Healthcare
Remote Healthcare
Solutions and Services
Dr. Sanjay Sharma
MS (Genl Surgery), PGDBA, FICA, FAGE
Market Analysis
The Global remote healthcare delivery market is an ~$12Bn
market growing at 18.6% and dominated by the services
segment
Source: Information Week / BCC Research Report
The
Global Telemedicine market grew
from $9.8 billion in 2010 to
$11.6 billion
in
2011 and will almost triple
to $27.3 billion in
2016,
growing at
a CAGR
of
18.6%
The telemedicine market is segmented into tele
hospital and tele home markets
. The tele hospital
market was worth $6.9 billion and tele home
market was valued at nearly $2.9 billion, however
the tele home segment is growing faster
than the tele hospital segment
at a projected
CAGR of 22.5% vs. 16.8%
The tele medicine market is also segmented into
technology & service segments
.
The
technology portion is expected to grow from $3.9
billion in 2010 to reach $11.3 billion in 2016, with a
CAGR of 19.8% and service market is expected to
grow from $5.9 billion in 2010 to $16.0 billion in
2016 at a CAGR of 18.1%
18.6
%
In 2016, Global Telemedicine
Market poised to reach $ 27.3 B
5.9 11.3 3.9 16 2010 2016 $ B ill io n
Global Market for Remote Healthcare
Delivery
Technology Services
BRIC remote healthcare delivery market is growing at 15.8%
however unlike Global market is dominated by technology
BRIC telemedicine market expected to reach a
market size of $418.4 million by 2014 at a CAGR
of 15.8% from 2009-14.
Chronic diseases driving growth in BRIC
markets.
Telemedicine market is witnessing
growth due to increase in the number of
patients suffering from chronic diseases such
as chronic heart failure, diabetes, asthma,
hypertension
.
Fast Technology adoption growth.
An
increase in IT spending and growth in
telecommunication network has positively
impacted the Telemedicine market in
BRICS
The
BRIC Telemedicine technology market
is
expected to reach a size of $307.4 million by
2014 , ~3 times the
BRIC telemedicine service
market
which is expected to reach $111 million
in 2014 with CAGR of 13.8%. This indicates
that emerging markets are facing difficulty in
realizing the RoI from this market
Source: Telemedicine Market in Brazil, Russia, India, China (BRIC) – Advanced Technologies, Global Forecast by MarketsandMarkets
Indian remote healthcare
delivery market is expected to grow at a CAGR of 20%
New Delhi Chennai Hyderabad Silvassa Daman Diu Raipur Bhopal Jaipur Gandhinager Bhubaneshwar Patna Lucknow Delhi Dehradun Chandigarh Shimla Srinagar Aizawl Imphal Agartala Kolkata Kohima Dispur Shillong Itanagar Gangtok Ranchi Mumbai Bengaluru Panaji Thiruvananthapuram Kavaratti Port Blair JAMMU & KASHMIR ANDAMAN AND NICOBAR ISLANDS (INDIA) TAMIL NADU LAKSHADWEEP (INDIA) GOA KARNATAKA ANDHRA PRADESH Yanam (PUDUCHERRY) MAHARASHTRA ORISSA CHHATTISGARH MADHYA PRADESH
DAMAN & DIU
DADRA & NAGAR HAVELI RAJASTHAN WEST BENGAL JHARKHAND BIHAR UTTAR PRADESH DELHI NCT HARYANA PUNJAB UTTARAKHAND SIKKIM MEGHALAYA TRIPURA MIZORAM MANIPUR ASSAM (Asom) NAGALAND
ARUNACHAL PRADESH GUJARAT HIMACHAL PRADESH KERALA Cuddalore PUDUCHERRY Karaikal PUDUCHERRY Mahe (PUDUCHERRY) Bay of Bengal Indian Ocean Arabian Sea 0 0 200 200 400 Miles 400 Kilometers
India
India Telemedicine market size
Indian private sector tele medicine
market was estimated to be $7.5
million in 2011
and is expected to
grow at a
CAGR of around 20%
over
the next 5 years to $18.9 million in
2016.
However, including government, PPP
and other initiatives, the market is
expected to grow to $500Mn by 2016.
