VIMS Journal: December 2016

Medical Audit

Changing Trends in Services Marketing of Cataract Surgery : ASeven Years Retrospective Study in A Kolkata Based Eye Hospital

Dr. Bhaskar Mukherjee, Dr. Malini Majumdar

Keywords :
Services Marketing-Cataract Surgery-KolkataEye Hospital-RSBY-Vision 2020.

Abstract :
A seven year retrospective study was conductedat a Kolkata based trust eye hospital. Recordswere drived from HIS from 2008 to 2015, all theother P's of Services Marketing were constantexcept Product (P1), Price (P3), and Promotion(P4). Paradigm shift of P1 was observed fromECCE with sutures IOL microsurgery to Phacowith foldable IOL surgery. Price (P3) range ofcataract surgery changed from 3500-15000/- in2008 to 9500-40000/- in 2015. State of art highpriced top of the order foreign phaco machinewas promoted (P4) in 2011-2012 which lead toincrease of Phaco surgery from 40.1% to 81.2%.Statistics showed changes in P1, P3, P4 and otherexternal factors directly influenced yearly OPDand Surgery turnover. Introduction andempanelment of RSBY directly affected yearlycamp registration and surgery. However, moreenrollment of RSBY patients will help to achievethe target of Vision 2020 formulated by WHO.

Introduction :
A seven year retrospective study was carried outat Dr. Nihar Munsi Eye Foundation (NMEF),1/3 Dover Place, Kolkata-19. This is a trusthospital registered u/s 12A of Indian Income Taxact & empanelled by CGHS, BSNL, ESI, WBHS,RSBY, all mediclaim TPA’S and otherbeneficiaries. This hospital was started on28/1/1993 as a specialized Eye treatment center.It also has a community ophthalmology wingfor conducting camp operations at the basehospital after screening patients for the poorpopulation.

Service : A service is any act or performancethat one party can offer to another that isessentially intangible and does not result in theownership of anything. Its production may ormay not be to a physical product [1] .
Services Marketing : Services marketing isdefined by the American Marketing Associationas the process of planning and executing theconception, pricing, promotion and distributionof services to create exchanges that satisfyindividual and organizational goals [ 2 ] .Economic statistics attribute at least two thirdsof the global economy to services sector [3].

Service Products : Service products consists of :-
a) A core product that responds to the customersneed.
b) A array of supplementary servicing elementsthat are mutually reinforcing value addedenhancements that help customers to use thecore product more effectively. [4]

The Service Marketing Mix [5]
The 7P's mix of services marketing are:-
- P1-Product
- P2-Place
- P3-Price
- P4-Promotion
- P5-People
- P6-Physical Evidence
- P7-Process

The health care services marketing processconsists of analyzing the health care marketingopportunities, researching and selecting targetmarkets, designing health care marketingprogrammes, organizing, implementing andcontrolling the market efforts.

Among all the non communicable diseasesleading to decrease of manpower of a nation andDALY (Disability adjusted Life Year), blindnessdue to cataract is one of the important disease.Ninety percent of blindness is avoidable. Cataractcan be cured by inexpensive surgery [6] .

Cataract Operation and Intra ocular lensimplantation (IOL) is also a profitable businessin Ophthalmology. India performed estimated0.5 million Cataract surgery in 1981-82. Thisincreased to 4.8 million in 2006 with 90% IOLacceptance [7] .

About 3.1 % of death worldwide are directly orindirectly due to cataract and other eye diseases.In India, the economic burden of blindness wasestimated in 1997 to be about 4.4 billion dollarsannually [8] .

AIM: To study any changing trends in servicesmarketing of cataract surgery at NMEF.

Objective:
1) To analyze the effect of change in three P's(Product-P1, Price- P3 and Promotion- P4) on year wise registration and number of surgeriesperformed at NMEF.
2) To analyze the causes of year wise changingtrends in registration and cataract surgery(P1).

