India's Prowess in Healthcare Vs China

For all that has been written about China’s impending aging crisis, few foreign investors and operators are paying equal attention to India’s own demographic problem.  By 2050, China’s 60+ population will have grown from 110 million people today, to over 400 million.  During the same period of time, India’s 60+ population will have grown from 100 million today, to over 300 million.  Given current projections, by 2050 China’s population will have held at roughly its current level of 1.3 billion.  In contrast, by 2050 India’s population will have grown from 1.2 billion today, to 1.6 billion.  While China’s aging industry has garnered most of investor and senior care operators attention thus far, there are compelling reasons to believe that more should be paying equal – if not greater – attention to the market in India.

The first reason India’s aging cohort may deserve more attention than China’s is that the consumer in India may be more amenable to spending on intangible services than their Chinese counterpart.  While this is admittedly a contentious point, it may also be the most important one.  The Indian economy has positioned itself as a service-based economy, in contrast to China’s, which has done a superb job in more tangible manufactured sectors.  The dilemmas of selling services to Chinese companies and consumers are well known, and the subject of much handwringing from the management consultant, financial services and healthcare sectors across China.  To the extent a notable difference between the two countries does exist in this respect, it is certainly possible the gap will close; however, for today, as senior care investors and operators compare the two countries, taking into consideration not only the ability for either set of consumers to pay, but also their willingness to do so, is an important distinction.

The second reason India’s aging cohort is worth paying attention to has to do with the relative prevalence of private, for-profit healthcare institutions in both China and India.  Yes, both countries have for-profit primary care, hospital and specialty care operators; but few would argue that India’s capabilities in the for-profit healthcare arena are more developed than China’s.  Again, this could change given the many reforms China’s Ministry of Health has rolled out over the course of the last three years; however, the general statement that private hospitals and specialty clinics are more trusted by the Indian consumer, and have more viable and scalable commercial models than what exists in China today is another important difference.

The third reason India’s market for senior care services is worth equal attention as China’s has to do with the relative ease, as seen from the point of view of a foreign investor or operator, of doing business in the senior care segment within India versus China.  The best example of this specific to senior care is home healthcare.  Even though China has publicly stated that the central government’s policy on how the country will deal with its aging population prefers home healthcare (the often-referenced “90/7/3” to denote that 90% will receive care via home healthcare, 7% via community care centers, and 3% via nursing homes), neither China’s regulatory or reimbursement scheme supports this message.  In fact, China’s current regulations around home healthcare explicitly draw a line around precisely those sort of clinical interventions that ensure home healthcare is both economically viable to the payer, and clinically valuable to the patient and their family.

Globally, home healthcare has evolved around the idea of extracting a patient who is ill enough to need additional long-term care, but stable enough to not have to be in the hospital.  This typically requires either physician, nurse or trained caregivers in the home who can administer infusions, do basic rehabilitation exercises, provide respiratory therapy, and other moderately invasive procedures, up to and including hospice care.  China’s current regulations explicitly prohibit this unless the home healthcare provider is licensed under what is for all practical intents and purposes, the same licensing standard as a private hospital is held to in China.  India’s regulatory scheme – or perhaps to say this differently – its lack of regulations in this area, means home healthcare providers can emulate the higher acuity care pathways that have proven to be clinically and commercially sustainable in the developed world, a critical difference when thinking about India versus China in this market segment.

It should come as no surprise that India is already seeing a growing number of home healthcare providers expand across the country.  After all, the same sort of problems persist in both India and China relative to families that are geographically separated such that grandparents cannot live with their adult children.  One of the most exciting home healthcare companies in India is Portea Medical, which last week announced a strategic investment by Qualcomm Ventures, the venture investment arm of Qualcomm.  This follows an $8 million USD Series A round of funding completed in December 2013 from Accel Partnersand Ventureast.  Several things distinguish Portea from not only competitors in India, but also other similar home healthcare providers in China.

First, Portea’s home healthcare model has a critical technology component to it.  While the company is protective of its technology platform, Meena Ganesh, Co-Founder and CEO of Portea Medical shared with me that the company uses technology in two ways:  “to improve field force management and to improve health outcomes.  All clinicians carry smart phones which allows our team to track where they are in real time and align the closes clinician to the patient.”  While this may seem like a small operational utilization of technology, in home healthcare where patients, clinicians and caregivers are all deployed across a city, and in a location where traffic congestion can be extremely problematic, Portea’s ability to quickly allocate resources in the most efficient manner goes to the heart of their profitability.  Meena added that beyond this capability, “Portea is in the process of making its clinicians even more tech enabled.  When Portea clinicians visit a patient, they use blue tooth enabled diagnostic tools that capture patient data, upload it via their smart phone to an EMR platform.  This platform then uses predictive analytics to analyze health trends and ‘push’ proactive healthcare interventions if the trends indicate that the patient’s health is deteriorating.”  In addition, the company’s internal mobile app platform has a variety of standard operating procedures caregivers can access, as they need to.

The second reason to watch Portea is that the company has already clearly separated itself from what they call the “fly-by-night operators in the market.”  This has been achieved largely by the scope of services Portea is able to deliver in the home versus competitors.  Their overall workforce is composed of doctors (5% of the total), nurses (30%), physiotherapists (35%), and trained caregivers (30%).  As Portea has expanded – the company currently offers services in 18 cities across India – they have been able to take care of the highest acuity patients, which tends to be those with terminal diseases or a rapidly declining ambulatory or mental capacity.  Across the country, Portea is currently doing over 20,000 home visits a month, with plans to expand to 50 cities in the next two years.

Both China and India have compelling aging problems.  The most important difference between the two may boil down to which country gets out of the way of those healthcare entrepreneurs with a technology-rich care model that is affordable to private paying patients.  Yes, China has a small number of home healthcare entrepreneurs; however, each of these will admit in private that they run a very real regulatory risk in trying to provide more clinically intensive care pathways.  Foreign home healthcare providers that are un-attached to hospitals will likely continue to test drive less healthcare-centric models, if only because of the regulatory limitations in China.  What India has to offer is as large of a market, but one that may be more amenable to private pay and with greater latitudes from a regulatory point of view than what China has to offer.  These are important differences that could enable India’s senior care market to scale much faster and more profitably than China’s, even though India’s need is not as great as its neighbor’s.