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Have you ever walked into a 5-Star hotel and ordered a soft drink? If you have, you will know that the simple, colored and sweetened water sells at 5 times the price at which it is available in your grocery store. So, how did that innocuous bottle of dark colored liquid appreciate 5 times in value between the 5- Star hotel and the grocery store that is perhaps just across the road?

The answer is fairly evident to all of us. That, in a 5-Star hotel, it is not just the cost of the soft drink. It is the ‘ambience’. The palatial surroundings. The expensive chandeliers. The ivory-lined water fountain… in short, the overheads.

In essence, this is exactly the story when you need to undergo a surgery. You have the option of paying for just the surgery, which is what happens in a Day Surgery setting. Or you have the option of paying for the surgery and for the vast infrastructure of the big hospital where the surgery was performed. The hundreds of nurses, of who probably one or two paid you a visit. The retinue of interns. The 500 beds, of which you slept in one. In short again, the overheads associated with a big hospital. 70% of the spend in a tertiary care facility is for 30% of the patients but the cost is distributed to 100% of the patients.

What is Day Surgery?

Day Surgery or Ambulatory surgery (also referred to as outpatient surgery or same-day surgery)comprises all surgical procedures that allow the patient to return home within 24 hours of the surgery being performed. 70 percent of all elective surgeries can be performed as ambulatory surgical procedures. These procedures span across all specialties excluding polytrauma, neurosurgical and cardiac cases.

What is in-patient care?

In-patient care is the conventional method of hospital care. Here a patient is admitted following a diagnosis, retained overnight for pre-operative procedures, a surgery conducted and retained again for a recuperative period that depends on the complexity of the surgery as well as the Doctor’s recommendation. Typically, the average length of stay (ALOS) in most tertiary care hospital varies in the range of 3.2 – 5.5 days. In-patient care is available across the board – in big corporate hospitals as well as smaller nursing homes.

Cost of Day Surgery vs Cost of in-patient care at Corporate Hospitals

To understand and compare the costs in day surgery and in-patient care, it is necessary to first nderstand the cost structures of both these set-ups.

For the purpose of this exercise, let us consider a 100-bed hospital, which is a medium sized hospital by today’s standards, on one side. And an Ambulatory Surgical Center, say Nova (since I am well versed with the cost equations here) on the other.

Typical hospitals would have a ratio of one operation theatre per 40 patient beds. The focus of the industry has been on having a higher bed count. A typical Nova center, on the other hand, has 4-5 OTs, 16-20 beds with ICU facilities and only 2-3 rooms for stay.

The 100-bed hospital is typically built on acquired land. And the land area is mostly upwards of 60,000 sq ft., sometimes going up to 100,000 sq ft. Nova on the other hand, requires lesser space - 10,000 – 15,000 sq ft. and we can simply lease the space, which brings down capital expenditure even before an ambulatory center starts off. A 100-bed hospital can cost anywhere between Rs. 120 crore – Rs. 130 crore to set up. In comparison, setting up a Nova center costs just Rs.10 crore – Rs. 12 crore

The number of Operation Theatres in a 100-bed hospital and those at Nova would be similar. Four or five OTs per center. But then, just consider the staff that mans these two set-ups. The 100-bed hospital is generally managed by a staff of 300 while a Nova center, with the same number of OTs has just about 35 staff members. This makes a crucial difference in the operating cost of the two set-ups. While a 100-bed Hospital needs around Rs.2 crore – Rs. 3 crore per month for operational expenses, the corresponding cost for a Nova center is between Rs.35 lakh and Rs. 40 lakh per month.

It is clear then, that with a much capital cost and lesser operational costs, Ambulatory Surgery Centers like Nova, are well positioned to pass on cost benefits to patients.

Costs of Day Surgery vs Costs of in-patient care at Nursing Homes

Let us now look at how Ambulatory Surgery Center costs compare with in-patient care at nursing homes.

In terms of the cost structure, the costs associated with nursing homes and those for an Ambulatory Surgery Center would be broadly similar.

