Day Surgery need of the hr Feb 2012

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Presentation made at the Annual Conference of the Association of Medical Consultants, Mumbai , Feb 2012/ M G Bhat

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Dr. M G Bhat MS, FRCS(England), FRCS ( Edinburgh), FICS, DMLE (Law), DMIRCSEd (Informatics) Consultant Surgeon, Bangalore Medical Director, Nova Medical Centers Ltd, India Greetings From… ©2009. Nova Medical Centers. Strictly private and confidential drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012 1

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drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012 2 Day Care Facility - Need of the Hour (Ambulatory) Surgery

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Plan for this Presentation Introduction to day care facility Health care scenario in India Health care facility in India How Day Care will be answer Day care surgery centers Stand alone vs. multi specialty Results from our centers Literature support Conclusions drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012 3

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Stand Alone Day Care Surgical Centers Part of a Multi Specialty Hospital The Day Care Facility-Surgery Ambulatory Surgery Centers drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012 4

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Health Care in India Indian Health Care scenario Facilities Total Beds - 1.37 million Only 50% beds functional & relevant Hospital bed to Population ratio of 1.5 per 1000 23% 77% of the population pays out-of-pocket for healthcare. Only 23% covered by insurance (private, social etc) Doctor to population ratio is 1 : 1,722 OT to population ratio of 1 per 100,000 77% drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012 5

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An ideal model would have a good mix of PHCs, Ambulatory Care Services & Tertiary Care Hospitals The PHCs/Nursing homes/Clinics take care of initial consulting needs of a patient The Ambulatory Care Services center, provide expert consultation & nearly 70% of the surgical needs which do not need beyond a day hospitalization The tertiary Care centers provide Critical care & longer stay needs The Ideal Health Care Delivery Model drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012 6

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The Current Delivery Models Current Models and their Efficiency The current models are skewed towards Tier 1 cities Patients in Tier 2 & 3 cities travel a min distance of 100 kms . Day Care or Ambulatory Centers (ACC) help plug the lacunae in Access Help increase bed to patient ratio Cost of Health care increases by 30-40% drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012 7

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The Current trend in Health care delivery is… Tertiary care hospitals Studies show that 40% of beds located where 10% population resides Is this the best way towards delivery efficient, quality healthcare access to all? The Delivery Dilemma drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012 8

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More hospital beds spread across all types of cities Establish large number of Day Care or Ambulatory Surgery Centers (ACC) How can this need be fulfilled? The Delivery Dilemma What is the need? More access to quality healthcare for Tier 2 & Tier 3 drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012 9

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Taking Healthcare to the People The Ideal Model How Lacunae will be filled Villages – Outreach Clinics A consulting room Min diagnostics For a few Villages – Primary Health Care Centre (PHC) -one for a few villages Consulting Basic diagnostics Tests Small procedures Mumbai 4th Feb 2012 drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012 10

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Taking Healthcare to the People The Ideal Model How Lacunae will be filled Cities – Ambulatory Care Centers (ACC) - Many Centers Diagnostics Surgeries – 70% of all surgeries & nearly 1400 procedures which can be done in ACC Health Checks Pharmacy The ACC would be ideal to be attached to a large Tertiary Care Centre for channelizing the non-critical surgeries The ambulatory services centers will handle all non-critical care surgeries drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012 11

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Stand Alone Ambulatory Surgical Centers drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012 12

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The Day Care Facility-Surgery (Ambulatory Surgery Centers) Not New Started in Post World War II 70% Surgeries in US are Day care Armed Forces Clinics in Delhi (from 1966) Quality & Care of Surgery – Same drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012 13

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Ambulatory Care Centers (ACC) - The Impact ACC free up ‘precious bed’ for critical care in Tertiary Care Centers The ambulatory care centers increase bed to patient ratio OT to Patient ratio Doctor to Patient ratio (for Tier 2 & 3) Hospital Acquired Infection can be significantly reduced Cost saving Treatment - 20-25% Stay, travel – 25-30% drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012 14

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How will this Delivery Model help The occupying of the space of Ambulatory Care Centers (ACC) will have a beneficial ripple down effect ACCs formal tie-up with Tertiary Care Center will help more less-critical care in ACC ACC can be set up at 10% of the cost of a 100 bed hospital ACC offers multi-services Pathological Health checks Surgical OTs Win-Win Situation Patients Service Providers Insurance companies Ambulatory Care Center (ACC) PHCs Tertiary Care Center Outreach Clinics Secondary Care Center 15 drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012

