Higher quality, lower costs: India’s cancer grid promise

No matter the time of day, the visitors in queue at Mumbai’s Tata Memorial Hospital (TMH) always have a discomfiting poise. Most have travelled long distances; but the group seems curated by one illness, cancer. An illness that can be manageable, like a chronic disease, but often isn’t. 

In 2012, the leadership at TMH, the largest cancer centre in the country, took a decisive step to address parts of the colossal task at hand. Having brought existing centres in Guwahati, Chandigarh and Visakhapatnam into its fold that year, it set about framing common standards, setting up an IT platform, and sharing best practices—the entire structure for a functional network. 

Then, in a benevolent gesture, they decided to open this up to scores of regional cancer centres across India. Thus, the National Cancer Grid (NCG) was born. An unprecedented initiative to tame a disease that the World Health Organisation (WHO) estimates will affect one in three household in India by next year. The numbers look ominous—1.73 million new cases by 2020, with only 12.3% of patients receiving early treatment.

Already under Ayushman Bharat—the government’s universal healthcare insurance scheme which covers 40% of the population—30% of reimbursements are for cancer treatment. Is that money optimally spent? It’s certainly worth examining since there are rumours the scheme may be expanded to cover more people. 

Seven years on, the NCG sees 700,000 new cancer patients pass through its network of 177 centres each year. Some of the world’s leading cancer centres are even helping the NCG build out its capabilities since it’s also serving 40-plus countries in one way or another. These include the National Cancer Institute and American Society for Clinical Oncology in the US, King’s College London, and Cancer Research UK.

Fast emerging as a global health centre, could NCG also impact the sprawling, yet largely unregulated, private healthcare providers in India which serve the remaining 60% of cancer patients? CS Pramesh thinks it could. A director at TMH, Pramesh, a practising thoracic surgeon and the lead architect of NCG, talks about this democratic, ground-up machinery that has caught the world’s attention.

The Ken: Why have a cancer grid? 

The single most important mandate of NCG is to have uniform standards of care. Look at the patients that come here or at any top centre; only a small percent comes from the state where the centre is. At TMH, only 15% of our patients come from Mumbai; 25% from other parts of Maharashtra. We geotagged 75,000 patients (map below).  A large percentage comes from pockets like North, East, or North-East; not so much from the West or the South. 

Overall, the biggest challenge for patients is to stay here with their family. Think of the cost of staying in Mumbai, the loss of income for the family… So our main aim was to provide the same level of care close to their homes.

The Ken: In seven years, how far have you come? 

The network has grown phenomenally. From the 14 centres which participated in our first meeting in August 2012, when 29 regional centres were invited, when there was a lot of scepticism, it has grown to 177 centres. These centres see 700,000 new cancer patients every year, almost 60% of India’s total cancer cases. 

The Ken: That’s volume. But what about quality and impact on clinical practice? 

NCG has grown in size and scope. From the single mandate of quality care, it grew to improving the quality of human resources. We have stringent rules in this country which determine which centres can train medical people and which cannot. This means several centres which can train are not training because of these rules. We wanted to break these silos and get any centre capable of training to train. If not in a formal way, then at least in an informal way—by task sharing and task shifting, where the time of the oncologist, a rare expertise in India, is better used. 

We run so many quality [testing/assurance] programmes for pathologists and physicians. For instance, somebody from the North-East (NE) said they were finding it difficult to attend medical conferences in big cities—traveling from Naharlagun (in Arunachal Pradesh) to Chennai is a two-day affair. We created continuing medical education (CME) programmes and ran them across 11 cities in 26 days, covering the entire NE. This kind of a model doesn’t exist anywhere. 

Quality control in cancer pathology is critical. TMH follows the College of American Pathology (CAP) guidelines, but at NCG we have created a leaner version of CAP and put it online. It’s offered free of cost to any centre voluntarily wanting to upgrade. Today, 100 centres avail this quality certification. They think getting an NCG stamp is important. Now the National Accreditation Board for Testing and Calibration Laboratories (NABL) has started suggesting to centres that they go through NCG’s quality control of pathology.

Then there’s research, which is uncommon in India. TMH is the largest cancer centre in the country, and hence it can do all kinds of research by itself that other places can’t. It’s a very inefficient way of doing research. If you are doing a 1,000-patient study, it takes 7-8 years to do it. By the end of it, and when the outcome is analysed, we realise that the original question may or may not be relevant. We need to be quicker, more efficient; we need to know if this research, which works in TMH, will work in Silchar or Guwahati or Kanyakumari. 

The Ken: Can NCG drive the cost down? Magical cell therapies like CAR-T are available, which cost anywhere from $500,000 to $850,000. Will India have to wait a decade or more for such treatments?