Methodology :
Year wise statistics is calculated based on thefinancial year i.e 1st April to next years 31stMarch.
All data were derived from VB (Visual Basic)and saved in SQL (Structured query language)in NMEF-HIS (Hospital information system).Previous datas beyond 2008-2009 were not takeninto account as there was not much variation in7P's of Cataract Surgery services marketing atNMEF.
Cataract Surgery (Product-P1) with IOLimplantation can be performed in four ways.
1) ECCE-Extra capsular cataract surgery withsutures.
2) SICS-Small incision cataract surgery(manual phaco).
3) Phacoemulsification Surgery.
4) Femtosecond Laser Cataract Surgery.
Since NMEF is a charitable trust hospital,implementation of Femtosecond laser unit forcataract surgery is financially non sustainablehere as the investment cost is about 2 crores.

Results : Table:1-OPD Registration

Year NMEF case Camp case
2008-2009 6935 281
2009-2010 7275 276
2010-2011 7785 253
2011-2012 7954 231
2012-2013 7957 214
2013-2014 7607 201
2014-2015 7449 151


Table : 2 - Year wise cataract surgeries (P1)

Year NMEF case Camp case Total
2008-2009 1212 257 1469
2009-2010 1532 267 1799
2010-2011 1776 226 2002
2011-2012 1960 212 2172
2012-2013 2000 201 2201
2013-2014 1860 189 2049
2014-2015 1865 142 2007


Table : 3 - Different Procedures of Cataract Surgery (P1)

Year ECCE SICS PHACO PHACO% TOTAL SURGERY
2008-2009 822 401 246 16.7 1469
2009-2010 611 623 565 31.4 1799
2010-2011 416 782 804 40.1 2002
2011-2012 110 300 1762 81.2 2217
2012-2013 91 301 1809 82.1 2201
2013-2014 05 262 1782 86.9 2049
2014-2015 00 145 1862 92.7 2007


Table:4-Year Wise Surgery Price Range (Rs)/ NMEF Case (P3)

Year Price Range(Rs) /Cataract Surgery
2008-2009 3500-15000
2009-2010 4000-18000
2010-2011 5000-20000
2011-2012 7000-25000
2012-2013 8000-30000
2013-2014 9000-35000
2014-2015 9500-40000

Discussion:
The following changes in services marketing ofNMEF were noticed from the results.
1) The number of OPD registration for NMEFcases was on the rise from 2008-09 till 2013-14. However there has been decrease inregistration in the year 2014-15 (Table 1). Thisis probably because two big eye care providerhospitals namely Vasan Eye Care and Disha EyeCare hospital was established during this periodwithin 5kms distance from NMEF, which hasdrawn its patients.

2) OPD registration of camp cases has beendecreased over the year (Table 1). This is becausecamp service for poor people was marketed byvarious NGO'S tying up with NMEF. With theintroduction of RSBY (Rastriya Swastha BimaYojana) (9)-literally 'National Health InsuranceProgramme' in April 2008 and implemented in25 states in India, camp cases are gettingconverted into RSBY beneficiary cases. A totalof 36 million families have been enrolled as ofFebruary 2008. Every below poverty line (BPL)family holding a yellow ration card pays Rs. 30as registration fee to get a biometric enabledand marked card containing their finger printand photos. This enables them to receive inpatient medical care of upto 30000/perfamily/year in any empanelled hospital (NMEFis empanelled).

3) Number of surgeries of NMEF case havealso decreased in 2013-14 and 2014-15 comparedto 2012-13 (Table2). This is probably for twobig eye care hospitals as mentioned above. Likewise decrease of Camp surgeries is not an exactfigure as many of these cases got treatment asRSBY beneficiary.

4) Phaco Surgery has various advantages over conventional cataract surgery. It producespredictable results, improved success rate, betterrehabilitation, early ambulation of the patientwith minimal post operative glass power. Dueto advancement of training of Eye surgeons, peerpressure, introduction of Phaco fellowships byvarious institutions (sponsored by Govt./Privatehospitals/Pharma & IOL industry) surgeons havegradually shifted to Phaco surgery, although ithas a long learning curve. However, since Phacois a costly procedure & time consuming, SICSis preferred for bulk camp surgery as it is lesstime consuming and does not need costlyinstruments. All the cataract surgeries for campcase at NMEF were either ECCE or SICS in lateryears. Table (3) shows a sudden jump of Phacosurgery in 2011-12 than previous years. This isbecause from 2008-2011, low cost entry pointfirst generation Indian Phaco machine were used.Also the surgeons were in their respective learningcurve of Phaco surgery. In 2011, state of art topthe order foreign phaco machine was introducedwith high safety margin. So there was a changein Promotion of Services Marketing in CataractSurgery at NMEF (P4). Introduction of thisforeign Phaco Machine was well advertised inprint/electronic media by NMEF. By this time,the surgeons had also became prolific in theirart. So gradually there was a rise in Phaco surgeryrate. ECCE was almost discarded and SICS wasperformed in non phacoable cases, camp casesand those who can't afford Phaco surgery. Thisidentifies a changing trend in Product (P1), inservices marketing of cataract surgery at NMEF.