The market is witnessing increased
acceptability, however estimates vary
because of the nascent stage of the
industry
A
multitude of factors are coming together to create an
enabling remote healthcare delivery ecosystem in India
Renewed
government
focus
Remote
healthcare
delivery
Ecosystem
Changing focus of
private healthcare
providers
Human Resource availability
Monetary & Policy level support Efforts to address standardization issues Public Private Participation Training of paramedics, IT staff , Doctors Insurance Companies Local entrepreneurs 1 2 3 Increased interest by IT firms /cloud computing
Improved
telecom
infrastructure
Initiatives by ISRO, Ministry of ICT , Healthto improve connectivity ICT & satellite
Connectivity; Increasing telecom presence Technology development support
3/8/2015
Dr. Sanjay Sharma
5
However there are key challenges that need to be addressed
Regulatory
No legal framework governing Telemedicine in India ; Prescribing medicines other than conventional
prescription procedure actually amounts to criminal offense
Infrastructure
Infrastructure issues such as poor bandwidth in some areas & expensive bandwidth in others;
potential maintenance of equipments
Implementation
Systemic problems such as training of technicians at village end, IT staff and local doctors. At
consulting doctors end, pushy administration & coordination issues. Cultural issues such as
unwillingness of hospitals to share data is also one of the major deterrents
Acceptance
For a village doctor & rural patient, using high end technology may be too inhibiting and
radical. Once benefits are seen, the acceptance rate will be higher.
Viability
Telemedicine in India, has largely been a part of hospitals’ social responsibility, with
hospitals ulterior motives of improving bed occupancy in case tele patient requires
hospitalization and needs to transform into a sound revenue generating model,
attractive for village level entrepreneurs & other investors.
S
W
O
T
OPPORTUNITIES
• Growing enthusiasm for research & development by academic institutions, government , individual researchers, technology firms
• National level organizations & government funded companies established to develop & promote tele health
• Increased Doctor acceptance for remote healthcare delivery if clinical effectiveness proven
• Growing awareness of the potential of remote healthcare delivery as an alternateto bridge the skewed doctor population ratio between urban and rural
• Lack of national level standardizations in tele health in terms of technical standards, business models, payments, etc.
• Absence of a legal framework governing remote healthcare delivery, making way for potential legal liabilities
• Unevenly distributed telecom networks that may become an obstacle for tele-health development
• Infrastructure challenges in remote areas
• Lack of commitment since most often remote healthcare delivery is setup as an add-on practice and not a dedicated cell
• Human resource constraints in terms of computer literacy amongst medical practitioners & rural paramedics / ground staff
• Absence of legal framework might detract comprehensive usage of remote healthcare delivery
• Large scale private sector implementation might not happen if clear revenue streams and physician compensation models are not designed
STRENGTHS WEAKNESSES
THREATS
• Vast and diverse geography with dominant rural population
• Disparity in healthcare infrastructure
• Low cost, locally developed technical solutions & ICT expertise
• Fast adoption of Mobile technology
• Policy on adoption of ICT in service delivery in 12th Plan
• Budget Allocation under National Rural Health Mission
• National Optic Fiber Networkbeing laid
Government initiatives and growing overall acceptance are the
drivers; however unclear legal and revenue model are detractors
Collaboration has come out as key success factor for remote
healthcare delivery as seen in various state government led PPP
Odisha : Establishment of Odisha Telemedicine Network in a phased manner by connecting 3 government medical colleges to SGPGIMS, Lucknow on one side & to all district headquarters hospitals on the other side. ; Construction of a State-level Telemedicine Resource Center at Cuttack ; Taking Telemedicine beyond districts on a PPP mode
UP :
State Medical College Network, Three Medical Colleges- Allahabad, Kanpur and Meerut connected with SGPGIMS, Lucknow – Super Specialty Hospital. Rural Telemedicine Centers at Raibareli District Hospital & Bachrawan Community Health Center