The advantages start showing up when you consider how the two operations are run. In an Ambulatory Surgery chain like Nova, each center is standardized in terms of layout, interiors and medical equipment. A central team deals with vendors and Group purchasing helps achieve cost effectiveness. And even if the surgery costs for a patient are comparable in these two formats, the difference to the patient becomes evident when an overnight stay kicks in. In an Ambulatory Surgery set-up, the largest cost component is the surgery and consumables. However, in-patient care starts calling in additional resources in terms of overnight stay, the costs associated with medical support staff during the recovery period and meals.

So, it is safe to say that even in the case of in-patient care at Nursing homes (and not just Corporate hospitals), Ambulatory Surgery centers have a distinct cost advantage.

It is important to note here that one would assume a certain standard of medical care, in terms of nursing homes considered, when doing these comparisons. Else, we would end up comparing apples to oranges.

Cost validation – from Insurance Companies

The biggest validation for the Ambulatory Surgery model comes from the most critical enabler in the healthcare area – the Insurance companies. While an overnight stay is mandatory for insurance claims on procedures in big hospitals, insurance companies have clearly seen the value that Ambulatory Surgery centers bring to the table. A more affordable treatment is one of the reasons (among others) that have persuaded Insurance companies to approve more than 800 procedures in the day surgery mode.

Ambulatory Surgery Centers vs In-patient care – The macro perspective

Finally, let’s look at the macro perspective. While it is good that Ambulatory Surgeries help in bringing down the cost for a patient, there is a bigger, societal angle to this.

In-patient care confines a patient to a hospital for an extended period of time. This period is mostly non-productive for the patient and for his work place. In times when cutting costs and increasing productivity are becoming mantras not just for organizations, but for nations as well, can you calculate the loss of confining a healthy, productive individual to a bed for 3 or 4 days?

Productivity is a topic that developed countries like the US understand much better than developing ones like India. Part of the reason is that the manpower costs in the US are much higher than in other countries. This probably also explains why Ambulatory Surgery Centers, that send back patients home in a day, ready to get to work the next day, have become so popular in the US.

India is clearly headed the same way. We are fast becoming a knowledge society. The service sector has become the back bone of our economy. And in scenarios such as these, it is but inevitable that productivity starts taking center stage sooner rather than later. Which is why, faster development of Ambulatory Surgery Centers across India, is not just an urgent need, but an imperative.

Free Standing Ambulatory Surgery Centers vs Hospital based Ambulatory Surgery Centers

Having spoken about in-patient care and ambulatory surgery and the costs associated therein, let me turn my attention to the many faces of Ambulatory Surgery Centers itself.

Ambulatory Surgery Centers can be of two types – free standing (or standalone centers, like Nova)or Hospital based centers that are housed within a bigger premise (say a corporate hospital). All cost advantages mentioned in this article pertain primarily to free standing centers. Ambulatory Surgery Centers that are housed within a bigger premise, while still offering some cost arbitrage (no overnight stay costs, for example), will still be bound by the ‘overhead’ cost dynamics of a bigger center, thereby blunting its cost advantage overall.

Further, since the facilities are shared by the ambulatory center housed within a hospital and the hospital, the efficiency of the center is undermined be it with respect to OT utilization, surgical duration, patient check in and check out which invariably leads to higher running costs.

Summary

In summary Ambulatory Surgery reduces the cost of medical care—commonly referred to as "COST CONTAINMENT".

• Overheads associated with in-patient care at Corporate Hospitals clearly demonstrate that Ambulatory Surgery Centers are better positioned to give more affordable surgical care to patients
• The cost of stay and associated expenses in terms of patient care for a longer duration makes in-patient care at Nursing homes more expensive than Ambulatory Surgery Centers
• Insurance Companies have validated the cost benefits associated with Ambulatory Surgery centers
• Ambulatory Surgery centers also make a society more productive by putting patients back on their feet, and ready for work faster than in in-patient care.
• The most affordable surgical care can be provided in free-standing or standalone Ambulatory Surgery Centers rather than Ambulatory Surgery Centers that are housed in a bigger hospital set-up.

