Jan-Jul 2018

Access and Change: Health 3.0

Access and Change: Health 3.0

The recent Health 2.0 Conference, co-organised by the Max Institute of Healthcare Management at the Indian School of Business, brought together a range of stakeholders – entrepreneurs, investors, healthcare providers and others – interested in the future of healthcare technology. One of the highlights of the day-long event was a free-wheeling, on–stage conversation between Professor Sarang Deo, Associate Professor of Operations Management and Executive Director of the Max Institute of Healthcare Management and Shashank ND, Founder and Chief Executive Officer (CEO), Practo. The edited transcript of the discussion follows.

Sarang Deo: To reflect on the evolution in healthcare, if someone wanted to use the word “technology” in the context of healthcare ten years ago, they would not say health-tech, they would say medical technology. The context of technology was medical devices, maybe some electronic medical records and telemedicine.

Fast forward to today, and we are hearing all kinds of new words such as health apps, machine learning, Artificial Intelligence. Shashank, you have been on this journey for ten years. If you went out on the street and asked people what Practo does, they would say that Practo provides an online directory of providers with reviews and ratings, and it helps people to make choices. Is this an accurate characterisation?

Shashank ND: First of all, it is great to be back in this room. I was in the fourth row from the back at one of the events here about 12 years ago. I think it was ISB Connect. It was my first event in entrepreneurship. I was studying Computer Science at the National Institute of Technology-Suratkal, thinking that I would want to be a Wall Street investor. I remember coming to this place, and listening to the kinds of conversations that happened on the stage. And that was the time period when I decided that this entrepreneurship thing sounded good. So I want to thank that event for having a big role to play in what I do today and why I am here.

The other connection to this event is Health 2.0. I was at a Health 2.0 event in 2014. It was a phenomenal event which broadened my thinking of how to make healthcare more consumer-driven and how to put the consumer at the centre of healthcare. And I am glad to have the opportunity to talk at an event that connects both of these dots together for me.

To answer your question on what a consumer thinks about us: our data shows that consumers see us as the best place to find a doctor and book an appointment. Consumers want choice, and they want a neutral platform to help them with that decision. We partner with providers and play that responsible role of being a neutral platform which both the consumers and providers can trust. But that is our start, and we definitely want to go beyond that.

The call to action that we want for our consumers is that when they think about their healthcare needs, they think about Practo. We want Practo to be the consumers’ home for health. Their need for transacting in the healthcare platform can start with Practo. There are four things that we are currently focusing on: (1) finding and booking doctors, (2) instantly connecting with doctors on chat (3) helping with access to labs, and (4) getting medicines delivered home. And we want to be the start of consumers’ healthcare journeys.

Today, we help consumers find the best doctors in the country, connect with them instantly, and book appointments. We are moving on to helping consumers get access to the best laboratories at their homes. The lab can come to your home, pick up your samples and get you your lab results. We want to make it easier for consumers to get access to medicines. We have to continue partnering with our valuable providers, payers and pharmaceutical companies to actually deliver on our promise.

Today, because of more transparency in the whole ecosystem, consumers can see and understand which hospital or treatment costs how much and where they can get what kind of care. In this way, the correct demand and supply matching can happen.

What I take away from that overview is a consumer-driven model where you are empowering the consumer or the patient with information. What matters is not only information but how they translate that information into quick actions, because at the end of the day, the value comes from taking appropriate actions. Has there been any effort to quantify or understand changes in patient behaviour and the actual value not only in terms of patients’ satisfaction through the search process, but also in terms of clinical outcomes? 

Oh, absolutely. It was only three years back that we launched our first consumer product, so it is very early days, but the initial signs are exciting. As a healthcare ecosystem, we are here to serve the consumer. And ten years back, Practo started because I, as a consumer, was not satisfied with how providers treated me. But I felt the reason providers could not treat me the way I wanted was not because of intent but lack of tools and technology at their fingertips. The gap that we wanted to fill at Practo was to empower doctors, payers as well as pharmaceutical companies, and enable them with technology so that they can serve us better.

Now we are beginning to see all the stakeholders aligned with that thought process. And when that happens, you get more willing partners, who are experimenting a lot more. So the pace at which the consumer’s life will change, both clinically and non-clinically, with the use of technology will only accelerate with this acceptance from all stakeholders.

In terms of specifics on what has changed, at least on the non-clinical side — which to be honest, is the easier side to bat for– we have made some strikes starting with wait times. I am sure all of us have had frustrating wait times in hospitals. We are now seeing wait times drop significantly, not just through Practo but because of a very vigilant provider community.

The ability of consumers to access healthcare has increased dramatically. We have a vast number of doctors from different specialities and cities in India on our platform for consultation and online chatting. Accessibility and choice have increased for consumers. If your doctors are out of station, say they are out for three months, maybe on a vacation or learning something new, you don’t have to be worried about where to find an alternative.

The next step is visibility and transparency, which has created and increased trust between consumers and providers. Providers are now a lot more comfortable in sharing pricing information. I hope they will also share outcome information in the future. This kind of transparency leads to much-improved trust between both parties. It leads to better market dynamics where consumers can choose doctors based on services and pricing.

