Attachment G5

WORKING PAPER - DO NOT CITE OR DISTRIBUTE

WITHOUT PERMISSION OF THE AUTHORS

CASE STUDY:
TRANSLATING A LOW-COST, HIGH-QUALITY MULTISPECIALTY HOSPITAL
MODEL TO NEW ENVIRONMENTS: THE CASE OF NARAYANA HEALTH AND
HEALTH CITY CAYMAN ISLANDS

Andrea Taylor, Innovations in Healthcare, Duke University

Erin Escobar, Innovations in Healthcare, Duke University
Krishna Udayakumar, Innovations in Healthcare, Duke University

Prepared for:
The Commonwealth Fund
2015 INTERNATIONAL SYMPOSIUM ON HEALTH CARE POLICY

1
 Attachment G5

WORKING PAPER - DO NOT CITE OR DISTRIBUTE

WITHOUT PERMISSION OF THE AUTHORS

Abstract: Narayana Health (NH), one of the largest chains of multispecialty hospitals in India, was
founded in Bangalore to provide high-quality affordable cardiac care. It combines innovative technology
and a highly efficient delivery system, boasting quality outcomes that rival the United States and the
United Kingdom at a fraction of the cost. Through a joint venture with Ascension Health, NH recently
established Health City Cayman Islands (HCCI), a 101-bed tertiary-care hospital on Grand Cayman. By
incorporating NH’s efficiencies, HCCI is designed to dramatically increase access to high-quality,
affordable specialty care to residents of the Americas and the Caribbean facing a scarcity of tertiary care,
as well as to medical tourists facing prohibitive costs in their own countries, including the United States.
The experience of implementing HCCI, documented in this case study, highlights the challenges in
wholesale replication of health care innovations from abroad. At the same time, our findings point to
components that U.S. health care leaders might consider adopting.

2
 Attachment G5

WORKING PAPER - DO NOT CITE OR DISTRIBUTE

WITHOUT PERMISSION OF THE AUTHORS

BACKGROUND
Health systems worldwide are searching for innovative health care models that lower costs,
improve quality, and increase access to services. Narayana Health (NH) is one of the best-known
examples globally. Formerly known as Narayana Hrudayalaya Hospitals, NH was founded by
Devi Prasad Shetty, M.D., in 2001 in Bangalore, India, to provide high-quality, affordable
cardiac care to everyone, regardless of ability to pay.

Evolving lifestyle and diet in India have caused an unprecedented increase in heart disease.
Around the time of NH’s founding, approximately 2.4 million people in India required heart
surgery annually, but prohibitive costs meant only 60,000 surgeries were performed each year.i

This gap was the catalyst that inspired Dr. Shetty to create NH, now one of India’s largest
multispecialty hospital chains, providing tertiary care in nearly all specialties. By combining
innovative technology and a highly efficient delivery system, NH is able to optimize productivity
and minimize costs.

WHAT IS THE INNOVATION AND HOW DOES IT WORK?

The success of the NH model is achieved through multiple complementary mechanisms.
These include:

 leveraging economies of scale;

 using assembly line concepts for surgery;
 having an extreme focus on efficiency;
 reducing the average length of stay for the benefit of both patients and the hospital; and
 reengineering both design and materials to reduce the cost of ownership across equipment
life cycles.

Because of these innovations, the average cost of open-heart surgery, as reported by NH, is
$2,000. The same procedure at a U.S. research hospital typically costs more than $100,000.ii

Utilizing a pay-per-use model with suppliers for some diagnostic equipment, NH is able to
minimize capital costs and thus expand very quickly.iii Strict sterilization procedures at NH,
permitted by the Joint Commission International (JCI), allow reuse of devices, such as guide
wires and some catheters in cardiology, that are typically disposed of after a single use. A
centralized cloud environment connects all NH hospitals and hosts critical hospital applications,
enabling central monitoring of transactions across locations. Centralized purchasing allows NH

3
 Attachment G5

WORKING PAPER - DO NOT CITE OR DISTRIBUTE

WITHOUT PERMISSION OF THE AUTHORS
to take advantage of economies of scale. Bar coding of stock enables precise inventory counts at
any time, minimizing holding costs and releasing blocked working capital.

In addition to services at its own facilities, NH has one of the world’s largest telemedicine
networks, connecting 800 centers globally. It has treated over 53,000 patients through
telemedicine programs. NH uses mobile outreach vans to further increase access to diagnostic
and consultation services in semi-urban and rural areas of India.