Tripura: First telemedicine network in Tripura between GB Pant Hospital and IGM Hospital, Agartala and five other Nodal Centers. 2nd & 3rd Telemedicine projects on the development and application of Telemedicine for Tripura Government Hospitals sponsored by the DIT, MCIT, GoI. Implementing Agency WEBEL ECS Ltd. & IIT Kharagpur. National Rural Health Mission (NRHM) supports maintenance and manpower ; Network for alternate medicine – AYUSH
Kerala Telemedicine Network:
Onconet - Cancer Care For Rural Masses (in 6 hospitals),
Telemedicine Kerala for Taluk hospitals (in 8 hospitals) , Telehealth and Medical Education Kerala ( in 18 hospitals), Rural Telemedicine Project for primary care in Tirur taluk (in 11 hospitals)
Uttarakhand:
Telemedicine PPP Model EOI
Gujarat:
Telemedicine PPP Model EOI
Bihar: State of Bihar Initiated an unique telemedicine project for delivering service in alternative medicine – Ayurveda , Yoga, Unani, Sidha & Homeopathy (AYUSH)
Maharashtra:
Government of Maharashtra telemedicine project was operationalised in the year 2007. The present setup of Telemedicine network in Maharashtra is one of the largest in India
Punjab:
PPP model with e-Health Point
IL&FS has been able to create a revenue model through
partnership
Public
Private
Government IL&FS PPPYearly payment
to IL&FS for
management
fees
Running the
service
including
recruiting
paramedical
and training
them
Apollo IL&FS Rural entrepreneur
• Provides its brand name
• Doctors for consultation
• Scouts for rural entrepreneur
• Training the rural entrepreneur
• Finding quality healthcare provider
• Setup the infrastructure (Min. INR 1.2lakhs)
• Create awareness among local population
Role
Benefit
• Faster footprint expansion through partnership • Capitalize on Apollo brand name• Help realize their social commitment
• Lesser CAPEX investment – Under this model Apollo does not charge INR8Lakh for franchise and yearly license fees
Patient
E-Wallet
60% 20% 20%
Payment
Source: Primary discussion and PwC analysis
Tele diagnosys have developed a revenue model by working as
outsourcing partners
Diagnostic centres in different countries (US, Africa, Asia) Telediagnosys• On-board Radiologists certified in the country from where they read images
• Reading room with access control, Web based PACS, Medical Display Monitors
• VPN Connectivity offered for data security
• Internet – Bandwidth provided by multiple Tier 1 ISPs directly from their backbone with 99.9 % uptime
• Power – Direct power from 2 providers followed by UPS and Generator backup
• Server – Mirroring of data in primary server and alternate server available at a different physical location
• Confidentiality – Secure IT infrastructure
• 24 x 7 monitoring of network connection and server
• 24 hour Toll Free dedicated helpline
Infrastructure
Partnership
Radiology images Report at 30-40% lower cost
Payment as per contract for service. Any technology implementation is charged separately
• Radiology image capture capability
Infrastructure
Source: Primary discussion and PwC analysis
Tele rad providers generates revenue through tele radiology, tele
consultation as well as tele-education
Diagnostic centres/ hospitals/ CRO Radiology services including CT radiology Par tn e rsh ip Radiology images Report
• Reporting fees range from Rs. 30 for Xray reports to Rs. 400 for CT / MRI for domestic customers
• Reporting fees range from US$ 10 for Xray reports to US$ 40 for CT / MRI for overseas customer
Tele radiology providers
Radiology learning program Radiologist Enroll for 7-15 days program by paying the fees Images Report which is checked by specialist and feedback is provided
Source: Primary discussion and PwC analysis
World Health Partners
22
VALUE PROPOSITION
The various components of WHP’s network model are:
• SkyCare Providers Local rural health providers who already live in the village are trained to act as WHP’s direct local health agent
• SkyHealth Centres enable remote diagnosis and audio-visual communication between rural patients and city doctors at a Central Medical Facility
• Central Medical Facility The CMF houses a panel of physicians who consult with clients in SKY Centres located in the villages
• Diagnostic Test Laboratories: Diagnostic facilities throughout the project area support Sample collection & report delivery to central medical facility
• Shops: Rural shops, most of them pharmacies, ensure that clients have access to all the medicines and products they need
BUSINESS MODEL
• WHP operates a market-based model, where the local entrepreneur is free to decide the consultation fees based on market needs. Similarly, the
Specialist is free to decide his/her consultation charges. WHP gets a margin from the local entrepreneur for every consultation. The CMF doctors are paid a monthly salary based on the number of patients seen.