CAR-T is not sustainable, even in the US. In fact, it’s at the tipping point. They are at 18.5% of GDP expenditure on healthcare. If they reach 20%, the bubble will burst. 

We are looking at it in two to three different ways. First, educate people and physicians about the value of care. This doesn’t come intuitively to either patients or physicians. If you ask an individual ‘what is the cost of your life?’, the person will say, the earth. The reality of life is money is finite. Public health budget is earmarked for it. While I agree that India’s health expenditure must go up, what we can do now is make sure that the 1.5% of GDP that is spent on public health is spent well. Unfortunately, that’s not happening now. It’s mostly because of the market hype. When you have blockbuster drugs, advocates of that disease want that drug to be paid for in all cases, regardless of patients’ ability to pay. 

I am all for universal health coverage. But do we know that money is spent well, based on value? Let’s assume there are drugs which improve survival by two months, but cost Rs 10 lakh ($14,286). What is happening today is that with this Rs 10 lakh expense, somebody with a perfectly curable condition is not getting those funds. We need to make value judgments. It’s not easy. You could effectively be saying you can’t fund two months of someone’s life. 

I’ve been on panels where government officials have said they did not know most of the cheques they have signed are for treatment of patients in their final months.

Which is why our revised guidelines are stratified. 1) Optional care: You can have state-of-the-art care. If the richest man wants to spend $1 million for two days, so be it. It’s his life. He can get that. 2) Optimal care: Where we bring value into the equation—what is the quality of value adjusted as years of life saved versus the cost one pays. If Rs 10 lakh improves survival by two months, say no; if it saves 10 years, say yes. This may seem like rationing, but this is the rational way of rationing. Better than what we have today where the first 50 people get the treatment and the remaining 950 are deprived because the money has run out. 

The Ken: Is there a life before and after NCG, for patients and for doctors? 

There are some areas where we can see the impact. We are nowhere close to conquering the cancer problem in the country, but I can say that serious inroads have been made. We are very conscious of the fact that we need early surrogates of success. We started with a flat way of how the system would operate. We didn’t say these are 1-6 things that need to be done and let’s start with #1. In the past, most collaborations in India have been top-down and prescriptive. One of the reasons NCG has worked is because every centre feels it is contributing.

Mind you, TMH is not driving it. To say that would be undermining the effort of many, many people. NCG is extremely democratic. Most ideas have come from member centres. For instance, guidelines for treatment is not a new idea; we have set these in the past. Typically, they are formed by getting a group of experts from elite cancer institutes, who look at the guidelines from abroad and select a bunch based on evidence. We [at NCG] are not trashing that effort, it’s systematically done. But they are extremely cumbersome for physicians to follow. Some guidelines for a single cancer, like colorectal, run into 70 pages. The moment you have 70 pages, no chance a busy physician would even turn the pages. So we made it very concise—two pages, and in an algorithmic format.

The Ken: You mean input-based?

Yes, all that the clinician needs to do is to fill the specific figures/report outcomes in the matrix and the algorithm comes up with a treatment recommendation. For instance, if your patient has early breast cancer, then what’s the size of the tumour, has it spread to lymph nodes or any other part of the body, what is the biopsy report, etc. You fill in the data and the guidelines will tell if surgery has to be followed by radiation or chemo and so on. The same information is available in 72 pages otherwise.

An important part of this method is that the moment you get new evidence, you revise your guidelines. Our first set of guidelines came in 2017; a revision is underway as we speak.  

The Ken: Talk about one instance of data-based treatment driving this revision. 

Take the breast cancer drug, Herceptin. [Sold in India by Roche (the innovator), Mylan and Biocon; costs upwards of Rs 10 lakh ($14,286) for a full cycle.] It’s a breakthrough drug. We did a survey in 2008 at TMH where we looked at what proportion of women eligible to get the drug actually get it. It was 8%. Half of those got the drug because they were part of the clinical trial. Effectively, only 4% could afford to take the drug. This is true in most cancers based on western guidelines. 

We looked at data afresh. A study shows that instead of a year, if you give Herceptin for nine weeks, it is almost as effective as giving it for a year and at a fraction of the cost. We put this in the guidelines and now we repeated the survey, 10 years after the first survey. Now, 50% of women who need this drug are getting it, up from 4%. Of course, we were supported by philanthropic money, but still. We cannot allow ‘perfect’ to become the enemy of ‘good’. This practice is now being adopted in several other low-income countries, including several in Africa. 

The Ken: Have you been able to reduce migration? 

A lot of patients travel for the second opinion. Even coming from a capital city like Bhubaneswar in Orissa to Mumbai—to see the doctor, do the tests, come back to the oncologist and go back home—is an ordeal. We created an online second opinion platform in partnership with Navya Networks. Any patient, either from India or anywhere in the world, can take a photo of their reports and upload. We have given them, at the backend, a set of minimum requirements, what reports to collate in a structured manner for each cancer. For example, if it’s lung cancer, then we need a chest X-ray, a biopsy, a CT scan; and if there are other symptoms, then an MRI or a PET scan.

