic, and oncology surgeries are on the rise.

Panigrahi illustrates this using the Fortis example. “Earlier 40 per cent of the surgeries were cardiac. That has come down to a high 20 per cent, while oncology surgeries are 17-18 per cent,” he says.

But do high-end, complex surgeries mean higher margins for corporate hospitals?

Hospitals disagree.

Dilip Jose, MD and CEO of Manipal Hospitals, says, “The complex surgeries don’t need to have higher margins than the rest. They may cost a patient more, but the implants, consumables, and intensive care unit stay usually associated with complex procedures also drive up the cost of delivery of care.”

Panigrahi says if a hospital charges a 50 per cent margin for robotic surgery, it would become unaffordable. “While margins are protected, the costs are worked out in a manner that they remain accessible to patients,” he says.

A senior hospital administrator says it is not uncommon for senior doctors to charge extravagantly, but typically, for all surgeries, hospitals tend to maintain a 20-35 per cent margin.

“Only recently, for a heart surgery in Mumbai a doctor charged Rs 20 lakh and the hospital charges were Rs 30 lakh,” he says.

Affordable prices will drive more patients from overseas to come to India and stop Indians from looking towards foreign shores.

Hospitals provide some numbers — a PET scan costs $300 in India, compared with $2500 in the US. A breast cancer procedure can happen comfortably within Rs 7 lakh here, and if any patient needs some special medicines then at best it stretches to Rs 12 lakh. By comparison, it costs Rs 45 lakh in the US.

“India has 350 million middle-class citizens, almost equivalent to the US population. Therefore, if one can cater to these people alone, there is a huge market for hospitals. Investments in technology and focus on high-end surgeries are here to stay,” adds Ajaikumar.

Fact box

304,000 patients travelled to India for medical purposes in 2021 compared to 183,000 patients in 2020 (a pandemic-hit year)

• India now ranks 10th in the Medical Tourism Index for 2020-21 out of the 46 destinations in the world
• A PET scan costs around $300 in India compared to $2,500 in the US. A breast cancer procedure can happen within Rs 7 lakh, while it costs Rs 45 lakh in the US
• Around 20-30 per cent of patients have started preferring robotic surgeries, according to an expert