Strategic Insights:Heart Valve Replacement Market - India

Contents

Introduction

For blood to go in only one direction, forward, it must pass through the heart valves, which function as one-way doors, opening and shutting with each beat of the heart. Just as there are four chambers to the heart, there are four heart valves. Blood must pass through one of these valves each time it leaves a chamber.
The Four Heart Valves:

  1. Tricuspid: The tricuspid valve is named because it has three leaflets. It is located between the right atrium and right ventricle.
  2. Pulmonary: The pulmonary valve is named because it is located below the pulmonary artery, between the right ventricle and the pulmonary artery.
  3. Mitral: The mitral valve is named because it looks like an upside down bishop's hat or mitre. It is the only heart valve with two leafets; all of the others have three. It is located between the left atrium and left ventricle.
  4. Aortic: The aortic valve is named because it is located below the aorta, between the left ventricle and aorta.

A superior view of the heart showing the four valves. The aortic valve is most commonly replaced.

The two valves located between the atria and ventricles, the tricuspid and mitral valves, are known as atrioventricular valves. The two other valves, the pulmonary and aortic, are sometimes called semilunar valves, because each of those valves has leaflets that are shaped like half-moons.

Sources:Alliance Heart Institute,Drexel.edu

Types of heart valves

When someone has to have a heart valve replaced, there are a few things that are done to determine what type of valve the patient will recieve. The patient could recieve one of the following valves: mechanical valves, tissue valves, homograft valves, or allograft valves. These all have there advantages and disadvantages.

Tissue Valves: A tissue valve is another field of valves that are taken from an animal and put into human hearts. These kinds of valves are chemically treated for safety and are prepared for the human heart (St. Jude Medical, Inc., 2007). Since these valves are weak, they are reinforced with a frame or stent to make them stronger, and to support the valve. The valves that aren?t reinforced are called stentless valves (St. Jude Medical, Inc., 2007). These types of valves aren?t a good choice for younger patients because they wear out quickly. They wear out because they stretch when the demand of blood flow increases (Aortic valve replacement, 2007). Another reason as to why they aren?t used often is because when these valves wear out, the patient will have to under go another operation to get a new valve implanted to replace the previous one. These valves last, on average, 10-15 years in the less active patients such as the elderly, while in the younger and more active patients, they wear out a lot faster (Aortic valve replacement, 2007).

Tissue Valve

Mechanical Valves: Mechanical valves are designed to mimic a real heart valve (St. Jude Medical, Inc., 2007) and to outlast the patient (Aortic valve replacement, 2007). All versions have a ring to support the leaflets (flaps) like a natural valve and has a thin polyester mesh cuff on the circumference of the valve for easier implantation. This is for easier implantation (St. Jude Medical, Inc., 2007). These valves are not controlled electronically but naturally. As the heart beats, the mechanical valve opens and closes (St. Jude Medical, Inc., 2007). These valves have been proven to last several hundred years by being stress-tested (Aortic valve replacement, 2007).

Mechanical Valve

Homograft Valves: The third type of valve is a homograft valve. This a valve that is taken form a human donor (St. Jude Medical, Inc., 2007; Encyclopedia of Medicine, 2006).These donor valves are only given to patients who will deteriorate rapidly because of a narrowing of the passageway between the aorta and that left ventricle (Encyclopedia of Medicine, 2006) This type of valve is better for pregnant women and children (St. Jude Medical, Inc., 2007. Unlike most valves, this type of valve does not require anticoagulation therapy over a long time (long-term) (St. Jude Medical, Inc., 2007).Durability of a homograft is approximately the same as a tissue valves (Aortic valve replacement, 2007).These valves are sometime, but rarely, taking from the patients own pulmonic valve (Encyclopedia of Medicine, 2006).