Dr. Mahesh Reddy
MS(Orth), MCh (Orth-Liverpool), FRCS (Eng)
Executive Director
Nova Specialty Surgery Pvt. Ltd.
email: This e-mail address is being protected from spambots. You need JavaScript enabled to view it
webpage: www.novaspecialtysurgery.com

Dr. Mahesh Reddy is the Co Founder and Executive Director of Nova Specialty Surgery. Dr. Reddy is counted amongst the foremost specialists in the area of shoulder surgery in India. Dr. Reddy completed MBBS, MS Orthopaedics, and MCH Orthopaedics from University of Liverpool. After training at the NHS in UK for 5 yrs,he moved to Bangalore where he set up the Shoulder Unit. He is also associated with two internationally renowned orthopaedic surgery research journals, namely the Journal of Bone and Joint Surgery (JBJS) and Journal of Shoulder and Elbow Surgery as a reviewer. Dr. Reddy is also Executive Member of the National Committee for health. Dr Reddy was recently conferred with Honorary Fellowship by the Royal College of Surgeons of England.

Administrator

Breast cancer is held to be the most common cancer in India’s female population. Running a close second is carcinoma of the cervix.

Till date, the treatment for operable carcinoma has been surgery. Medically, it is known as radical hysterectomy with bilateral pelvic lymph node dissection through a laparotomy. This treatment involves cutting open of the abdomen for removal of the uterus and considerable prescriptions of painkillers and antibiotics. The patient is also required to stay in the hospital for a duration of 7-10 days and is left with a large scar post surgery.

Recently though, there has been a pioneering procedure that could signal a huge shift in treatment, leading to faster recovery and less pain for patients. The new treatment still involves surgery, but by the less invasive laparoscopic route. Medically, the procedure is termed laparoscopic radical hysterectomy with bilateral pelvic lymph node dissection.

This ingenious new treatment was performed by Dr. Sanket Mehta (Consultant - Onco Surgery) and Dr. Laila Dave (Consultant - Gynec Surgery), renowned doctors from Nova Specialty Surgery, Mumbai.

The patient is 72 year old Ratnaprabha Ambolkar, a resident of a village near Nashik, suffering from carcinoma of the cervix. She was taken to Mumbai for treatment by her son, but given her age and the severity of the carcinoma, doctors were quite concerned.

The novel laparoscopic surgery recommended by Dr. Mehta and Dr. Dave last for 4 and half hours. And had many advantages. Not only did the patient lose only 200 ml of blood, but she was eating normally in just 24 hours, suffered very little pain, therefore eliminating the need for multiple painkillers and antibiotics and has next to no scars due to the tiny incisions. Even more encouragingly, the 72 year old patient was well enough to be discharged in just 3 days, as compared to the 10 days of stay needed with the older method.

Speaking about the advantages of this laparoscopic surgery, Dr Sanket Mehta, one of the operating surgeons said, “The advantages of laparoscopy are that there is very little pain, decreased chance of infection and need for antibiotics as the incision are very small. Besides, there is lesser blood loss as the dissection is very minute and precise due to magnification offered by laparoscopy. The concern for laparoscopy often is that it is more expensive. However, the decreased hospitalization, decreased need for painkillers, antibiotics and other medications in fact means that it indeed turns out to be cheaper than the traditional approach. These advantages are besides the fact that the patient has a barely visible scar and much faster recovery."

Carcinoma sufferers can now take heart. There is an easier, faster way to recovery.

Administrator

Scar-less weight loss surgery has become popular amongst the age group of 15-40 years recently. Scar-less surgery or single incision surgery is a technique by where the scar gets concealed in the umbilicus (naval).

Doctors say that women in the age-group of 20-30 years are keener to get this surgery done. "This surgery has gained popularity among young adults especially women. Over the past two years we have treated almost 50-70 patients for scar-less weight loss surgery. This surgery started in Ahmedabad two years ago, but has become popular in the northern areas recently," said Dr Mahendra Narwaria, bariatric surgeon at Artemis Health Institute, Gurgaon.

23-year-old Shipra (name changed), who got this surgery done a week ago from Artemis Gurgaon, shared her experience with The Sunday Guardian. She was 89 kg when her surgery was done and after the surgery she has lost close to 10 kg. "Now I can attain my goal of weighing between 50-60 kg. I had lost all hope earlier after trying almost everything. But nothing worked because I have been suffering from polycystic ovary syndrome (a condition in which there is an imbalance of a woman's female sex hormones) which added more weight. This made me extremely lethargic when I finally decided that I had to get a surgery done," said Shipra. She will be on a liquid diet for a month post her surgery.