Entire scans can be uploaded. This is then structured and sent to experts at NCG. I get formal and informal reports seeking second opinion. But to look at 75 pages of a report over email isn’t possible. But if it comes in a structured format, it takes just 3-4 minutes to give my opinion. This platform has machine learning technology at the backend which continually improves it. It already comes up with 2-3 suggestions, which takes into account evidence elsewhere in the literature. In many cases, this is all that the patient requires. If the second opinion is different from the local doctor’s prescription, she can share it with the local doctor. 

We were doubtful about how confident the patient will be in showing this virtual opinion to their local doctor. So we ran a survey on 1,000 patients and 78% had shared it with their local oncologist; more than 75% went for the second opinion treatment. 

This system was meant for patients in India, but the internet has spread it. Now, 80% patients are from India, 20% from overseas. People in close to 48 countries have availed this virtual second opinion service. It costs about $100. Poorest patients get it free. Doctors here get zero fee, they do it pro bono. 

We haven’t marketed ourselves well. We curate the experts carefully. We could handle much more but we don’t want to make it a commercial product. It’s spreading by word of mouth.

The Ken: Is the rising tide lifting other boats?

It is. And in many subtle ways, too. Earlier, smaller centres faced the problem of not getting a multi-disciplinary approach. It’s non-trivial in cancer. Even in developed countries, if you go with a problem to a surgeon, he’ll suggest surgery; if you go to a radiation oncologist, he’ll suggest radiation; if you go to a medical oncologist, he’ll suggest chemo. There’s a really nice study in prostate cancer in the US which proves this. Getting all specialists in the same room is important to arrive at a rational decision. Very few cancer centres in India have this kind of expertise or system. This is increasing but not as high as it should be. 

At NCG, we have created a virtual consultation service. In the last 30 months, for over five hours, three times a week, multiple centres log in and discuss cases disease-wise. Some 25-30 centres and 100-120 oncologists log in every time and complex cases are discussed. When we started the virtual tumour board, we wondered why simple cases are coming up. Now the cases discussed are so complex it’s safe to assume the local centres are addressing simple ones themselves. 

The Ken: You recently signed an MoU with Ayushman Bharat (AB). What for? 

Ayushman Bharat can truly be a game changer in cancer care. We want to give roadmaps to governments for optimal care. Under AB, we are partnering with the government to rationalise the packages because the tariffs in many cases are irrational and it would make no sense for any hospital to participate. We are also introducing evidence-based packages. AB was launched in a hurry [last year] and several things were missing. 

We are linking pre-authorisations [of hospitals] or reimbursements to the NCG guidelines. Earlier, there was no regulatory mechanism to find if any guidelines were followed. If any hospital wants pre-authorisation, our software gives recommendations. If the hospital treatment follows the guidelines, it’ll automatically pre-authorise. No human intervention is required. This will cover 70-80% of the situations. In the remaining 20-30%, if doctors disagree with the NCG recommendations and provide a rationale, then that goes to an anonymised expert in the NCG. If approved, then that case also gets pre-authorised. Considering that AB covers 40% of India’s population, and 30% of AB’s reimbursements so far have been cancer-related, NCG can extensively aid cancer care in this country. 

This should be a model for anyone else to follow. How can a cardiologist take a decision for stenting without getting an opinion from a surgeon. Or vice versa. Unless this kind of dialogue happens, patients will continue to get suboptimal care.  

The Ken: So the NCG takes care of 60% of patients who come via its centres. Can the remaining 40% who go to private hospitals or doctors benefit from NCG in any way? Moreover, the private sector is pretty unregulated, to each their own. 

It’s a difficult question. We need to look at it in two ways. There’s growing mistrust between providers and people. On private providers’ part, there’s reluctance to be regulated. And to be transparent about themselves. Take electronic medical records (EMRs). Most centres have adopted EMR, but it is merely a way for them to keep a record. The patient doesn’t benefit in any way. When we introduced EMRs at TMH 10 years ago, we ensured the system permits patients to access their complete records from anywhere in the world through a user ID and password. They get unrestricted access to all their records. Even in the US, patients get only partial access.

We encourage our doctors to share outcomes, long-term survival, short-term survival, and compare. It may not be useful for the uneducated patients, but this is available. This kind of transparency is lacking in the private sector. At some point, some kind of regulation is required. No healthcare system can work well without regulation. 

I believe at least 40% of the population getting the right treatment is a form of regulation. If I were the insurance provider, I’d be sold on the idea that patients get treatment under this. Why wouldn’t they? It saves money, both for the patient and the insurance provider. 