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The Ambulatory Care Centers are a 30 yr old concept in the West Ambulatory Care Center (ACC) The Potential and Vital Cog in Delivery Model US has nearly 6,000 such centers India has the potential to accommodate 15,000 such centers ACC are the vital cog for Effective ; World Class ; Quality ; Affordable Healthcare Quality Healthcare For All drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012 16

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17 Stand Alone Ambulatory Surgery Centers (ASCs) Standalone Ambulatory / Day Surgeries / Short Stay Surgeries started in the 1970s in the USA Recovery and discharge occurs from 2-72 hrs after Surgery is performed Typically ASCs are linked to a major Hospital for emergencies & complications Patients are Pre-screened to avoid complications and surgeries are planned Stand alone ASC avoid Poly-Trauma and Cardiac Cases There are ICUs and support systems at ASCs Back up system to address patient transfer in case of complications drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012 17 is a well proven Concept in USA & Europe since 1970s

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Mumbai 4th Feb 2012 18 drmgbhat@novamedicalcenters.com In the USA, there are over 6000 Stand Alone Ambulatory Centers (ASCs) 22 million Surgeries Per Year in the ASCs Federal government views ASCs as distinct types of Health Providers The Federal Government in US has different Regulatory Standards for hospitals and ASCs In the USA, an Average ASC is 13,000 sq ft and has 3-4 Operating Rooms In the UK, ASC form an integral part of the NHS systems and exist within Hospitals Stand Alone Ambulatory Surgery Centers (ASCs)

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Evolution of Ambulatory Surgery 19 1909 Ambulatory Surgeries first performed by J.H. Nicoll of Glasgow, Scotland. ~9K patients undergo ambulatory surgery at the Glasgow Royal Hospital 1916 Dr. Ralph Waters opens Anesthesia Clinic in Iowa, USA for minor surgical procedures & dental cases 1970 First ASC established in Phoenix, Arizona, USA by two physicians (Wallace Reed, MD, and John Ford, MD) 1975 - 79 American Association for Accreditation of Ambulatory Plastic Surgery Facilities Established 1980 Insurance Companies agree to pay for surgeries (~200 procedures) performed in ASCs in USA 1982 Discovery of new anesthetic agents combined with better techniques for administering anesthesia makes procedures in ASCs safe 1995 International Association for Ambulatory Surgery (IAAS) formed Medicare expands the ASC list to cover more than 2,000 procedures. Rapid growth. A total of 42 surgery centers are in operation in the US by 1975 and reaches triple digits by 1979 Accreditation Councils for Ambulatory Health Care established in USA 1991 First European Congress on Ambulatory Surgery Ambulatory surgery accounts for more than 50% of all surgical procedures performed in the US across 6,000 ASCs performing 23mn surgeries. Medicare covers more than 3,500 procedures under ASC 2009 Nova first chain to introduce Ambulatory Surgery to India 2008 Ambulatory Surgery Center Association (ASCA) formed with merger of AAASC & FASA* Over 5,000 ambulatory surgery centers in the USA Ambulatory surgery procedures starts at NHS,UK 1982 2010 drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012 19

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20 3291 1537 1317 1049 358 407 15 77 Koramangala 2009 Sadhashivnagar 2010 Kailash Colony 2010 Karol Bhag 2011 Chembur March 2011 Aug, 2011 Jan , 2012 Tardeo Jan , 2012 Nova Medical Centers - Expert Surgical Care drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012 20 Performance in India -June 2009 to January 2012

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Nova’s Performance in India- -June 2009 to January 2012 21 Since inception 10 centers across 6 cities in India & 1 in Middle East All Major procedures completed at Nova with Superior Outcomes One Fatality TWO Superficial Post-Surgical Infections EIGHT Cases Transferred to other Hospital (for observation) Acceptance from Top Insurance Companies & TPAs Only corporate institute to get approval for 800+ day surgery procedures Surgeon community - 400+ doctors affiliated Patients - 97.1% patient satisfaction * Includes Bariatric Surgery Over 8,500 Surgeries performed * drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012 21

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22 Process Flow for Nova Ambulatory Surgery Center Post Operative Check in OPD OPD Assessment, Diagnostic Investigations Surgical Appointment Insurance Approvals, Medical Screening Pre Operative Check Up, Surgery Post op Recovery Discharge Tele Check Nova Clinical Model Short Stay Surgical Procedures on Fit Patients & Straight Forward Surgeries Across Specialties Full time Anesthetists who Provide Round the Clock Support Provision for short stay up to 72hrs No Emergencies or Trauma or Infected cases drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012 22