Doctors believe that lately weight-loss surgeries have become essential. "Obesity has become a global epidemic and more so in the adolescent population. More than 40% of children in India are obese. Within the first month of the surgery more than half of the unwanted fat is reduced and after three months the body loses almost all of the unwanted fat. Personality change is the most immediate after effect as people become more confident after shedding the extra weight," said Dr J.P.S. Deed, a bariatric surgeon with Nova Specialty Surgery, New Delhi.

"Risks from the surgical process are negligible and subject to the clinical condition of the patient. But if a procedure is not performed well or a patient continues to take soft calories, then 10-15% weight gain can be expected. This will need diet modifications or under severe conditions another surgery," said Dr K. Lakshmi, senior consultant and laparoscopic bariatric surgeon of Global Hospitals.

Doctors add that patients can resume work 10 days to two weeks post surgery. "The duration of the ­surgery varies from five to ten hours and the cost ranges from Rs 4-5 lakhs. There are no ­complications as such but for the first two or three days we recommend ­taking multivitamins in case of ­deficiency," added Dr ­Mahendra ­Narwaria.

Administrator

They say ‘Honesty’ is the best ‘policy’. But that does not necessarily mean that honesty is going to be there in your policy. Health insurances come in all shapes and sizes. The only thing different about them is the fine prints that they publish in unreadable fonts in newspapers or ultra-sonic speeds on television. Though there have been technological advances in the medical field, majority of the medical insurance companies seem to be run by the same old sting person. Nevertheless, it is a necessary evil.

Have you ever watched Sicko- a documentary film by American filmmaker Michael Moore.?? It’s a must watch. The film investigates health care in the United States, focusing on its health insurance and the pharmaceutical industry. The film compares the for-profit, non-universal U.S. system with the non-profit universal health care systems of Canada, the United Kingdom, France and Cuba. And i say it is a brilliantly shot film.

Is the policy worth taking? In case you have a specific ailment, are there companies offering specialised schemes? But the last question happens to be the most important. What has been the past track record of the firm?

The problem in our country is that most of those who have access to an insurance policy belong to the rich class. Should the ‘have nots’ be given policies? Yes it should be. But the question being, who will take the first step? Talking industry lingo, the poor will never be a ‘target audience’ for companies looking at turnovers to the tune of billions. The sad thing is that insurance policies sometimes claim lives than save them. Ironically this reminds me of a television ad on some health insurance provider- it talks about giving the right importance to the first half of the health insurance!

Each and every single scheme has an ideal/goal attached to it, in which every single individual gets accessible health care whenever they need it at an affordable rate. However, very few of them actually put a plan into action that dictates how the ideal would be achieved. Coming back to Sicko, Universal health care systems could provide treatment for every individual, whether they could afford it on paper or not. There is so much more resting on universal health care than just health care alone.

Administrator

Ever since our inception, health camps and check-up have been an integral part of our operations. We try and organise these camps at regular intervals trying to help as many people as we can. The camps at Nova focus on various health problems and we have our expert doctors and surgeons addressing the need of our patients.

Most recently we had two camps held at our Koramangala and Sadashivnagar facilities accordingly. The camp at Koramangala focussed specially on PILES and was aptly called PILES TO SMILES. Patients suffering from piles were given treatment for discomfort after bowel movement, swelling / lumps around anus, painless bleeding from anus and other anal disorder etc. Nova had a total of 28 piles patients who came in for this camp.

Right after the camp at Nova Specialty Surgery the FREE EYE AND PHYSICAL EXAMINATION CAMP took place at Sadashivnagar. During this camp Nova offered its patients Evaluation of Age Related Retinal Disorder, Check up for Diabetic & hypertensive retinopathy, Glaucoma screening (Eye Pressure Analysis), Counseling on Cataract & other related disease, Free Refraction check up, Diet Counselling by Dietician,20% Discount on further Investigations (if recommended by doctor), 10% Discount on surgical packages. We had more than 110 patients who walked in to our centre for this camp and were benefitted of our services.