Ten years ago when TMH had paper records, 30% of them were lost. In fire, floods or stolen in train. EMR saves you. It must be accessible

Dr CS Pramesh, Director, TMH

The Ken: There are rumours that AB’s scope could be expanded beyond the 40% population it is now meant for.  

Even I hear that rumour. That’s how taxes in Canada and Australia work, and everyone gets the best college, healthcare and what not. 

You don’t want AB to be seen as a poor man’s policy. You want it to be a policy that is the best. It’s great that it starts with the poorest, but it should not stop there. Then it begins to be associated with low-quality, low-value care. Instead, it should be high-quality, high-value service at low cost. 

The Ken: With the volumes at NCG, are you able to leverage it for a national cancer drug pricing negotiation?

It’s already happening. About six months ago, we began collating demand for drugs from cancer centres. As we speak, the request for proposal and tender processes are being discussed. But you have to be very transparent in your processes because these are big sums of money we are talking about. We follow government norms—right from the choice of government-approved e-tendering vendors and other best practices.

We’ve collated demand, but not all centres are participating because the current government rules do not allow centres to negotiate as a group. (A hospital like AIIMS in Delhi cannot procure at rates that TMH has got for itself. Instead, it must float independent tenders.) This news reached the deputy CEO of AB. The government is drafting an advisory that will go to all central and state health agencies stating that if they are unable to procure at lower rates, they are free to procure at NCG rates.

Some change has already begun. The Punjab government asked us to share our procurement tender—our costs are low because of our volume. Punjab is procuring at our price, without floating a tender. But this is an exception, rather than the rule. 

The Ken: What kind of price reductions are we talking here? 

We studied six different states’ procurement to see what the variation was. It was anywhere from 5% to 60%. That’s substantial. We are also conscious of the fact that some states are procuring at rates lower than TMH, which is surprising because owing to sheer volume, we get the lowest rates. [Maybe quality is suspect.] We’d have be assured of best practices. TMH doesn’t buy off the shelf. We have a set of 17 criteria, which are surrogate markers of quality. 

The Ken: Many pharma multinationals in India are downsizing. Do we run a risk, as a country, of missing out on new drugs? All said and done, many of them work wonderfully. 

Why are costs high in India? Look at the price at the company’s point of sale and then you add the multiple levels of margins by distributors and retailers or hospitals. The markup is huge, often many times more than the actual price. The moment you eliminate that and factor in the volumes, India becomes a huge market. Even if cancer incidence is low, we see around 1.5 million patients every year. Just work those numbers out. In Herceptin, moving from 4% to 50%, they made profits. It’s the Walmart model. MNCs would be foolish to move out of India. 

The Ken: How about the really high-value, high-cost drugs? 

For high-value ones, we should work out ways. CAR-T is a good example. But at half a million dollars, which will fund a full cancer centre in India for a year, you are saving one patient. We should be asking how can we reduce the cost. You can develop your own CAR-T cells.

The Ken: But that’s proprietary technology. Plus, no Indian pharma company is interested in next-gen biologics. Who will produce it in India?

There are many ways to skin the cat [and not use Novartis’ proprietary tech]. Several academic centres in the US are doing it, and there’s no reason why we can’t. We are coming up with a CAR-T therapy centre at TMH, which is outside of pharma. We are building a GMP [good manufacturing practices] facility. It shouldn’t cost that much. Less than a tenth of the cost of CAR-T. 

The Ken: What is your baseline? Can you say this is how the average survival rate in XYZ cancer has improved? 

That’s something that has tormented us for a very long time. Even when we started we wanted some baseline to evaluate ourselves. The hardest endpoint is mortality or survival, but unfortunately, getting that kind of data is the toughest nut to crack. We wanted to start with getting the IT linkage. But two-thirds of these centres have no EMRs, at the remaining third, EMRs don’t talk to each other. Now, we are partnering with iSpirt (a think tank for the Indian software products industry) to sort this problem. Using speech-to-text and a few other technologies, we are running a pilot between four centres to see how we can capture and use the best patient data. 

So, we are forced to look at other surrogates, like how many people have we been able to train, how do people continue with research after our six-day boot camp, etc. But if you are asking for the big picture, how have we impacted the mortality of cancer patients, we are at least a decade away. That kind of data doesn’t exist. 

The Ken: Could NCG, at some point, become the audit bureau for private hospitals’ cancer centres? 

It most certainly could. It should. But from the NCG’s point of view, we’d like to make it voluntary. Restrictions and rules keep centres away for real and unreal reasons. 

If you have an NCG-approved process, that entitles you to 15% extra of AB tariff, that is an incentive. That’s how NABH (National Accreditation Board for Hospitals & Healthcare Providers) has done it—if you are accredited, your reimbursement from the government will be 15% higher. 

Leave a Comment