5) Table (4) shows a increase of Price rate (P3).This is because installation and maintanence ofa Phaco unit is costly. Phaco machines rangesfrom 6 lakhs to 55 lakhs and many of itsfunctional components are disposable. Also due to increase in number of surgeries and machineoperated by various surgeons with differenthandling techniques, depreciation value of Phacomachine is high.

Conclusion :
This seven years retrospective study showschanging trends in Cataract surgery servicesmarketing including paradigm shift in Product(P1), Price (P3), Promotion (P4) and other factorsinfluencing total OPD yearly registration andyearly cataract surgery turnover. Vision 2020 isthe global initiative for the elimination ofavoidable blindness, a joint programme of theWorld Health Organisation (WHO) and theInternational Agency for the Prevention OfBlindness (IAPB) with the Internationalmembership of NGO'S, Professionalassociations, eye care institutions andgovernment of different countries. This waslaunched in Feb 1999 (10). The NationalProgramme have the main elements:-
- Cost effective disease control
- Human Resource Development
- Infrastructure and Technology
The main elements a Government needs toemphasis is:-
- Comprehensive eye care services
- Eye treatment integrated with health system
- Access for everyone
In today's socioeconomic condition, an eyehospital has to increase its fees/rates in order tomake the institution financially sustainable.However by emphasizing more on RSBY andCamp cases, objectives of Vision 2020 can beachieved, in order to eradicate cataract inducedblindness in our society.

Abbreviation List :
1. NMEF - Dr. Nihar Munsi Eye Foundation
2. CGHS - Central Government Health Scheme
3. BSNL - Bharat Sanchar Nigam Limited
4. ESI - Employees State Insurance
5. WBHS - West Bengal Health Scheme
6. RSBY - Rastriya Swastha Bima Yojona
7. TPA - Third Party Assurance
8. DALY- Disability Adjusted Life Year
9. VB - Visual Basic
10. SQL - Structured Query Language
11. HIS - Hospital Information System
12. ECCE - Extra Capsular Cataract Surgery
13. SICS - Small Incision Cataract Surgery
14. OPD - Out Patient Department
15. WHO - World Health Organisation
16. IAPB - International Agency for The Prevention of Blindness

References
  1. Kotler P, Marketing Management, New Jersey; Printice-Hall, 2000:428.

  2. Rao Nageswara Dr. S. B. Marketing (Course-vi)Annamalainagar, Annamalai University; 2012:10.

  3. Iacobucci Dawn. Kellog On Marketing, New York;John Wiley & Sons, Inc, 2009:321.

  4. Lovelock C etal, Services Marketing, New Delhi;Pearson Education, Inc, 2011:22.

  5. Baines P etal, Marketing, New Delhi; Oxford UniversityPres. 2013:471.

  6. Park K, Park's Textbook of Preventive and SocialMedicine, Jabalpur; M/S Banarsidas Bhanot, 2009:350.

  7. Arvind S etal, Cataract Surgery & Intraocular lensmanufacturing in India. Curr Opin Ophthalmol, 200819(1):60-5.

  8. Dandona R etal, Socioeconomic Status and Blindness.British J of Ophthalmol. 2001; 85:1484-88.

  9. Rastriya Swastha Bima Yojana, 2015. Available from:https://en.wikipedia.org/wiki/Rastriya_Swastha_Bima_Yojana

  10. Vision 2020 The Right to Sight, 2014. Available from:http://www.iapb/advocacy/who-action-plan

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