We also had a scenario where consumers who could not afford a very large hospital would not know what the alternatives are. Today, because of more transparency in the whole ecosystem, consumers can see and understand which hospital or treatment costs how much and where they can get what kind of care. In this way, the correct demand and supply matching can happen. So I think there has been movement on pricing and convenience.

Lastly, to answer your question on the clinical front. This is a bigger challenge and probably the most exciting of them all. At Practo, we want to help make sure that we live a little longer and a little healthier.

You build things to make your personal life better, you build things to make your professional life better and you build things to make your health better. The first two are covered by the likes of Facebook and LinkedIn. Not enough people were focussing on building good technology for healthcare.

On that front, just the adoption of technology, of electronic medical records and of tools that many companies have built has led to quality improvements in the last ten years.

When we started ten years back, only five percent of doctors had any form of software to manage even the most basic information. Today that has gone up to about 30 -40%.

I am also happy to see the use of big data. A few companies have picked up some of our solutions, such as our product called Querent which helps in using data to improve clinical outcomes. I think from a clinical outcomes point of view, we will see a lot more in the next ten years.

One way to improve outcomes in the long run is by empowering patients, giving them knowledge so that they demand the right and appropriate care at the right time and the right place. And the other is more on the supply side. If providers want to practice evidence-based medicine, you first need to bring data to the providers at their fingertips. And data again needs to be translated into information and even knowledge. A doctor is spending two or three minutes with a patient. We always say that the doctor wants to do right by the patient. But how do you make it easier for the doctor to do the right thing?

When we started, we found that many doctors, hospitals and clinics were not connected to the internet. That was a bigger challenge for us. Few doctors had adopted technology to its full extent. And hardly any pharmaceutical companies or payers were talking to the consumers or providers.

The first thing was to get the healthcare ecosystem online. That is when the participants can start talking to each other. We spent the first four years just getting the providers online. Even today, 60% of providers are not online. And it is only through providers that we can reach patients.

Cut-copy-paste models don’t work in healthcare. Our ecosystem is different. In the US, you have a payerdriven ecosystem where payers take decisions and there are no out-of-pocket spends. In India, it is a lot of out-of-pocket spends. About 60% of our expenses are out-of-pocket.

So the first value proposition that we enable for providers is technology to bring them online. From a practical standpoint, how do you bring value to providers so that they can stay online every single day with a busy schedule? What do you do to make that happen? That is the first thing: you need the participant online. Then of course, data comes online if you have the right permissions. Then you can use that data and the actors (i.e. patients and providers) to get outcomes. Practo’s first value proposition is to bring providers, payers and pharma online, and to give them the technology to get online.

The second value proposition we provide to the ecosystem is the ability to drive business. And I call it business because at the end of the day, India’s healthcare ecosystem is a fantastic free market. Practo is able to play a role in the free market by helping generate three things: more business for everyone, better quality of care for patients and better business for all of the stakeholders. And we try stitching together mutually beneficial partnerships because we are not a payer, a provider nor a pharma company. In that sense, it becomes a symbiotic relationship. That partnership helps us serve the patient in the best possible manner.

Speaking of trying to connect patients and providers, Practo is embedded in an ecosystem of government regulation and policy. But even before we go that far, what, in your observation, has been the change in the broader competitive landscape in the past few years with organisations like Practo? 

At many of the events that I went to before 2010, I would be in the audience and there would be companies presenting on stage. And not a single company would talk healthcare. There would be social networks or technology companies, but not a single one working on healthcare. I was very surprised because as a consumer, I was frustrated with healthcare. And I was surprised that when there were so many problems with healthcare, why weren’t people solving them? Today, I am happier when I see so many smart people coming into healthcare. It is only going to make healthcare better for all of us.

There are three fundamental things on which we spend our time every day of our lives. You build things to make your personal life better, you build things to make your professional life better and you build things to make your health better. The first two are covered by the likes of Facebook and LinkedIn. The last one was not. Not enough people were focusing on building good technology for healthcare.

Even today, I feel that it is not even the tip of the iceberg. We are still at 1% and there is still the 99% talent needed in healthcare. There are some phenomenal problems to solve and some phenomenal solutions to build. I am glad to see more entrants coming into healthcare. We at Practo are one such entrant. We will continue wanting to make as much of an impact as possible, but with more people coming in, we can build an ecosystem and make a much bigger impact. That is on the online front.

On the offline front, we are seeing the offline providers, payers, and pharma companies believing more than ever in the fourth industrial revolution. We see them being more open and adapting to technology. I think it is a very conducive environment and ecosystem today to work together. The only thing missing is the ability for us to have standardisation and good regulation. Some amount of trust , I think, is a missing ingredient. Hopefully with time, we can solve this as well.

Today, I have two or three smart devices on me; ten years back, I probably had zero. In ten more years, there will be a lot more devices on me. And if devices are on me, then they are capturing my health data.

