Explained: Why COVID-19 Patients Are Travelling To Satellite Cities For Treatment

The scarcity of ICU and oxygen beds in major cities during the pandemic has led to an increase in people travelling to satellite cities to secure life-saving services.

The scarcity of ICU and oxygen beds in major cities during the pandemic has led to an increase in people travelling to satellite cities to secure life-saving services.

With many states and cities experiencing a shortage of beds and oxygen supply, patients have been forced to travel hundreds of kilometres to satellite cities in the hope of being treated in major hospitals, according to Prabhdeep Singh, Co-founder and CEO of StanPlus Ambulance Service.

"Patients who were sitting in Delhi with quaternary care are actually rushing into Panipat, into AIIMS Jhajjar, into Ambala, then as far as Patiala and Amritsar in search for a bed. And now what we are seeing this again after 10 days when the situation, let's say it doesn't improve in a hospital and people end up finding an ICU bed, then they need to come back to the major city, right?" Singh told BOOM.

However, this has also led to valuable resources being diverted added Singh. "If I am taking a patient from Delhi outside, then I am reducing one asset from ground that could have helped patients in short distance, emergency transport. Today from a long-distance point of view, we have gone from 12 to 15% to almost 26 to 30%. So, it has almost doubled in terms of long-distance requirement."

Edited excerpts of the interview follow

Govindraj Ethiraj: What made you get into this because I know that you were you were working in Life Sciences and you transitioned out of that business into ambulances?

Prabhdeep Singh: There were predominantly two reasons. One was when I was living abroad, I always felt helpless. Whenever my parents or relatives, or anyone, would ask for help, turns out, it is really difficult to get an ambulance in the country.

I think a lot of Indians that are now abroad are facing this, you know, the cries of help from abroad are plenty, but the helplessness of not having an ambulance. According to some data, it takes about 45 minutes for an ambulance to arrive. In the country, 14% of the Indians, get an ambulance when they need one. It's down to 5% with the pandemic and on top of it, two out of three ambulances, do not actually qualify as per the working condition defined by the National Ambulance Code.

So, one of the reasons was the general helplessness that I as a family member felt when I was abroad and second was, I believe that my background and with the large market opportunity, we could actually build a large Healthcare firm that is able to deliver to a billion Indians the medical response that they deserve today.

GE: So, I think the word medical response is appropriate when you are covering a much larger spot than just running an ambulance service. So, tell us about your day, a normal day right now, what happens? What's the kind of load that you are seeing? How is it spread out during the day and also across the country?

PS: So, we are essentially a B2B company. What this means is that, while we have customers calling us direct, our larger contracts are with some of the biggest hospitals in the country. So, large hospitals in Hyderabad, in Bangalore, in Raipur, in Bhubaneshwar, they outsource their ambulances to us.

So, some of the problems that hospitals face is that hospitals answer about 30% of their emergency calls and even if you try calling into a hospital today, the chances are very unlikely that they will pick up your call. So, this was a problem that a lot of hospitals used to face pre-pandemic as well because Indian hospitals are good at treating patients, they are not good at running a call centre of their own.

So, what we do is we answer emergency calls on behalf of large hospitals and then from running one or two ambulances that a hospital, you know, often finds insufficient, what they now do is they work a completely on-demand system with us. So, there is about 300-350 ambulances in Hyderabad, 300-350 in Bangalore.

So, a hospital rather than having just two ambulances previously, now actually has our entire network available. So, in Hyderabad, if a hospital is in Jubilee Hills, but a call is coming, let's say from outskirts, previously had to send the ambulance all the way, but now we are able to identify the nearest ambulance, pick up the patient in under 15 minutes. So, this is this is the magic that we have done at hospitals.

More and more hospitals are now asking us to come in, bring our hardware, our software and our care ware. So, a large Hospital in Bangalore like Sakra, for example, today the pilots are on a payroll, the emergency technicians are on a payroll. The ambulances are driven by us and we provide our entire network. So, what they've seen is a 2x to 3x increase in their total inbounds that happen and also patient satisfaction scores have gone up.

So, this is on the hospital side but we also work with some of the largest companies in the country. So, the largest Cola Company in the country, the largest retailer in the company, the largest electronics company in the country. Among 50 plus other companies, we run the emergency desk for them.

So, any emergency that happens in that company, they have a dedicated 1-800 line from us, so they call in. So, then what happens is because we have this entire network across hospital integration, we are able to respond faster. So, you know, what is happening with pandemic is that I am today activating five large company contracts in a day. So, we are running full steam.

I wake up every day to managing VIP cases, air ambulance cases or getting a Fortune 500, India's top 50 company on-boarded to our platform. We have seen 10x demand in April as compared to March and we're expecting the demand to double now from here on every month.

So, that is where the journey is and we are also expanding geographies. We are adding new assets every day. So, there is a lot of speed at which we are operating. Our ambulance brand is called Red Ambulance and we would like Red Ambulance to be the largest brand of ambulances in Southeast Asia in the next five years.

GE: Where are you seeing the maximum demand in your network at this point of time?