Using a shift system for surgery and task shifting among staff create an exponentially more
efficient operating theater, resulting in more procedures completed per day. Surgeons perform
only the tasks they are uniquely qualified to do, and less-skilled staff members perform other
tasks, such as preoperative preparation, patient education, and charting. Each staff member
practices at the top of his or her scope of practice. This allows quick patient “throughput,”
because the surgeon need only turn around to begin the next surgery on a fully prepped patient.
This high volume drives lower costs and better quality outcomes; surgeons gain tremendous
experience in a short time, helping NH clinicians to excel in their domain.

The powerful brand, social mission, and leadership of NH, as well as competitive compensation
and incentives, attract and retain highly qualified cardiac surgeons and other tertiary care
specialists from around the world. NH has approximately 16,000 employees, with 11,000
clinicians spread across the company, including HCCI (see appendix), and 4,000 people are
subcontracted for housekeeping and security.

Data use also drives cost reduction and efficiency across NH. Profit and loss statements are
updated daily and sent via email or text message to executives, allowing NH to identify and
address capital flow issues as they arise, rather than weeks later. Performance of individuals and
departments is monitored daily. NH designed a customer-centered complaints process in 2011
that provides a simple and powerful tool for monitoring and ongoing improvement.

NH is a profitable organization. Eighty percent of its total revenue is generated from inpatient
visits, 10 percent from outpatient visits, and 10 percent from remote consultations and diagnoses.

NH hospitals serve anyone who needs care, regardless of ability to pay. More than 50 percent
of patients receive subsidized inpatient care annually, with an average discount of 15 percent.
This is accomplished through a cross-subsidy model, in which wealthier patients pay more for
nonclinical amenities, such as private recovery rooms. The subsidization scheme is sustainable
because the full charge is still far below the cost of comparable services at other private
hospitals, making NH an attractive option for paying patients. Free care is also supported through
philanthropy.

4
 Attachment G5

WORKING PAPER - DO NOT CITE OR DISTRIBUTE

WITHOUT PERMISSION OF THE AUTHORS
IMPLEMENTATION AND SCALE
NH’s scaling strategy is multidimensional: growing its depth as large patient volumes drive
increased hospital bed capacity, while expanding in breadth as the number of specialties
provided increases, with additional growth across sectors (developing medical education
programs) and locations. Since its founding in Bangalore in 2001, NH has grown its network to
31 hospitals across 19 cities.

The recent adaptation of the Narayana model from India to the Caribbean illustrates how
ecosystems impact implementation and sustainability, in both positive and negative ways (see
appendix for discussion of the HCCI business model).
NH considered many locations for a potential replication; the choice of Grand Cayman was
driven by a serendipitous convergence of factors, including enthusiasm of local business
leadership, the Caymanian government’s identified need to diversify its economy in the wake of
the recent global recession, and NH’s strategic desire to establish a presence in the region (Box
1). The island’s well-developed tourism industry, strong infrastructure, low crime, and
geographic proximity to the target market made it an attractive environment.

The Caymanian government’s willingness to make sweeping changes to the regulatory and
policy environment to accommodate HCCI was the critical factor in the decision. The
government changed nine laws and 13 regulations in 2.5 years, including its health practice law,
Box 1. Key Partners in the HCCI Replication which now recognizes
Caymanian businessmen Harry Chandi and Gene Thompson were critical in the genesis Indian medical
of HCCI. Chandi, a Cayman resident of Indian origin, became a good friend of Dr. Shetty
after the doctor treated Chandi’s father. Thompson was Chandi’s business partner and qualifications and
a third-generation Caymanian director of Thompson Development Ltd., a premier approves Indian doctors
development company in the Cayman Islands. The government had approached
Thompson about developing avenues for economic diversification. Chandi and
and nurses to practice in
Thompson, inspired by Dr. Shetty’s vision, were vital in brokering relationships between the Caymans. Tort reform
NH and the Cayman government and developing the project’s master plan. “Ignorance capped medical
is empowerment,” said Thompson. “We knew no boundaries, limits, barriers; we only
saw opportunities.” malpractice payouts at
$620,000, thereby
At the same time, Ascension Health, the largest faith-based and largest not-for-profit
health system in the United States, was likewise motivated by NH’s mission-driven reducing insurance costs
approach. In Bangalore, NH had collaborated with TriMedx (a subsidiary of Ascension) for the hospital.iv
to service equipment beyond its usual lifespan, resulting in reduced capital expense
and operating costs. The executive leadership team at Ascension saw the investment in
Immigration law was
HCCI as an opportunity to provide affordable health care, particularly to vulnerable changed to support visa
populations, as well as to test innovative ways to increase quality while decreasing
costs that could apply in the United States.
concessions for countries
that are passport-bound,
allowing patients to freely travel to Grand Cayman for care, and duty tax was waived for
imported medical supplies. The government also preapproved expansion to match the project’s
15-year master plan timeline (see appendix).