From your vantage point, tell me how you would compare the healthcare start-up ecosystem or health-tech start-up ecosystem with say the start-up ecosystem within e-tailing in India. And the second benchmark is health-tech in more developed firms. Against those two benchmarks, where are we as an ecosystem? 

I painted a very rosy picture so far. In the not-sorosy picture, health-tech excites me, but it can also be complex. Healthcare is complex for two reasons: geographical differences and the number of stakeholders. Healthcare in every country is different. You can launch Facebook in a country and it can be adopted in many countries. But you don’t see a similar thing in healthcare, because the geographical complexity is more.

Second is the number of different stakeholders in healthcare. You have a large variety of players to take you from being sick to being cured. You have primary care, tertiary care, pharma and payers. I am not even including the preventative and other aspects. It is quite a daunting task to get everybody to the table and talk, and to bring real change.

In e-tailing, for example, the differences between China, India and the United States definitely exist, but to a lower degree compared to health-tech. Within health-tech, the complexity is much higher. The number of stakeholders and their power equations are different in different markets.

Because of these two things, health-tech is very different. It becomes a daunting task for any entrepreneur in this audience today to actually create impact.

You have seen a lot of start-ups, and a lot of entrepreneurs. How ground-ready are the entrepreneurs when they start thinking about health-tech as an area to work in, especially given the complexities? And, what could they do to get themselves ready, because it is not only technology that makes for a successful start-up? 

A single dose of passion might work in other industries, but you need a double dose in health-tech. In health-tech, you have to be extremely patient. All of us at Practo are excited by the impact that you can have in healthcare, even though we have never treated a patient. But you can talk about the role that you have played in taking someone’s pain away. That excites our team and motivates us.

For people to be ground-ready on getting into health-tech, being patient and hands-on are important qualities. You need to be comfortable being out there because healthcare is a local need of consumers. You have to be ready to hit the ground running. You have to hit the roads and hit the by-lanes. That is where healthcare is practised. For example, while working in health-tech, the only way to communicate with doctors is by being in front of them. That is the best way that builds trust between providers and a health-tech company. These are the two things an entrepreneur needs to be ready with.

The other benchmark was the health-tech space in more developed countries. You said that “copy paste” might work in other sectors but not in healthcare because there is too much difference. I have heard other investors and venture capitalists thinking that if something has worked elsewhere, let us make it more efficient and try it out here. What would you say to that? 

Cut-copy-paste models don’t work in healthcare. Our ecosystem is different. In the US, you have a payer-driven ecosystem where payers take decisions and there are no out-of-pocket spends. In China, it is mostly government driven, and the consumers largely go to government hospitals. In India, it is a lot of out-of-pocket spends. About 60% of our expenses are out-of-pocket. We decide which provider and medicine. As consumers, we decide everything. It is a very different ecosystem.

There are flavours of this model in other parts of the world. I see something similar to India in the Philippines and Indonesia, where out-of-pockets spends are comparable. These markets could be clubbed together in one bucket. Similarly, if you look at Brazil, it is largely payer-driven but these are private payers, and a little more similar to the US. So you can bucket the ecosystems in that manner, but there are still local nuances.

Some payers in some markets are far more developed. They have better APIs and you can do faster work there than other countries where there is a monopoly. Unfortunately, in healthcare, the number of permutations and combinations are so many that to become an international player is hard. And to copypaste is very hard.

Our philosophy in Practo is that if we choose a country, we go deep into that country. To have the maximum impact, we learn from each market, learn where the markets are going, because history always repeats itself. If you study enough, you can probably predict what is going to happen in the next five to ten years and hopefully align yourself. But you have to go deeper and deeper into each market rather than spread yourselves thin.

If you were to start as an entrepreneur today, what would you do differently?

I start each day afresh as if it is the first day I am starting with Practo. Having said that, if I had no responsibilities and was able to choose a completely fresh board to sketch on, one interesting area would be the Internet of Things (IoT). Devices are getting smarter and smaller. The IoT space is extremely exciting.

Today, I have two or three smart devices on me; ten years back, I probably had zero. In ten more years, there will be a lot more devices on me. And if devices are on me, then they are capturing my health data. In that sense, IoT is a great space and is accelerating at a much faster pace thanks to mobile and the internet. Healthcare will see huge benefits from the growth of IoT. I think that is what I would do.

What would be your advice not to the tech entrepreneurs, but to medical professionals and particularly to those who are about to graduate from their MBBS and looking at this exciting space? How should they approach this? 

I like the name of this conference: Health 2.0. I think Health 3.0 is coming soon. I meet a lot of providers who are healthcare professionals who don’t like the new world. They feel that this new world is a Google world, where patients come with questions. The new world doesn’t like waiting, complains a lot and is spoilt. I completely agree with all of that. But that is the new world, evolving at an incredibly fast pace.

I think more acceptance is required. The new generation of doctors is already doing this. The only advice or suggestion would be for the new doctors to be open to change in the way they practice and the way they think of future healthcare. And expanding from empathy towards their profession to a much larger empathy will do good to the entire health ecosystem.

It is interesting that we have done a full circle starting with technology and ending with empathy. Thank you.

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