Americare Neurosurgery International Inc (AMCANI) and The Institute of Neurosciences Kolkata (INK) India

The INK was founded by Ram Sengupta MD. A consultant neurosurgeon (cerebrovascular) and Professor Emeritus at Durham University, Newcastle on the Thames. Dr. Sengupta has worked in the English NHS for over 30 years and wished to return to his native West Bengal and give back to the community that he came from. His radical proposal for a self-funding, private, nonprofit neuroscience institute represents a novel model for health care delivery in India (see below). The institute will provide comprehensive care from an integrated team of MDs neurosurgeons, neurologists, psychiatrists and physiatrists.

West Bengal is the principle district of Northeastern India. It includes the city of Kolkata (formerly known as Calcutta), the largest city in India with a population of 15 million inhabitants. West Bengal and neighboring Bangladesh comprise a total population of 450 million for which the neurosurgical practitioners of Kolkata are the principle providers of care for diseases of the nervous system. In this region there are no integrated multidisciplinary groups, nor a local tertiary, let alone quaternary care or academic group, the nearest being approximately 1000 miles away in Bangalore, India. Though high quality neurosurgical care can be found in the region, it is accessible only to the wealthy. In general, there are two modes of neurosurgical care provided in India; private and government. Private neurosurgery groups are strictly fee-for-service. They treat the nervous system diseases of the upper 10% of the population. Below that lies the emerging middle class of India (GDP/per capita, India ranks 165/228; 31% of the wealth belongs to the upper 10% [1]) who average about $450.00 a month and can not afford the care of the private sector groups, unless they assume massive debt and possibly the forced sale of their homes, and most of their equity and liquid assets. For the remaining individuals of West Bengal and Bangladesh there are the government-sponsored neurosurgical groups. These are characterized by poor facilities, overworked staff, cursory workups, and care that is substandard even by local community standards. Again, the nearest tertiary/quaternary care center is over 1,000 miles away and twelve hours or more by train, and this care is not accessible to 90% of the population.

The INK is a nonprofit institute chartered under Section 25 of the West Bengal Government. 20% of all services will be donated to the indigent. 60% of the services will be done at a small margin above cost or at cost depending on the financial resources of the patient. The remaining 20% of treatments will be done on a fee for service basis. For example, INK charges 450 India Rupees ($10 USD) for an MRI; the next lowest MRI center cost is approximately five times that. The 20% of INK patients are wealthy aand are drawn to the quaternary care aspects and integrated service model of the institute, as well as its proximity to Kolkata and Bangladesh. To achieve this mix of patients, the institute has one floor of private suites for the fee for service and medical tourist, three floors of semi-private (2-4 beds) rooms for the cost-plus-margin work, and one open ward floor to care for the indigent. The ICU (used by all categories of patients) has 14 beds of which 7 have full ventilator support. The INK has four operating rooms (two fully equipped with microscopy, micro-instruments; the other two reserved for complex spine and non-micro cases), one single plane DSA for endovascular treatments, a Siemens 1.5T MRI, multiplane CT, and a digital C-arm. There are sufficient instruments (made locally) to equip two operating rooms with microsurgical capabilities. There is a Emergency Room that is appropriately equipped. Members of the faculty have teaching responsibilities (there are currently three neurosurgery residents) as well as sub-specialization in neurosciences.

Dr. Sengupta proposes a disruptive medical care model: Within Indian neurosurgical practice, particularly among the private groups, there is little if any cross-referral to colleagues even when they have better-suited skills for treating a particular problem, due to the intense pressures of fee for service. There is at present a small medical insurance system, but its is affordable only by the rich. Most neurosurgical care is delivered on a cash basis. For example, if a patient comes in with a carotid artery stenosis requiring surgery, the private neurosurgeon is not likely to refer to a cerebrovascular neurosurgeon, but would himself do the case, despite having performed few if any endartectomies. This non-referral pattern is necessary for the practitioner to preserve his income stream. Hence, private neurosurgeons do not refer patients to their most competent colleagues but instead do procedures irrespective of their skill level. Dr. Sengupta proposes to resolve this by insisting that his staff cross-refer patients to the most appropriate surgeons but, to keep incentives intact, the two doctors will split the revenue equally. During the AMCANI site visit, we visited with the following surgeons who will cross-refer for the benefit of patients:

• A complex spine/tumor surgeon

• A interventional neuroradiologist

• An intensivist-neuroanesthesiologist

• Dr. Sengupta who will do the cerebral vascular work

All were interviewed and expressed dedication to this model. There are a number of staff members dispersed through out the for-profit medical centers in Kolkata, awaiting the opening of the institution. Please see the faculty section of the INK website, http://www.neurokolkata.org/ for details.

INK's Request of AMCANI

INK wishes material assistance and technical training from AMCANI in the development of the functional neurosurgery (DBS, epilepsy, pain) as well as assistance in developing the features of the operating room that will draw the upper 10% of wealthy patients from West Bengal and Bangladesh to support the care of the remaining 90% using these same services. Specific requests were made for a neuronavigation system, stereotactic frame, DBS with microelectrode recordings system, and an intraoperative monitoring system, epilepsy surgery. They hope to install this equipment in 2011 to allow for basic services to start and an income stream to start in time for the formal INK opening within the next year to year and half. They also wish training and technical assistant with PMR/Neuor-rehab, neuropathology (specifically a cryotome). There is a need for ancillary hospital machines, two ORs worth of neurosurgical/spine instrument trays, and an ETOH sterilizer. They have specifically requested that donated materials not be worn due to the expense of repairs and parts. Additionally, obsolete equipment does not fit the organization's need to develop a state of the art care center that will attract that crucial 10% full payment population.

References
[1] CIA World Factbook