Homograft Valve

Allograft Valves:The fourth type of valve is an allograft valve. These valves are usually taken from pig's aortic valve (Encyclopedia of Medicine, 2006). They are chemically treated before they are put into a human heart. The life span of one of these valves is about 7-15 years, depending of the patient (Encyclopedia of Medicine, 2006). Because of the short life span of this valve, it is generally given to the older patients (Encyclopedia of Medicine, 2006).

Allograft Valve

Source:odec.ca

Disorders treated by heart valves

  1. Valvular Stenosis:This occurs when a valve opening is smaller than normal due to stiff or fused leaflets. The narrowed opening may make the heart work very hard to pump blood through it. This can lead to heart failure and other symptoms (see below). All four valves can be stenotic (hardened, restricting blood flow); the conditions are called tricuspid stenosis, pulmonic stenosis, mitral stenosis or aortic stenosis.
  2. Valvular Regurgitation:This occurs when a valve does not close tightly. If the valves do not seal, some blood will leak backwards across the valve. As the leak worsens, the heart has to work harder to make up for the leaky valve, and less blood may flow to the rest of the body. Depending on which valve is affected, the conditioned is called tricuspid regurgitation, pulmonary regurgitation, mitral regurgitation or aortic regurgitation.

Source:Medicinenet

Heart valve procedures

Procedure of Heart Valve Surgery

Heart valve surgery means repair or replacement of the diseased valves. In the surgery, some valves are repaired or mended to do its work properly. Replacement means removal of the diseased valves by a new valve. The procedures of heart valve surgery are :

  1. Valve Repairing : In the valve repair surgery, a ring is sewn around the opening of the valve to make tighter. The surgeons may cut the other parts or may separate and shorten it to help the valve open and close right.
  2. Valve Replacement : Sometimes by mending the valves, it is not possible to cure the unhealthy valve, and then replacement is required to get back its normal function. A prosthetic valve is used to replace. There are two types of prosthetic valves.
    1. Mechanical valves : These types of valves are made from man-made materials. While heart surgeons? use this valve, lifetime therapy with an anticoagulant is prescribed to the patient.
    2. Biological (tissue) valves : The surgeons take biological valves from pig, cow or human donors. The longevity of biological valves is less than the mechanical valves.

Source:Indian-medical-center

Procedure Segmentation

Heart valve procedures by technique

Transcatheter Aortic Valve Implantation (TAVI)

Description This technique involves insertion of a miniaturized valve through a catheter from the groin. The deployed valve is later inflated at the site of the aortic valve. The entire procedure is conducted under general anesthesia and takes about an hour. It is a non-surgical procedure. In TAVI inner organs are accessed via needle-puncture of the skin, rather than by using a scalpel.

Procedures in India TAVI is still in nascent trial stage in India. In mid of March, a team of doctors at Delhi's Fortis Hospital headed by Dr Ashok Seth operated three patients using TAVI.

Cost of surgery in India The cost of procedure is 29,350 USD which include the cost of valve 21,500 USD (approx).

Prevalence After the age of 75 years, 5% population is at the risk of developing a problem in their heart valve, out of which 35% are not suitable for surgery. If not treated, 50% of them will not survive for more than two years.

Source:Indiatimes

Ross Procedure

The Ross Procedure is a type of specialized aortic valve surgery where the patient's diseased aortic valve is replaced with his or her own pulmonary valve. The pulmonary valve is then replaced with cryopreserved cadaveric pulmonary valve. In children and young adults, or older particularly active patients, this procedure offers several advantages over traditional aortic valve replacement with manufactured prostheses.
Source:University of Southern California


Current Worldwide Market

Market size

Trends

Sources:MRG Report,Symetis Website

Recent Approvals

Date Company Country Product Approved Source
Apr 2012 St. Jude Medical Japan The new Trifecta aortic stented, pericardial tissue valve has been implanted in procedures atOsaka University Hospital and Saitama Medical University International Medical Center Medcity News
Nov 2011 Edward Lifesciences US The Sapien Transcatheter Heart Valve will provide some people with this condition who can?t undergo open heart surgery with the option of valve replacement Wallstreet Journal
July 2011 Sorin Group Europe Mitroflow Aortic Pericardial Heart Valve Sorin
Jan 2011 Sorin Group Europe Innovative Self-Anchoring Aortic Heart Valve, Perceval? S Sorin
May 2010 CryoLife US Cryovalve SG Pulmonary Human Heart Valve (and Conduit) FDA