PS: Wherever we are operating, we are overwhelmed, but at the same time from Corporates, we are seeing Bangalore and Delhi has two main choke points and it is predominantly for two reasons.

A lot of corporates do have Head Offices in these cities and the same time it is difficult for employees themselves to secure bed or an ambulance today, whereas, through our system because we work as super aggregators, we also have our own system operating. We find it much simpler to get help across to the employee. At the same time, through hospital systems, we faced immense requests coming in from cities like Raipur, Coimbatore, Vishakhapatnam, cities in Pune, Indore.

The reason is quite simple because many of these cities have a lot of feeder population that goes into large clustered Health Care markets, like Hyderabad, Chennai, or Mumbai. So, a lot of patients are looking to get transported into these cities. So, from an ambulance point of view, we are seeing a lot of long-distance demand coming in today.

GE: On social media, we see people asking for ambulances and then of course, asking for beds and oxygen. How are you able to help or not help or are your services confined to only those people who are your large institutional clients?

PS: Anyone can reach out to us. We have 1800 number, 1800 121 911 911. So, anyone can reach out to us, but we create dedicated numbers for hospitals and for large enterprises.

So, if your company has given you an 1800 number to dial in case of emergency, there's very high likelihood that StanPlus at the back end is managing that case. So, this is, this is how we operate. General individual, anyone in the country is able to reach out to a helpline, get the same quality of help that we deliver to large companies or large hospitals.

GE: Are you saying, for example, in Delhi, are you able to respond to most cases? What is the kind of time that you are taking? Are you able to hold oxygen in your ambulances for those who are being transported with the need for oxygen?

PS: Delhi is a particularly tough market, because a lot of oxygen off late has been channelled and rightfully so, to hospitals. There is a way to source oxygen for ambulances, but it is not easy. Cylinders are now being used, increasingly at home, in makeshift facilities, in places like Car Langar, which is absolutely right but we as ambulance operators, are finding it tough to source oxygen cylinders.

I believe that is a problem for the next 25 or 30 days and that situation will resolve. To answer your question, it is difficult to service and mean the SLAs that we are famous for. We need, in Hyderabad a 15-minute time frame, in Bangalore a 20-minute time frame. That is certainly not being met in cities like Delhi today.

However, we are confident that as the oxygen situation improves, we are also going to put our own Red Ambulance assets in Delhi, and that will reduce the time for the NCR region to under 20 minutes as we have done in each city that we operate in.

GE: Let us assume you have the oxygen or whether you have it or not, the patient has to be delivered to a hospital. Now, the hospitals themselves are for full. So, how are you linking backwards and how do patients know when the ambulance comes and fetches you that you will be taken to a hospital with a bed, or would you, does your system not then fetch them at all?

PS: So, what we have done is for large companies, we have launched a programme called Red Assist. We previously used to have a platform called Red 911 for large companies and this used to be an emergency desk. We have also launched Red Assist to assist people where we have a Doctor Consult available in 3 minutes, we have an ability to actually triage and understand what the situation is.

So, if the patient says that our SPO2 is hovering around 90, the first thing that we are able to do is connect them to an oxygen provider, get oxygen concentrator to their homes so that the patient doesn't require hospitalization in the near future but if they do, then what we work with them is to figure out where are the beds available.

We don't have any secret sauce here. We basically try all the public sources. We dial in to our partners and we work hard in securing a bed. Only if a bed is secured do we then link an ambulance to the person because if a patient boards an ambulance and then is in the ambulance for eight hours looking for a bed, it's far worse than having a person on oxygen at home because we are tripling or quadrupling the anxiety.

We are also then not utilizing that ambulance rightfully, because we need to be able to serve as far more patients than one patient in every eight hours. This is how we do the triaging. If we are able to help at the earliest, get the right advice, get the right prescription, get oxygen delivered to home and then once a bed is secured and if the need is to just have an ambulance come in and quickly transport the patient to the nearby facility.

GE: So, you are also there for helping in non-ambulance, medical support?

PS: The team quickly came together internally to create the Red Assist programme in which we are helping. We are not helping general public as yet because we do not have the lines or the capability to answer so many calls. We are still a small company, but we are able to assist our corporate partner through the Red Assist platform to their employees.

GE: So, what would be the 2-3 key needs or demands at this point of time in your Red Assist programme?

PS: Number one is of course Doctor Consult. People want to speak to a doctor, they do not want to download an app, they do not want to go through the hoops. They want to call and they want to speak to a doctor, and then they want a prescription and then they want medicines to be delivered to them.

While we don't do medicine delivery, there are companies far better than us like 1mg and Pharmeasy to do that. So that's a solved problem if a prescription is there. So once the teleconsultation is quickly done, then it is about arranging oxygen at home and getting access to some oxygen concentrator on rent or purchase.

Then the third request that comes is for an ambulance once the bed is secured. So, this is also the way we triage. This is sequential but of course this is also the funnel. There's a large number of cases that require tele consult and then much lower number that require bed.