Nova Specialty Surgery also has the Gift of Good Health Check Up Package (Rs. 495) for actual price Rs. 2500. Till date 325 Health Check packages were availed in July at the Koramangala centre and around 500 people at the Sadashivnagar Center.

These camps are a way for us to reach out to people in and around the city. We will continue to focus on such events and spread the message of day care surgery all across.

Administrator

Right from our inception, our aim at Nova has been to spread the concept of day care surgery all across our country. Our efforts have constantly been towards achieving this goal and we are pleased to share with you that we have made headway and progress on this front.

Nova is set to expand its reach across the NCR region with 2 day care centres scheduled to open in the next few months. A total of 6 centers will be opened in the near future. Nova Specialty Surgery will have access to the pool of seasoned doctors practising at MHC hospitals. MHC’s hospitals in turn would be the preferred referral destination for all major surgeries and advanced diagnostics cases required for the Nova patients, which cannot be performed at the day care centers.

The JV with MHC will provide Nova with a reputed partner for all additional procedures that are typically not undertaken at Nova. For eg major surgeries such as cardiac, obstetrics, organ transplants, emergency/trauma care, overnight stay, and advanced diagnostics like MRI, CT etc. The JV Company will be named ‘Nova Specialty Surgery NCR Region’

Boosted by the tremendous success Nova has seen in its first year we are all set to expand its reach across India with special emphasis on the Delhi & NCR region.

Administrator

National Mid term conference of Hernia Society of India

The coming week for us is going to be filled with activity and excitement as Nova prepares to sponsor HSI 2010 – National Mid term Conference of Hernia Society of India. This conference is going to be held in Bangalore at The Capitol Hotel on the 26th and 27th of June 2010.

The Hernia Society of India (National Chapter of Asia Pacific Hernia Society) has been created to promote and advance the teaching and research in hernia surgery in India and the Indian subcontinent.HSI conducts such symposiums on a regular basis to reach out to the surgeon community and develop a systemised approach to the treatment of hernias.

Hernia repair is today, one of the most common surgical procedures done by a practicing surgeon and the field offers so much more for research and medical advancement. Hernia repair in a day care surgery mode is bound to revolutionise the way the disease and its treatment has been perceived over the years. The introduction of laparoscopic / endoscopic hernia repair has generated a lot of debate and discussion among the medical fraternity and a forum like HSI 2010 is just the ideal platform to facilitate such talks.

This hernia congress will focus on both open and laproscopy treatment and aims to bring together well known national and international surgeons. This prestigious event provides a platform for idea sharing and discussions on changing surgical techniques for hernia. This two day symposium will involve invited lectures,symposia,panel discussions and live workshops to demonstrate and discuss technical aspects connected to hernia.

Nova Specialty Surgery takes great pleasure in being the sponsor of this conference and workshop. It helps us in taking the benefits of day care surgery to the medical fraternity and through them to common man.

If you are interested in being a part of this conference please contact Shabeena at 988088068.

Don’t miss this opportunity to come and meet with top surgeons from all over the world.

Administrator

The past few weeks have been significant for us at Nova Specialty Surgery.

We turned one earlier this month and it has truly been a remarkable journey for us!

When we began operations in May 2009, our aim was to spread awareness on day care surgery among people here in Bangalore and in our country at large. It is with great pride today, we share that in the last one year we have performed almost 600 surgeries at just one centre in Bangalore. Surely, facts like this only go to show that day care surgery is becoming more popular amongst people.

Our patient testimonies stand proof to the fact that we provide world-class facilities and care to each and every person who walks into our center for treatment. In the last year we have conducted a number of health camps for people in Bangalore and have received astounding responses to them as well.

As much as we would like to thank all of you out there for your support and encouragement, we would also like to thank every surgeon, medical personnel and staff at Nova, for helping us have such a great start in Bangalore!

Taking on from our first anniversary celebrations, we have touched yet another milestone,

We are now fully funded for our Rs 250 crore 25 centers project!

When we set out to establish NOVA we had the goal of expanding out to 25 centers by 2012. We have been able to raise capital for this project through two US-based venture capital firms – GTI Group and New Enterprise Associates (NEA].