Market in India

Strategic Outlook

Level 1

Dolcera Analysis

Level 2

Dolcera Analysis

Overview of market

Current size

Source:Senior Executive at TTK Chitra Hindu Article

Source:Interviews with experts in the field


Regulatory landscape

Overview

According to the final draft of the newly proposed regulations, all medical devices have been broadly classified into the following categories:

Recent approvals

Heart Valves notified as ?drugs?: As per the notice dated 16/May/2005 from The Ministry of Health and Family Welfare, Govt. of India has notified Heart Valve devices to be considered as drugs under Section 3, Clause (b) . Sub clause (iv) of the Drugs and Cosmetics Act, notification number s.o.1468 (E). CDSCO: Medicines in India are regulated by CDSCO - Central Drugs Standard Control Organization. Under Ministry of Health and Family Welfare. Headed by Directorate General of Health Services CDSCO regulates the Pharmaceutical Products through DCGI - Drugs Controller General of India at Chair.

Registration Certificates issued for the Heart Valves along with their manufacturing sites and Indian Authorized agents in since 2010
Date Name of Indian Agent Name of Manufacturer Name of the Device File No. R. C. No. Validity of the Registration Certificate
Jan. 2012 to Feb 2012 M/s. St. Jude Medical India Private Limited, Plot No. 18 & 19 Laxminagar, behind TB Hospital, Hyderabad-500038 M/s. St. Jude Medical Puerto Rico LLC, Lot 20-B, St. Cagaus Puerto Rico 00725 1. St. Jude Medical Mechanical Heart Valve 2.SJM Master Series (Rotatable)-Aortic + 9 31-28-MD/2006-DC (Re-Reg. 2_ MD-28 30-06-2015
Jan. 2011 to 20th December 2011 M/s India Medtronic Pvt. Ltd., 1241, Solitaire Corporate Park, Building Number 12, 4th Floor, Anheri-Ghatkopar Link Road, Andheri (E), Mumbai- 400094 M/s Medtronic Inc., 710 Medtronic Parkway N. E. Minneapolis MN 55432 USA having manufacturing premises at M/s Medtronic ATS Medical Inc., 3905 Annapolis Lane, Suite 105 Minneapolis, MN ? 5547, USA 2. Open Pivot Aortic Valved Graft (AVG) 31-892-MD/2010-DC MD-893 31-12-2014
Jan. 2011 to 20th December 2011 M/s Edward Lifesciences (India) Pvt. Ltd., E.F. 201-204, Remi Biz Court, Plot No. 9, Off Veera Desai Road, Andheri West, Mumbai- 400058 M/s Edward Lifesciences LLC, One Edwards Way, Irvine CA, USA 92614-5686 1. Carpentier-Edwards Bioprosthetic Valved Conduit 31-93-MD/2006-DC (Re-Registration 2010) (End. 1) MD- 93 31-01-2013
Jan. 2011 to 20th December 2011 M/s Edward Lifesciences (India) Pvt. Ltd., E.F. 201-204, Remi Biz Court, Plot No. 9, Off Veera Desai Road, Andheri West, Mumbai- 400059 M/s Edward Lifesciences LLC, One Edwards Way, Irvine CA, USA 92614-5687 2. Edwards MC Tricuspid Annuloplasty System 31-93-MD/2006-DC (Re-Registration 2010) (End. 1) MD- 94 31-01-2014
Jan. 2011 to 20th December 2011 M/s India Medtronic Pvt. Ltd., 1241, Solitaire Corporate Park, Building Number 12, 4th Floor, Anheri-Ghatkopar Link Road, Andheri (E), Mumbai- 400093 M/s Medtronic Inc., 710 Medtronic Parkway N. E. Minneapolis MN 55432 USA having manufacturing premises at M/s Medtronic Mexico S. de R.L de C.V. Avenida paseo del Cucapah 10510, Parque Industrial EI Lago, Tijuana, B.C. 22570< Mexico 1. Sprinter rapid Exchange Balloon Dilatation Catheter 31-381-MD/2007-DC (Re-Reg. 2010) MD-381 14-02-2014