As a country, our endeavour should be to reduce the number of people that are in hospitals, so that only the ones that needed the most should be occupying the marginal bed.

GE: You mentioned that a lot of people are travelling longer distances. I mean understandably because the best healthcare is in the big cities. Can you put a number on that, even percentage-wise and how has that changed or impacted maybe the access possibility for other people or any other insights that you have because of this large migration of patients?

PS: A very interesting thing that has happened is that previously we used to do a lot of transport from non-metro cities into metro cities, which is, explainable because a patient that is in a tier three city, I'll give you an example.

Let us say if someone is in Jhansi or someone is in Patiala, would want to come into major healthcare centre for quaternary care and sometimes even for tertiary care. So, we have a lot of patients coming in to Hyderabad, for example, from smaller cities, like, Siddipet, or from Kaman or Kurnool and when we ask the patients why are they doing it, it is because the doctor in their hometowns has recommended that for higher qualified care it is important to go to a large hospital.

So, we would have about 12 to 15% of all the cases that we do, of similar format, long distance, longer than a hundred kilometres. What is very interesting now, what we have seen over the last month in cities, particularly like Delhi is reverse transport.

Patients who were sitting in Delhi with quaternary care are actually rushing into Panipat, into AIIMS Jhajjar, into Ambala, then as far as Patiala and Amritsar in search for a bed. And now what we are seeing this again after 10 days when the situation, let's say it doesn't improve in a hospital and people end up finding an ICU bed, then they need to come back to the major city, right?

So, this is very interesting, it's an aberration to the cause but I believe that it also is not good for the ambulance system at large, because if I am taking a patient from Delhi outside, then I am reducing one asset from ground that could have helped patients in short distance, emergency transport. Today from a long-distance point of view, we have gone from 12 to 15% to almost 26 to 30%. So, it has almost doubled in terms of long-distance requirement.

GE: You said that someone would go from Delhi to Panipat and also, then be brought back?

PS: So that's also important, right, because not everyone goes out looking for an oxygen bed, which was especially happening in the last 10 days in Delhi, but if situation worsens, it is possible that they decide that an ICU in Delhi is better than an ICU in Sonipat or a highway ICU. So, in 10 days if the situation has not improved, they need to come back to Delhi but you can't come back, especially in that setting on a personal vehicle and you need an ambulance.

GE: For many of these people who are travelling out away from big cities, are they finding beds with oxygen in some of the smaller places around?

PS: That is why they are travelling. I am hoping that is why they are travelling. We have seen a few instances where people don't have beds, but they have been given assurance ki le aayiye patient ko (bring the patient), we will see. We find it hard to track the outcome if they got admitted or not because you know, we are a logistics company but I am assuming that people are travelling because they have assurance of some bed.

GE: You said that almost 25 to 26 percent of your total cases that you are handling now, I am assuming almost every day, are long distance transfers?

PS: If we had more assets that number would be much higher, our inquiry to case ratio is actually down in mid 50s, which used to be mid 80s. So that means that we are only able to meet one out of two requirements and that is primarily because the long distance, once an ambulance goes, it goes for 8 to 10 hours.

So, we have a total in NCR, about 800 to 1000 working ambulances and what we are getting were 30,000 plus cases every day. So, that means only one out of ten cases could get an ambulance, but if a case goes out for 8 hours, 10 hours, then the real assets on ground actually decreases.

GE: At this point of time what is the kind of policy support that you would need? What would make your life simpler and assuming it makes your life simpler, it makes life simpler for those who desperately want to access urgent medical care?

PS: I believe that one thing that we have requested the Government repeatedly is to reduce the GST on ambulances, even if for a short time. The GST is 28% and I believe that is unsustainable because if I am buying an ambulance for 30 lakhs, I am paying almost 9 lakhs on GST and considering that I cannot charge my patients GST, that is not an input credit, it is just expense for us and if you are able to reduce that, so instead of three ambulances, I am able to buy five ambulances and the country needs more ambulances and the country also needs larger players like us to exist because we are able to operate at scale, we are able to answer the calls at scale and also we have transparent pricing.

That brings me to my second point. I believe that in a couple of cities because of a few unqualified operators, the Government has lashed out very hard and done price controls but it has been counterproductive because most people then have chosen to sit at home because operating an ambulance is not easy.

Someone is putting their life at risk to transport a patient. So, we need to have the risk, money is on the table. So, the Government starts getting into price control, it becomes economically unviable for players. So, my request to the Government is that let the free market play its role, and have insurances step in.

Currently, insurances do not pay for ambulances, they only pay for up to 2500, but rather than doing price controls, the Government should encourage the IRDA to bring ambulances under the insurance fold that will really help in making this market more formal.

What we saw today from the RBI Governor on, you know, having a line of 50,000 crores introduced for Healthcare Capital expenditures. I think that will that will help us quite a bit because we will want to take up that support and put new ambulances was on the ground. The country is crying out loud for new assets and that is what we are going to do with that.

So, reduced GST, do not lash out and put price controls and considering what the RBI Governor today introduced, I think more such SOPs to build capacities will be very welcome.

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