A telemedicine company brings $1 virtual checkups to poor countries.
There aren't too many doctors in the village of Hari Ke Kalan, in the Punjab region of northern India. But for $1, residents who bicycle to a new health clinic can get an appointment with a physician appearing on a large-screen television and beamed in over broadband Internet.
The clinic, built by a startup called Healthpoint Services, is one of a network of eight "e-health points" that the for-profit company has built in India as part of a growing effort by entrepreneurs to capitalize on the rapid expansion of cellular and broadband access in the poorest parts of the world. With successes such as text-message-based mobile payments taking off in some countries, many experts see medicine as the next major application of technology in poor nations.
In India, the rural population often has little access to medical services. When villagers get sick, they must either make a costly trip to visit clinics in big cities, take their chances with poorly trained local practitioners, or go to free government clinics that are staffed by physicians only a few hours a week.
Healthpoint's clinic in Hari Ke Kalan is a money-making enterprise, says Al Hammond, Healthpoint's cofounder. It charges about 80 cents for a consultation with a doctor and about a dollar for diagnostic tests, such as blood tests to measure blood sugar or check for infections. "For a family with an income of $3 to $4 per day, that's affordable, and we can cover our costs with those prices," he says.
Hammond, who calls himself a "serial social entrepreneur," says he decided after studying low-income consumers that a for-profit company had a better chance than a nonprofit of delivering medical care to millions who need it. "It only makes sense to do this if we can scale enough to change the health-care system," he says. "I wouldn't, as a startup, try to change the U.S. health-care system. But in rural India, there is no health-care system, so it's much easier to innovate there."
The company was initially funded by U.S. angel investors who were attracted to the social impact of the venture, including the cofounders of Athenahealth, a producer of electronic medical records technology based in Watertown, Massachusetts. Hammond says Healthpoint has quickly become self-supporting and that the clinics are "cash-flow positive."
Each Healthpoint clinic typically starts as a water service, where local families can fill jugs with clean water for a monthly subscription fee of $1.50. Hammond calls the service a form of preventive medicine, and not only because many infectious diseases are spread through tainted water. Villagers who come for water often end up getting seen by a doctor. In addition to eight e-health point clinics, the company has 16 water points in India, with plans to expand to South America and Africa.
Clinics are staffed by health workers who measure vital signs, such as blood pressure and heart rate, and transmit the information to a doctor in a nearby city. Local workers also run diagnostic tests, such as cholesterol or pregnancy tests; the results are relayed to the physician and recorded in the patient's electronic health record. Eventually, Hammond hopes to enlist government or other aid to fund care for those who can't afford the cost of an appointment.
Telemedicine is well suited to address two major challenges confronting health-care delivery in India: a growing population and a shortage of physicians. "Many [doctors] have gone abroad, and those who are here don't want to go to remote villages," says Sunita Maheshwari, a physician and cofounder of Teleradiology Solutions, an outsourcing company whose on-call doctors analyze radiology images for hospitals in India and other countries. "Telemedicine would address such a gap."
Some previous efforts to expand telemedicine in India have stumbled, including a 2005 plan by the national government to budget funds for 50 facilities. "Practically speaking, they never took off," says Maheshwari. She says that effort foundered because of unreliable satellite connections, lack of inexpensive broadband access, and too little practical know-how on the ground. Now, as broadband costs have dropped and reliable wireless communication has penetrated more and more of the country, chances are better that telemedicine will succeed.
Indian patients have been amazingly quick to accept telemedicine, says Maheshwari. Radiologists with her company provide consultations over the Internet for free clinics in northern India built by Cisco Systems. "We see about 20 patients a day," she says. "Now everyone wants a doctor in Bangalore."
Luxury Hospital Suites
The feverish patient had spent hours in a crowded emergency room. When she opened her eyes in her Manhattan hospital room last winter, she recalled later, she wondered if she could be hallucinating: "This is like the Four Seasons - where am I?"
The bed linens were by Frette, Italian purveyors of high-thread-count sheets to popes and princes. The bathroom gleamed with polished marble. Huge windows displayed panoramic East River views. And in the hush of her $2,400 suite, a man in a black vest and tie proffered an elaborate menu and told her, "I'll be your butler."
It was Greenberg 14 South, the elite wing on the new penthouse floor of NewYork-Presbyterian/Weill Cornell hospital. Pampering and décor to rival a grand hotel, if not a Downton Abbey, have long been the hallmark of such “amenities units,” often hidden behind closed doors at New York’s premier hospitals. But the phenomenon is escalating here and around the country, health care design specialists say, part of an international competition for wealthy patients willing to pay extra, even as the federal government cuts back hospital reimbursement in pursuit of a more universal and affordable American medical system.
"It's not just competing on medical grounds and specialties, but competing for customers who can go just about anywhere," said Helen K. Cohen, a specialist in health facilities at the international architectural firm HOK, which recently designed luxury hospital floors in Singapore and London and renovated NewYork-Presbyterian’s elite offerings in the McKeen Pavilion in Washington Heights. “These kinds of patients, they’re paying cash — they’re the best kind of patient to have,” she added. “Theoretically, it trickles down.”
A waterfall, a grand piano and the image of a giant orchid grace the soaring ninth floor atrium of McKeen, leading to refurbished rooms that, like those in the hospital’s East 68th Street penthouse, cost patients $1,000 to $1,500 a day, and can be combined. That fee is on top of whatever base rate insurance pays to the hospital, or the roughly $4,500 a day that foreigners are charged, according to the hospital’s international services department.