Jan. 2011 to 20th December 2011 M/s India Medtronic Pvt. Ltd., 1241, Solitaire Corporate Park, Building Number 12, 4th Floor, Anheri-Ghatkopar Link Road, Andheri (E), Mumbai- 400094 M/s Medtronic Inc., 710 Medtronic Parkway N. E. Minneapolis MN 55432 USA having manufacturing premises at M/s Medtronic Mexico S. de R.L de C.V. Avenida paseo del Cucapah 10510, Parque Industrial EI Lago, Tijuana, B.C. 22570< Mexico 2. Sprinter legent RX Balloon Dilatation Catheter 31-381-MD/2007-DC (Re-Reg. 2010) MD-382 14-02-2015
Jan. 2011 to 20th December 2011 M/s India Medtronic Pvt. Ltd., 1241, Solitaire Corporate Park, Building Number 12, 4th Floor, Anheri-Ghatkopar Link Road, Andheri (E), Mumbai- 400095 M/s Medtronic Inc., 710 Medtronic Parkway N. E. Minneapolis MN 55432 USA having manufacturing premises at M/s Medtronic Mexico S. de R.L de C.V. Avenida paseo del Cucapah 10510, Parque Industrial EI Lago, Tijuana, B.C. 22570< Mexico 3. Melody Transcatheter Pulmonary Valve 31-381-MD/2007-DC (Re-Reg. 2010) MD-383 14-02-2016
Jan. 2011 to 20th December 2011 M/s. St. Jude Medical India Private Limited, A & B, 2nd Floor, Brij Tarang, Greenland, Begumpet, Hyderabad-500016 M/s. St. Jude Medical Cardiology Division Inc, DBA 177 County Rod, B East St. Paul, MN 55117, USA Trifecta Valve Aortic (19mm-27mm) 31-26-MD/2006-DC (Re-Reg. 2009 (End 02) MD-26 30-06-2012

Reimbursement landscape

  1. Aarogyasri in Andhra Pradesh State
  2. Jeevandayi Yojana in Maharashtra State
  3. Kalignar's Insurance Scheme

Aarogyasri

Jeevandayi Yojana

Kalignar's Insurance Scheme

Reimbursement rates

In India, the reimbursement rate for procedures varies from one insurance company to another. Typically, Heart Valve Replacement procedure falls under major illness category. The amount of reimbursement is typically dependent on the sum assured.

Source: UIA, LIC, ICICI Lombard

Technology landscape

An artificial heart valve is a device implanted in the heart of a patient with heart valvular disease. Natural heart valves become dysfunctional for a variety of pathological causes. When one of the four heart valves malfunctions, the medical choice may be to replace the natural valve with an artificial valve.

There are two main types of artificial heart valves:

One of the greatest biomedical engineering challenges today is to develop an implantable device that resists the natural conditions to which heart valves are subjected, without eliciting host reactions that would impair their function. Currently, no artificial heart valve device, either mechanical or tissue-derived, fulfills the required prerequisites for an ideal heart valve.


Regenerative medicine approaches to heart valve replacement:

Regenerative medicine is based on principle of using the patient?s own cells and extracellular matrix components to restore or replace tissues and organs that have failed. Modern approaches to heart valve regenerative medicine include several research methodologies with the most intensely researched approaches being:

The regenerative medicine approach is however still in its nascent stages.