• Initially, WHP funded 75% of the setup costs for the SkyHealth centre with the remaining 25% coming from the local entrepreneur. In the current model, local entrepreneur makes 100% of the investment. This also helps to ensure commitment from the local entrepreneur and attract the right talent, in addition to reducing the cost burden on WHP.
• The biggest cost component is setup and maintenance of technology infrastructure. Local entrepreneurs pay a refundable deposit of INR 25,000 to WHP for provision of technology infrastructure such as computers, broadband connection etc.
• Physical infrastructure setup & maintenance is the responsibility of local entrepreneurs running the SkyHealth Centre, so WHP does not incur any direct costs in that aspect
• Training duration is kept short to minimize expenses & Local staff salaries are paid by outsourced agency, reducing the burden on WHP
IMPACT
• WHP serves 3 districts in the state of Uttar Pradesh, covering a population of 4 million in close to 1100 villages. Typically each Skyhealth Centre sees 4-5 patients per day.
• In the first 18-month period, WHP’s Uttar Pradesh project provided over 25,000 tele-consultations with qualified physicians to rural villagers, in addition to 188,401 couple years of protection (CYP) averting an estimated 107,658 unwanted pregnancies. This increases couple protection in the area over time by 37%, from 28 to 38.3
Nanavati hospital has partnered with government under PPP and
also provides option of franchise and corporate tie ups
PPP Franchise
Nanavati hospital
Partnership with Corporate and NGOs E-Clinics•
Doctors
•
Hospitals in small cities
& villages
•
Laboratories
•
Paramedics
•
PHC
•
Retail outlets in
Shopping Malls
•
Business houses in
Branded Retail segment
•
Government of
Maharashtra
•
Government of Madhya
Pradesh
•
Pan Africa through
Ministry of external
affairs
•
Companies can tie up
with Nanavati to provide
Remote Healthcare
facility to its employee
•
Telemedicine facility
will be run by Nanavati
for the Corporate house
•
Employees get the
facility of Super
specialty consultation
•
Consultation by phone
•
Consultation by email
•
Consultation by Video
conference
Services provided include Tele CME, Tele Cardiology, Tele Neurology, Tele Urology, Tele Paediatrics, Tele Dermatology, Tele Orthopaedics,
Tele Oncology, Tele Nephrology, Tele Ophthalmology and Tele OBGY
Source: Secondary research and PwC analysis
Social impact of remote healthcare delivery
Improved health
access
Social
Impact
Quality of life
Better
Affordability
Increased patient
acceptance
Geriatric care
focus
Chronic disease
management
Reduction in travel
costs incurred
Learning &
Development
Technology
Innovation
Entrepreneurship
Improved Public
Health Outcomes
Quality of care
3/8/2015
Dr. Sanjay Sharma
14
Industry Trends
Key industry trends affecting the growth of tele-consulting in India
By 2018, India will have more than 200 million people above the age of 65 (who
constitute the majority of home care patients)
Increasing elderly population
Increasing advent of lifestyle diseases like diabetes , hypertension and Cardiovascular
Diseases in India.
Shifting disease Pattern
Doctors ratio in India is highly inadequate (0.7 per 1000 population); Nursing staff also
inadequate (1.3 per 1000)
Inadequate medical personnel
45% of the population travel more than 100 km to access a higher level of care.
Accessibility issues
70% of India’s healthcare infrastructure is concentrated in the top 20 cities.
Regional disparity
Over 6.5 lakh beds to be added in the next 5 years
Infrastructure gap
Reduced travel time & cost, greater continuum of care, greater access to healthcare
services
Potential Benefits
Expectations from the provider, patient and payer
Private Hospital Chains &
Clinics/District Hospitals
•
Increased penetration into
population of Tier-II, III cities
•
Low CAPEX –High return model
•
Increased probability for IPD
conversions at nodal hospitals
•
Hands-on training of resident
doctors for newer formats
•
Reduced hospital re-admission
rates
•
Lower ALOS
•
Low cost treatment- will save on
travel expenses & patient
transportation costs
•
Medical expertise & care from
base location
•
Continuum of care
Patient seeking
consultation /
monitoring
•
Insurance companies save on
potentially higher claims if
patients transported to Tier-I
cities
•
Patients’ condition is addressed
and necessary interventions
eventually lead to better health
of the insured patient and
consequently lesser claims
Government / Private
Health Insurance
Providers
Provider
Patient
Payer
Key industry trends affecting the growth of home health-care in India
By 2018, India will have more than 200 million people above the age of 65 (who
constitute the majority of home care patients).