But in the age of Occupy Wall Street, catering to the rich can be trickier than ever, noted Avani Parikh, who worked for NewYork-Presbyterian as in-house project leader when the 14th floor was undertaken. She pointed to the recent ruckus at Lenox Hill Hospital, where parents with newborns in the intensive-care unit complained that security guards had restricted their movements and papered over hospital security cameras in their zeal to please Jay-Z (real name Shawn Carter) and Beyoncé Knowles, whose daughter was born on Jan. 7 in a new 'executive suite.'
Many American hospitals offer a V.I.P. amenities floor with a dedicated chef and lavish services, from Johns Hopkins Hospital in Baltimore to Cedars-Sinai Medical Center in Los Angeles, which promises "the ultimate in pampering" in its $3,784 maternity suites. The rise of medical tourism to glittering hospitals in places like Singapore and Thailand has turned coddling and elegance into marketing necessities, designers say.
The spotlight on luxury accommodations comes at an awkward time for many urban hospitals, now lobbying against cuts in Washington and highlighting their role as nonprofit teaching institutions that serve the poor. Indeed, NewYork-Presbyterian, which once opposed amenities units, would not answer questions about its shift, and declined a reporter’s request for a tour.
In Greenberg, where the visitors' lounge seems to hang over the East River in a glass prow and Ciao Bella gelato is available on demand, the patient who likened her suite to the Four Seasons was not paying for it. She did not want to be identified because her wealthy boss, who picked up the bill, would not want publicity.
During a reporter’s unofficial visits to both units this month, however, some people enjoying the perks expressed uneasiness about those priced out. In space-starved New York, many regular hospital rooms are still double-occupancy, though singles are now the national standard for infection control and quicker recovery.
"The concierges act like butlers," said John Frehse, 37, who was visiting his ailing father, Robert M. Frehse, 86, the retired chief executive of the Hearst Foundations. He and his mother, Dale Frehse, paused in their praise of the care to recall the fate of a family friend stuck for three days in the NewYork-Presbyterian emergency room for lack of a hospital bed last winter. At the time, they recalled, the Saudi king had been granted the whole 14th floor for his entourage.
The younger Mr. Frehse contrasted the unit's mouth-watering menu with the "inedible food" his father faced when he was treated on the non-elite second floor. "Here he has mushroom risotto with heirloom tomatoes," he said.
The hospital said in a statement: "NewYork-Presbyterian is dedicated to providing a single standard of high quality care to all of our patients."
At Mount Sinai Medical Center, where the aesthetic of the Eleven West wing is antique mahogany rather than contemporary sleek, and the best room costs $1,600, William Duffy, the hospital's director of hospitality, said his favorite entree was Colorado rack of lamb, adding, "We pride ourselves on getting anything the patient wants. If they have a craving for lobster tails and we don't have them on the menu, we'll go out and get them."
The 19-room unit, which opened 18 years ago but received a recent face-lift, takes in $3.5 million a year, Mr. Duffy said, estimating that 30 percent of its clientele comes from abroad. If the emergency room is backed up, a regular patient may be upgraded, he added: "Bump 'em up to Business, as we say."
Wayne Keathley, Mount Sinai’s president, minimized the unit's role in the 1,171-bed hospital, on Fifth Avenue at 101st Street. "It is not nearly as large or elaborate as some others," Mr. Keathley said. He called the money it brought in "a rounding error in my budget," and said that patients came for the clinical care, not the amenities.
In Eleven West's library on a recent Friday, Nancy Hemenway, a senior financial services executive, was reading the paper in a spa-style bathrobe. "I was supposed to be in Buenos Aires last week taking tango lessons, but unfortunately I hurt my back, so I’m here with my concierge," she said.
"I'm perfectly at home here - totally private, totally catered," she added. "I have a primary-care physician who also acts as ringmaster for all my other doctors. And I see no people in training - only the best of the best."
Mr. Keathley said the lack of interns and residents on Eleven West was a function of clinical judgments and limits to the training program, not the preferences of rich patients.
But even the rainmakers - doctors who bring in such patients - can sometimes resent the tilt toward luxury. "The one misgiving is patients with Medicare, which pays physicians almost nothing," said Dr. Brian Katz, 59, a laparoscopic surgeon in scrubs who took a break in the same library later. "Yet those patients will come up here and pay to enjoy five-star comfort."
Increasingly, hospitals serving the merely well-off are joining the amenities race. Beth Israel Medical Center near Union Square added a deluxe unit in 2008, catering mainly to patients after elective orthopedic surgery. The green-carpeted lobby may be more Radisson than Ritz, but its 12 single rooms starting at $450 feature Bose stereos and flat-screen TVs, and chef-prepared kosher food is served on china.
"A very insignificant portion of our beds are identified as deluxe accommodations," said Gail Donovan, the chief operating officer of Continuum Partners, which includes Beth Israel and St. Luke's-Roosevelt Hospital. "Our mission is really to be the safety net hospitals of our communities."
The conflicts echo those of a century ago, in another era of growing income inequality and financial crisis, said David Rosner, a professor of public health and history at Columbia University. Hospitals, founded as free, charitable institutions to rehabilitate the poor, began seeking paying patients for the first time in the 1890s, he said, restyling themselves in part as 'hotels for rich invalids.'
"Every generation of hospitals reflects our attitude about health and disease and wealth and poverty," Professor Rosner said. "Today, they pride themselves on attracting private patients, and on the other hand ask for our tax dollars based upon their older charitable mission. There’s a conflict there at times."
His perspective on McKeen's amenities unit, where afternoon tea is served daily, is colored by the emergency room experience of one of his graduate students on the same hospital campus this month, he added. She spent two days on a gurney in terrible pain from herniated disks, he said, until a dean intervened to get her a room. "She hadn't even been given a bed pan," he said.