Future and perspesctives:

Effective treatments of valvular disease continues to present multiple challenges. The exciting lines of investigation in this area are:


Ross procedure

Arkalgud Sampath Kumar- Biography

Percutaneous Transcatheter Aortic Valve Implantation (TAVI)


Dr. Ashok Seth, Fortis Healthcare, Delhi


Transcatheter Pulmonary Valve (TPV) Therapy

Source:Medtronic

Distribution landscape

Value Chain- Heart Valves

Source:Interviews with experts in the field

Sales Force Structure

Source:Interviews with experts in the field

Distributors & Stockists

Source:Interviews with experts in the field

Distribution Channel:

Distribution channel at government hospitals:

Inventory management

Procurement of heart valve at the time of surgery:

Margin structure:

Pricing landscape

The major cost of the surgery includes cost of the

Medical device The heart valve typically costs from INR22,000 ($420) to INR200,000($3,800). The most cost effective valve is manufactured by TTK. The valve is called TTK Chitra. Depending upon the type( mechanical, tissue, percutaneous etc)of valve the price could go up to more than INR10 lakhs($18,800).

Procedure The hospitals generally charge a fixed amount on money for the whole procedure. In Tier 1 cities it is INR2 lakhs($3,800) in most of the hospitals.

The ratio of cost of device to procedure generally is 30% to 70%.

Pricing committee

Each hospital in the chain has a pricing committee which decides the price of valve based on factors such as :

Hence price of same valve may be different in a hospital of same chain

Purchasing committee

Key hospitals & institutions

Dolcera Analysis

Narayana Hrudayala Hospitals

Narayana Hrudayalaya is founded by one of the India?s oldest construction company ?Shankar Narayana Construction Company?. Narayana Hrudayalaya group currently has 5000 beds in India and aims to have 30,000 beds in the next 5 years in India to become the one of the largest healthcare player in the country.

Narayana Hrudayalaya - Highlights

NH Institute of Cardiac Sciences, Bangalore

Narayana Hrudayalaya is located close to the Electronics City of Bangalore covering 26 acres of land with a building to accommodate 1000 beds, 26 operation theaters and infrastructure to perform 70 heart surgeries a day. Within the first 5 years of commissioning this institution, currently 25 heart surgeries are done on a daily basis, out of them about 30% are on children with heart problem. Rest of them is adult open-heart surgeries.
The institute is one of the world?s largest pediatric heart hospitals. It is the brainchild of renowned cardiac surgeon Dr. Devi Shetty, who performed over 15,000 heart operations.

Heart Valve Procedures

The Ross Procedure
The Ross Procedure, also known as Pulmonary valve translocation, was developed by Donald Ross in 1967.This operation uses the patient?s own pulmonary valve and part of the main pulmonary artery as a unit to replace the aortic valve and ascending aorta. A homograft valve is harvested from a cadaver, is then placed in the pulmonary position. The pulmonary valve is identical in shape, size, and in fact stronger than the aortic valve and is therefore an ideal replacement for the diseased aortic valve. Narayana Hrudayalaya has a full fledge functioning homograft heart valve bank for the benefit of the needy patients. The surgeons of the Narayana Hrudayalaya have a large experience in successful valve replacements using homografts and Ross operations. These operations are being done only in very few centres in our country. Surgeons at Narayana Hrudayalaya have performed about 100 of these procedures with excellent results. They are perhaps one of the most experienced surgeons in the World in performing operations like Bental Procedure for Aortic Aneurysm and Aortic Arch replacement surgery for dissecting Aneurysm of Aorta.

Mitral Valve Repair in New Born Babies and Infants
Mitral Valve leakage is a dreadful condition affecting small percentage of children suffering from congenital heart disease. Only option for these children is repair of the valve, which is done on a regular basis at Narayana Hrudayalaya.