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Doctor Acceptance Patient Selection Patient Acceptance Patient Counseling Anesthetic Support Pain Management Home Care Ambulatory Surgery drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012 23

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Representative Surgeries Performed at Nova Opthalmology ENT General Surgery Hernia (Lap & Open) 250 Laparoscopic Cholecystectomy 271 Haemorrhoidectomy 126 Laparoscopic Appendicectomy 52 Sleeve Gastrostomy 17 FESS 205 Tonsillectomy 78 Adenotonsilletomy 61 Adenoidectomy 37 Cataract Surgery 129 Lasik Surgery 102 Cataract - Phacoemulsification with Acrylic Foldable Lens 51 Squint Surgery 8 drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012 24

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Representative Surgeries Performed at Nova 25 Gynaecology Orthopedic Hysteroscopy & D&C 162 Diagnostic Laparoscopy with CT 51 Hysterolaparoscopy 65 Vaginal Hysterectomy (Lap & Open) 44 Hysteroscopic Polypectomy 35 Abdominal Hysterectomy 31 LAVH 13 Hysterolaproscopy & D&C 12 Arthroscopic Bankart Repair 83 Rotator Cuff Repair 72 Arthroscopic SAD 66 Arthroscopic Meniscectomy 50 Total Knee Replacement 46 K-Wire Fixation 29 Arthoscopic Shoulder 28 Total Hip Replacement 11 drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012 25

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Representative Surgeries Performed at Nova 26 Urology Plastics *PCNL - Percutaneous Nephrolithotomy ** HIFU - High Intensity Focused Ultrasound Laser Prostatectomy (incl Vaporisation of Prostrate) 249 Lap.- Nephrectomy, Radical Prostatectomy, Pyeloplasty 242 PCNL (incl. Mini & Micro) 227 HIFU for Prostate Cancer 206 Sling surgery for stress incontinence 106 Turp 38 Liposuction 78 Rhinoplasty 36 Abdominoplasty 16 Breast Augmentation 12 Breast Reconstruction with expander implant 4 drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012 26

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Day Care Surgery Unfit Patients (co morbid conditions) Large Hernias Emergency Hernias Requiring More Days of Stay Psychologically Unsuitable No Help to Take care at home Doctors Comfort Not Suitable drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012 27

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Anesthesia and Analgesia In Day Care Surgery GA LA Regional drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012 28

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Well Streamlined Service No delays Anesthesia Analgesics Financial Benefits Satisfaction Service and Outlook Differences drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012 29

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30 Freestanding ASCs provide significantly better outcomes and are the preferred service providers 20 15 22 40 40 25 45 55 65% of ASCs had less than 3 unexpected complications per 1,000 patient encounters 89.5% of ASCs had less than 3 post-surgical wound infections per 1,000 patient encounters 98.4% reported zero fatality per 1,000 patient encounters drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012 30 The 2010 Outcomes Monitoring Project by ASC Association shows that :

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Straight Forward Surgery Fast Tracked in Fit patients Patients Recovers from Surgery and Fit to Return Home within the Day or in 24 hrs The Day Care Surgery drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012 31

Insurance in India: Present:

http://www.thehindubusinessline.com/2010/04/07/stories Insurance in India: Present IRDA (Insurance Regulatory and Development Authority) has allowed insurance companies to cover patients that availed day care facilities. drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012 32

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Day Care Surgery Concept= Starbucks of US McDonalds of US Tim Hortans of Canada ‘ Darshini ’ of Bangalore Day Care Facility Surgery Adavantages : drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012 33

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Mumbai 4th Feb 2012 34 drmgbhat@novamedicalcenters.com Day Care Surgical Facility with Provision for Short Stay Will Improve Health Care Delivery in India The Aim Should be: Stand Alone Centers State of the art facilities Safe Surgical Practice This will provide cost effective safe health care delivery Large Multi specialty hospitals will take care of All tertiary, emergency, trauma and Long Stay

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drmgbhat@novamedicalcenters.com Mumbai 4th Feb 2012 35 Dr M G Bhat Medical Director and Consultant Surgeon Nova Medical Centers Pvt Ltd, Bangalore www.drmgbhat.com

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