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Digital Orthopaedics Transformation Tour India Part 1

Digital Orthopaedics
Transformation Tour:
India Part 1

Digital Ortho Tour DOCSF

Last week I wrapped up my visit to India, a complex and massive country that is growing at a solid economic pace and is showing strong potential growth of its musculoskeletal care market, markets the likes of which no longer exist in the “west” in terms of both size and unmet demand.

Publicly accessible sales data from publicly traded companies clearly show that the Indian market for arthroplasty, for example, is growing at 10-20% per year. The markets are divided into the premium and value markets. Premium markets are adopting robotic technology at a fast pace. During my stay, I was able to couple my extensive prior experience in India with insights from VCs, entrepreneurs, clinicians, and several Indian re-pats who had come back to work in India after a stint abroad working for big US-based companies. The picture that emerges is not complete nor does it intend to be. I had no access to policy makers or insurance company CEOs. However, I was able to speak to a remarkably diverse set of change makers. Each of them provided a fascinating insight into their innovation journey, one as colorful and diverse as the country they live in. The podcasts are going to be absolutely fascinating. In the meantime, I’ll touch on a couple of themes that played out in the conversations.

Government policy: A recent Indian government set of policies including the implementation of a unique patient identifier and the requirement for all citizens to have a bank account. They further required to banks to not levy transaction fees on small accounts and have no lower limits on these accounts. Besides enabling micro-economic growth, this fascinating policy allows the government to issue funds directly to recipients and bypass bureaucracy and corrupt government infrastructure. This mechanism further enabled the government to issue a national health care card that would cover treatment for a set of diagnoses for the lowest income earners. Over time, the program has grown to cover two-thirds of the population and is likely to eventually cover everyone. The government, unable to build infrastructure to cover all these newly insured people, has issued fixed price points for services rendered at private hospitals. While some hospitals and providers deemed the price point too low, others figured out a way to turn this massive increase in volume into profitable service lines and a veritable boom in healthcare delivery has ensued. While parts of the policy sound vaguely familiar (I have seen this movie play out in Europe with private hospitals accepting a fixed rate for care delivered to patients with state insurance), the program was implemented at a scale that is quite remarkable.

Indian markets: unlike in the old world with fixed, addressable markets, India has two separate markets, both of which are growing and have unmet needs. There is a premium, high-end private market and a second value-driven, higher-volume, lower-cost market. Both have massive growth upsides that the government will not address directly, relying instead on private providers to do so. Each will likely grow for decades just to catch up to unmet demand. I am sure there is some more erudite terminology in economics to describe this trend, but I am not aware of it.

Tech Innovation: The infrastructure is simply not there… yet. And while there is plenty of money from Angels and even international Venture that could be deployed, the “local” latter and former are not as sophisticated or nuanced as in the western markets. They are less likely to take risks and more likely to avoid innovative ideas, favoring investments in the darlings of Silicon Valley or “hot trends” over the less well-known local companies tackling perhaps uniquely Indian problems. Some startups exist in areas that one would expect (AI for example) and the government is funding basic science research to stimulate innovation. 

India is seeing some very successful US-based entrepreneurs moving back to India with a socially conscious approach to development and innovation. The major financial infrastructure programs that I mentioned above were engineered by Indian re-pats for example. Less famous but no less fascinating is the story of Nishant Doshi which you will hear on the podcast. He runs a highly successful prosthetics business. As someone acutely aware of the challenges faced by people with disabilities, he created a camera-vision-enabled technology that allows blind merchants to check the value of currency, identify products on the shelf or read books to get a basic education. Five months after starting his venture, he has sold over 2000 devices and has a word-of-mouth order backlog in the thousands. Talk about meeting a pain point! His is a fantastic story of market fit and entrepreneurship. 

We will also hear about “meeting people where they are” from Dr. Shrikant Parikh who was a senior leader at IBM doing product engineering. He and his Ph.D. University of Texas NIH-backed researcher’s wife decided to return to India with the lofty goal of making healthcare accessible anywhere and anytime to everyone. Their solution is a classic case of how the best innovations often come from outside the industry and with the clarity of thought that only comes from those who question EVERYTHING. 

The last great story from this group will be one on “innovation driven by necessity” and comes from Dr. Vikram Jain who, about 7 years ago, decided to decline a coveted residency position in the US to take care of the villagers in his home state in India. Challenged by the distances to the big city hospitals and the vagaries of crops and weather, the population was underserved. With his physician wife as partner and gambling all their assets, they raised the capital necessary to build a 200-bed hospital and went to work in 2016. His story of perseverance coupled to a little bit of good timing is truly inspiring. He now runs a newly expanded 500-bed hospital with a solid technology core, trains nurses from the local community, and teaches young residents in orthopaedics. Besides serving as CEO of the hospital and primary trauma surgeon, he also does 700 joints a year in a farming community in which previously knee or hip arthritis simply meant one could not work and care for ones’ family.

Technology adoption: In orthopaedics when someone says “technology” they generally refer to robotics. Soft tissue and hard tissue robot placements in India are rapidly being adopted as private hospitals use new tech to differentiate themselves from the competition. This was quite a surprise to me. I assumed that the sheer cost of the robots, often nearing a million US dollars, would be too high a threshold for hospitals in emerging economies. I was wrong and refer you back to the massive markets in which high-volume surgeons will commonly do well over a thousand joints per year. The implementation of technology like ML protocols to manage OR times and busy clinics is a little more spotty, but not absent. Further, EMRs have been harder to implement because most of the care delivered in India is still paper-based and, as everybody knows, paper is faster than keyboarding… at the moment. There is also no clear front-runner platform and thus there may be more chaos and confusion from the haphazard digitalization of medical records than benefit until the market consolidates as it is starting to in Europe or adopts data sharing standards.  Most administrators are keenly aware of the need to transition to digital and this step is next on peoples’ “to-do” list. As often happens, it seems that the pharmacy sector in India will be the first to digitize.

Beyond the Health Record: There is a massive opportunity for cellular-based technologies to be introduced and widely adopted in health care. I am referencing patient engagement tools. Even though English is one of 25 or so languages spoken throughout the subcontinent, translation engines and LLMs can come to the rescue in that regard. It is worth noting that 70% of India’s population owns a smartphone, makes payments using their phone, and has decent internet access. The potential to expand care to underserved communities through digital platforms backed by cost-effective digital payments is unlimited. All that is needed seems to be a contextually appropriate UI and appropriately complex, not overly engineered tech (ie: text-based platforms might be a good place to start). Concerning other technologies, VR and AR are seeing rapid adoption in a niche market that was widely promoted in the US but never really took off: remote training.  In India, it seems that remote training for new employees or customers spread over a massive service area has become quite popular. In India, headset-based training is well accepted as is the use of live video streaming. I recall doing the first Kinematically Aligned Total Knee Arthroplasty “live” in front of 2 television cameras, one closed circuit TV, and a couple of dozen observers in 2017 in New Delhi at AIMS. What was then cutting-edge and nearly sci-fi is now relatively routine. 

In the next blog, I will share with you a most extraordinary experience that I had when seeking to better understand some of the work being done with AI in Kerala, a state in Southern India.

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