Chronic disease burden-More than 40 million Indians lose their lives to chronic diseases
each year
Increasing elderly population &
chronic disease burden
Increasing need for continuity care pre/post-hospitalization ; Growing demand for
elderly care, post-surgery rehab services and palliative care
Inadequate medical personnel
Due to changes in the family structure — from the multi-generation family under one
roof, to the nuclear family — many adult children are facing challenges in caring for their
elderly parents. NRI children want to cater to their ailing parents at home.
Societal Changes
Shortage of hospital beds and other medical facilities
Infrastructure
Increased intensity of disease monitoring and management will create improved patient health with reduction of acute and chronic complications, and will translate directly into decreased
consumption of expensive emergency health care resources (emergency room visits and re-hospitalizations) and decreased long-term disease complications.
This, in turn, should translate directly to decreased consumption of expensive medications, personnel, equipment and hospitalization days required to manage those long-term complications
Potential Benefits
Expectations from the provider, patient and payer
Private Hospital Chains
•
Reduces risk of infections
•
Reduces risk of re-admissions
•
Increase capacity (‘virtual beds’)
•
Reduces Average Length of Stay
(ALOS) for many patient
categories (e.g. post-operative
care, IV antibiotics etc), thus
enabling more potential
revenue-generation
•
Significantly reduces OPD
workload where appropriate
•
Reduces crowding (fewer
patients and families)
•
Low cost treatment- will save on
travel expenses & patient
transportation costs
•
Medical expertise & care at
home
•
Continuous monitoring of
patients’ disease progression
Patient seeking
intervention/monitoring
•
Reduces costs of treatment
•
Reduces risk of re-admissions
•
Patients’ condition monitored
real time and necessary
interventions eventually lead to
better health of the insured
patient and consequently lesser
claims
Government / Private
Health Insurance
Providers
Provider
Patient
Payer
Multiple factors lead to home-healthcare being a sustainable and
a scalable business concept
Shortage of hospital beds
Chronic disease burden-More
than 40 million Indians lose their
lives to chronic diseases each year
Increasing need for continuity
care pre/post-hospitalization
Increasing elderly/aging
population
•
Health care is a secular field and home healthcare offers excellent prospects both in terms of scalability and
creating a disruption in the current healthcare delivery model.
•
This model helps save a lot of time for patients, because they don't need to wait outside a clinic for a long period to
service very basic healthcare needs.
•
Technology development, and workflow integration along with training of field staff are among the most
important factors for business scalability
Strong demand for professionally driven specialty home
healthcare service
Key Industry Trends affecting the growth of tele-ICU in India
Most elderly people require hospitalization in Intensive Care Unit (ICU) in the last two
years of their life
Increasing elderly population
A lot of young people admitted to ICU because of trauma and adverse effects of lifestyle
diseases like diabetes and hypertension.
Shifting disease Pattern
There are merely around 100 intensivists in India, who assess , resuscitate, and manage
patients with life threatening problems; Shortage of trained paramedical staff as well
Inadequate medical personnel
Smaller hospitals can’t afford a full time specialist
Operational challenges
Many of the smaller hospitals in Tier-II,III cities have inadequate infrastructure and
intensivists to support critical care interventions; ICU care is primitive or non existent at
district hospitals in rural India
Regional disparity
70,000 ICU beds available including all types and across all hospitals and small time
nursing homes in India that cater to five million patients requiring ICU admission every
year
Infrastructure gap
Remote monitoring saves on travel costs and decreases bedside infections by around 60%
Potential Benefits
12 RICOH: Remote Healthcare Delivery • Phase - III Report : Tele-ICU
Section 3 – Competitive Landscape