This joint investment makes us completely equipped to set up our 25 centers across India. This also means taking the concept of day care surgery all across the country and increasing the acceptance of a surgery of this kind. The association with GTI LLC and NEA will help Nova in forging strategic partnerships with internationally renowned health care providers, practitioners and regulatory bodies.

As part of the expansion plans Nova intends to set up its day care surgical centres in Mumbai, Delhi and Bangalore in the coming months.

We believe day care surgery facilities will play an important role in shaping India’s healthcare delivery system, and as pioneers we look forward to working to make a difference in the medical sector in India.

Watch this space for more developments from our end!

Administrator

The Royal College of Surgeons (RCS), England – pioneers and one of the oldest institutions in surgical care is organising “The Art of The Possible”, a multi speciality surgical symposium in the city. The Royal College of Surgeons of England are committed to enabling surgeons to achieve and maintain the highest standards of surgical practice and patient care, and towards this we are committed to supervising the training of surgeons in approved posts, providing educational and practical workshops for surgeons and other medical professionals at all stages of their careers.

For the first time, India has the honour of hosting this mega surgical symposium which takes place once in every three years in different countries across the globe. This unique event on multi specialty surgery is being held for the on 13th and 14th of May 2010 and will be inaugurated by His Excellency Shri. H R Bhardwaj, Governor of Karnataka.

Around 250 renowned surgeons from India and over 75 top international surgeons are expected to attend and participate in the symposium. During the two day symposium, the scientific programme includes sessions on different surgical topics like Surgical Infections, Breast Reconstruction, Spina Bifida, Major Limb Trauma, Paediatric Surgery, Transplantation & Vascular Surgery, Cancer Care 2010, Inflammatory Arthritis 2010, Horizons in Endoscopy, Examination & Training in Surgery in India, Robotic Surgery etc.

Also during the programme 12 surgeons chosen from India for their exemplary work, including three surgeons from Bengaluru, Dr Mahesh Reddy – the co-founder and Director of Nova Specialty Surgery, Dr Devi Shetty and Dr Sharan Patil and will be conferred with the prestigious honorary fellowships by the RCS, England.

Updates from the symposium will soon follow on our blog.

Administrator

A small part of negligence on our end would suffice the welcome of these ailments. Staying healthy during summer requires just a few little precautions for you to take – to enjoy a happy, disease free summer!!

Some of the common summer diseases are:

KIDNEY PROBLEMS

In summers, as temperatures are higher than usual people tend to sweat and perspire more.

This leads to loss of great deal of water from the body.To make up for the loss one has to drink extra glasses of water or natural coolers like Lassi, butter milk, coconut water etc. Reduced intake of water slowly leads to development of kidney stones.

A person with kidney stone may pass melly urine which may be accompanied with blood, frequent burning sensation while urinating, fever and vomiting are associated symptoms for kidney stones.

If these symptoms arise, tests are advised and usually if the stone is small it will pass by its own. If the stone is larger than 5-6mm, then it is advisable to undergo lithotripsy (procedure in which large stones are broken down into very small pieces which can come out in the urine easily).

URINARY TRACT INFECTIONS

Urinary tract infection is one of the most common problems people face in summer. Dehydration due to the heat causes infections to set in and bacteria to invade the bladder. Women usually bear the maximum brunt of the urinary tract infections in summer as the female urethra is shorter than for men and so bacteria in urinary tract infection come to the urethra easily.

High fever, severe pain in the bladder area, burning sensation while urinating and also increased frequency in urination are some of the symptoms of urinary tract infection. Drinking plenty of water, wearing cotton undergarments, a hygiene check on genital areas are some of the tips to avoid urinary tract infection. If urinary tract infections are recurrent, then one is advised to consult the physician.

CARDIAC DISEASES

Usually it is observed that in summer there is an increase in the number of cardiac diseases. The excessive sweating increases thickness of blood and that results in clotting (embolism) and narrowing of the arteries (arteriosclerosis) resulting in elevating the blood pressure.

But one can prevent severe consequences of the same by taking certain measures. like regular and timely medications for the heat prescribed by the doctor, taking multivitamins, having a healthy diet consisting of vegetables, fruits, and salads

How day care surgery is different in handling Summer Diseases?

Go ahead and enjoy the summer… minus the diseases!!

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