Ross's Procedure for Aortic Stenosis
Best treatment option for Aortic Stenosis is Ross's Procedure in which the patient's own pulmonary valve is used to replace the aortic valve and in the place of pulmonary valve a homograft taken from a dead body is replaced.

Procedure Charges

Narayana Hrudayala uses economies of scale to keep the cost of treatment low.
Heart Surgery


Unlike other hospitals, the bulk of its profits come from the out- patients ward, where the cost to the patient is low but the margins are as high as 80 percent. The number of walk-in patients remains high because they know the cost of surgery will be subsidised should they need it.

Source:IBN Live Article; Have a heart foundation

Doctor Profiles

Dr. Avery Mathew
Email: dravery.mathew@hrudayalaya.com
Gender: Male
Designation: Senior Consultant Cardiac Surgeon
Brief Profile: He has done M.Ch(Cardiothoracic) in Kasturba Medical College,Mangalore His forte lies in Aortic Aneurysms Surgery, besides Coronary Artery and Valve Surgery.

Dr. Binoy C, MCh
Gender: Male
Designation: Consultant Cardiac Surgeon
Brief Profile: Dr Binoy completed his training in cardiac surgery at the prestigious Seth G.S Medical College and King Edward Memorial Hospital at Mumbai and The Royal Prince Alfred Hospital at Sydney, Australia. His fields of interest and expertise include Total Arterial Coronary Revascularization procedures using bilateral Internal Mammary Arteries, aortic surgeries and Pulmonary Thrombo Endarterectomy. He also leads the Extra Corporeal Membrane Oxygenation (ECMO) programme in the hospital.

Dr. Chinnaswamy Reddy H M, DNB(Gen. Sur.), DNB(CTS), FPCS
Gender: Male
Designation: Senior Consultant Cardiac Surgeon
Brief Profile: He has done M.Ch(Cardiothoracic and Vascular Surgery) in Jayadeva Institute of Cardiology,Bangalore University. He specializes in Bex-Nikaidoh operation, REV operation, Double-switch Ross operation and the latest Cone Reconstruction of Tricuspid Valve in Ebstein\'s Anamoly.

Sri Jayadeva Institute of Cardiovascular Sciences and Research

Overview

Sri Jayadeva Institute of Cardiovascular Sciences & Research is a Government owned Autonomous Institute and is offering super specialty treatment to all Cardiac patients. It has got 600 bed strength with State of Art equipments in the form of 4 Cathlabs, 4 Operation Theaters, Non-Invasive Laboratories and 24 hours ICU facilities. Presently on an average 800-1000 patients are visiting this hospital every day and annually 21,500 In patients are treated. About 2500 Open Heart Surgeries, 8500 Coronary Angiograms, 3500 Procedures including Angioplasties and Valvuloplasties are done in this hospital. The prevalence of heart attach, which was 2% in 1960 has increased to 12% in 2008. Unfortunately heart attack and other related heart ailments steadily increasing among the poor people. 70% of the patients who comes to our hospital are well below the poverty line. The consumables used for various procedures like Open heart surgeries (Valve replacement), Angioplasty procedures, Pacemaker procedures are becoming very expensive, however quality treatment is given at affordable cost. Well equipped special ward facilities with round the clock angioplasty services are also provided.

Heart Valve Replacement Procedures

Procedure Charges

Cost of Valve Replacement Procedure (MVR / AVR / DVR ) INR Rupees

Doctor Profiles

Dr. C.N. Manjunath M.B.B.S, M.D (Gen.Medicine), D.M (Cardiology)
Director and Prof. & HOD of Cardiology
Degree College University Year of passing M.B.B.S M.M.C Mysore 1982
M.D. (Gen. Medicine) B.M.C Bangalore 1985
D.M. (Cardiology) K.M.C Mangalore 1988
Marital Status : Married
Nationality : Indian
Designation : Professor & Head of Cardiology;Director
Sri Jayadeva Institute of Cardiovascular
Sciences & Research, 9th Block Jayanagar
Bannerghatta Road, Bangalore ? 560069.
E-mail: cnm_vidhatri@satyam.net.in
cnmanjunath@vsnl.net
Phone: 080-22977422, 22977433,
Direct -080 ? 22977456 fax: 26534477
Cell Phone: 9844006699
Residence: 26692155, 26697558

Key Opinion Leaders

The surgeons are the decision makers regarding the kind and make of the valve. Almost in all hospitals surgeons recommend the type and brand of the device. Dolcera team performed a research exercise that involved interviewing doctors at top hospitals. During this exercise we found that the following factors are taken into account while taking a decision for selecting a heart valve:

  1. Indication of patient
  2. Paying capacity
  3. Quality of valve(durability)
  4. Supply/ Availability
  5. Need for anti-coagulation
  6. Haemodialysis dynamics


The Dolcera team found following insights from the discussions with surgeons:

  1. Patients are not aware of the brands available in the market.
  2. Sometimes patients ask for a foreign valve only.
  3. Patients usually have information about tissue or mechanical valve and want to know which one was used the procedure and why?


Here is a list of few of the key influencers in the industry:

Please click on the names to get biographies of Physicians

  1. Dr. Vivek Jawali
  2. Dr. Ashok Seth
  3. Dr. Naresh Trehan
  4. Dr. Ajay Kaul
  5. Dr. Surendra Nath Khanna
  6. Dr. Z. S. Meharwal
  7. Dr. Sunil K Kaushal
  8. Dr. Y. K. Mishra
  9. Dr. Sanjay Gupta
  10. Dr. Vijay Dikshit


Market Drivers

Rising middle-class and ageing population

India has a population close to 1.1 billion people, making it the second most populated country behind China, and 5% of them are over 65 years of age. And unlike China, India does not impose restrictions such as ?onechild? policy upon its citizens. Over the next couple of decades, India is expected to surpass China as the world?s most populous country. During the forecast period to 2015, India is expected to reach 1.3 billion in total population. And as the ageing population grows, the demand for healthcare services and products will also rise. The most important driver for India however, is the rising middle-class population that will exceed 450 million by 2015. Although most of the population cannot afford premium healthcare, there are 100 million middle-class people with an annual income of over $5,000 who demand quality healthcare. While $,5000 may be a small amount in comparison to international standards, in terms of purchasing power parity (PPP), Indian citizens can enjoy premium health services within this income bracket on a par with people in developed nations.

Medical Tourism

Medical tourism has been gaining more attention resulting in an increased influx of foreign patients into India over the past seven to eight years. About 50% of specialized urban hospitals are actively focusing on tapping medical tourists to grow their business and gain international recognition.

Source:Interviews with experts in the field

Cost effectiveness against developed countries(Medical Tourism)

India is fast becoming a popular destinations for procedures like heart valve replacement surgeries primarily due to:

The following table provides a snapshot of the comparative cost (in USD) for major heart procedures across 6 countries:


Procedure Country (cost in USD)
Costa Rica Mexico Thailand Singapore India USA
Heart Valve Replacement 18,000 21,500 11,500 15,500 12,000 170,000
Angioplasty 11,000 16,500 14,500 14,500 10,500 61,500
Heart Bypass 29,000 26,500 13,000 22,500 11,000 127,000

Source: Medical Tourism by John Connell, PR Inside News, World Med Assist


Recent Trends

Transcatheter Aortic Valve Implantation (TAVI)

Description:This technique involves insertion of a miniaturized valve through a catheter from the groin. The deployed valve is later inflated at the site of the aortic valve

Procedures in India: TAVI is still in nascent trial stage in India. In mid of March 12, a team of doctors at Delhi's Fortis Hospital headed by Dr Ashok Seth operated three patients using TAVI.

Cost of surgery in India: The cost of procedure is $29,350 USD which includes the cost of valve $ 21,500 USD (approx).

Regulatory affairs: Sources at the health ministry revealed that a dialogue is on between Drug Controller General of India and the manufacturing company. Cost is said to be the bone of contention.

TAVI Procedure ? Insights from Doctors in India

"The valve is known to last up to 15 years but its efficacy for the Indian population is still being assessed.?

?Mass availability of the valve is also an issue, as there is only one company manufacturing it?

?The disease of AVS is on the rise in Indian population affecting close to 1 million elders every year.?

Source: Timesofindia

Recent Developments

India

  1. March,2012 - Medical devices: Budget unveils moves to drive growth
  2. March,2012 - New technique offers alternative to vulnerable heart patients
  3. March,2012 - India?s First Successful Percutaneous TAVI Performed at Fortis Escorts
  4. November,2011 - India Medtronic Launches Pulmonary Valve Replacement Therapy for Congenital Heart Disease Patients


US

  1. March,2012 - Edwards Sapien Safely Replaces Aortic Valves at Two Years
  2. November,2011 - Colibri Heart Valve Will Present at Upcoming 23rd Annual Transcatheter Cardiovascular Therapeutics Scientific Symposium
  3. November,2011 - Less Invasive Heart Valve Replacement Is Approved
  4. March,2011 - Medtronic Announces Global Launch of New Heart Valve Repair Ring Designed to Adapt to Heart?s Natural Valve

Key Players

Overview

Major products in india.png

Key Players

Medtronic

St Jude Medical

Edwards Life sciences

TTK

New entrants

Comparative Analysis

Comparative Analysis Medtronic St. Jude Edwards TTK
Product Product line is good, but untimely product recalls have caused losses Huge portfolio expanded very rapidly High end products serves only niche segments Single product (Best Seller)
Pricing Adapted to Indian market competitively priced Adapted to Indian market competitively priced Priced very high as compared to peers Unique selling proposition. Priced lowest in world deal in huge volumes
Marketing Specialized in introducing new technology & key opinion leader management Focus on aggressively reaching out to a large set of surgeons as they deal low margins & high volumes Not much focus Tie up with Insurance schemes has benefited in a huge way
Training Conduct training Not much focus Conducts training Not much focus

Recommendations

Institutional challenges in India (a special case)

Dolcera Analysis

India strategic outlook - Phase wise approach

Major hospitals in India and their presence across cities

Note:Fortis Healthcare has acquired Wockhardt Hospitals

Find hotspots - Attractive customer segments

Dolcera Analysis

Segment champions

  1. Bottom of the pyramid: TTK
  2. Local segment: St. Jude
  3. Local segment (global aspirations): Medtronic
  4. Global outlook: Medtronic, Edwards

Key opinion leader management

Government Hospitals
The Head of department, who is generally the most experienced surgeon would test a new heart valve initially with few surgeries, depending upon his experience he would recommend the use of new heart valves and generally .The surgeons need to be convinced about the safety & durability of the valve through training various online illustration and manuals that talk in detail about the procedure .Generally they are interested in relative comparison with competitors. Also the approval of new heart valve is given by the respective head of dept. at the state / government owned institutions .The list of approved valves are allowed to bid for the tender.

Private hospitals
Especially the chain of hospitals, have key doctors that drive the most of business, they have a big team of cardiac surgeons under them. For example Dr Vivek Jawali at Fortis Bangalore has under him team of 17 cardiac surgeons which performs almost 25 procedures daily (not all heart valves) .His opinion is regarded very highly in the industry. In private hospital the procurement & pricing is generally handled by a separate committee hence the doctors in that committee are also very crucial.

Training

Sales & distribution plan

Dolcera Analysis

Unmet needs

Cost Reduction

Dolcera Analysis

Strategy formulation

Data collaboration & content analysis

Dolcera Analysis

Developing strategy options & selection

Dolcera Analysis

Review & ongoing assessment

Dolcera Analysis