5
 Attachment G5

WORKING PAPER - DO NOT CITE OR DISTRIBUTE

WITHOUT PERMISSION OF THE AUTHORS
Efficient construction methods (e.g., insulated concrete forms that decrease air conditioning use
by 40 percent) sped up construction of the HCCI hospital, resulting in completion within budget
within 12 months (Box 2).

In its early stage, key factors threatened to hinder the model, including the work culture, volumes
relative to scale and supply chain advantages, and administrative inefficiencies. As HCCI grows,
it may be difficult to continue importing medical teams, so the administration is working to
embed the NH work culture locally. However, the work culture itself will need to adjust to
cultural norms in the
Box 2. Efficiency in Construction: Completed Early at $420,000 per Bed
Cayman Islands.
Hospital construction integrated many concepts and lessons from India, including Dr.
Shetty’s philosophy of incorporating natural light into all areas of the building,
especially operating rooms. There was a firm commitment to lean and green hospital Regionally, there are
design. A number of operational customizations, such as on-site oxygen disparate health care
manufacturing, use of solar power, and recycling of outflows for non-potable uses,
will allow for long-term cost-savings and mitigate environmental concerns. “The sum
markets. Every island in
the Caribbean has its own
total of multiple efficiencies in the construction process had greater impact than one
silver bullet of saving,” notes Gene Thompson. market drivers. HCCI must
The hospital was built at $420,000 per bed, compared to an average of $1 million per study this to successfully
bed in the United States. Minimalistic yet utilitarian, HCCI has just over 100,000 grow patient volume.
square feet, less than half the size of a typical Western hospital. This created
construction and operational savings. Higher operational costs
and the supply chain
logistics of an island, along with territorial issues for local companies, are other early stage
ecosystem challenges.

In the short to medium term, HCCI is targeting Caymanians and other Latin American and
Caribbean residents covered by government or private insurance, as well as wealthy patients who
pay out of pocket (Box 3). Through a partnership with the Heart to Heart organization, HCCI
Box 3. Targeting Multiple Markets also provides subsidized
cardiac surgery for Haitian
Employer-based insurance is required by Cayman law, with the remainder of citizens
covered by government plans, resulting in nearly universal insurance coverage and children. Traditional
very low out-of-pocket expenditures. HCCI reports that for its Caymanian patients, insurance companies in the
95 percent of health spending to date is through insurance, with only 5 percent out
of pocket, an anomaly in the Caribbean. The islands’ educated, savvy patients often United States are not the
go overseas (typically Miami) for specialty care because local services have been immediate way forward for
scarce or unavailable.
growing volume, though
HCCI has already engaged the key insurance providers in the Cayman Islands. self-insured companies may
However, the Cayman Islands has only 55,000 citizens, not sufficient volume to drive
the efficiencies that are the hallmark of the NH model. Therefore, the HCCI
be willing to partner with
marketing team is aggressively analyzing gaps in the Caribbean market. It is working HCCI.
with insurance companies, self-insured companies (more incentivized than
traditional insurers by deep cost cuts), and cruise lines. The main targets for near-
term growth are Jamaica, Turks and Caicos, the Bahamas, Trinidad, St. Marteen, and Since its launch in 2014,
the Dominican Republic. HCCI has been working to
Recent JCI accreditation (received in April 2015, making it one of the youngest dispel myths that were
hospitals to receive the international gold standard certification) gives the hospital
significant credibility and positions HCCI to ramp up marketing both regionally and in 6
international markets. HCCI’s medium-term strategy will target patients from the
United States and Canada, with longer-term prospects from South America and
Europe. In Canada, for example, they plan to target people for whom the
opportunity cost of wait times for surgery outweighs the price of paying out of
 Attachment G5

WORKING PAPER - DO NOT CITE OR DISTRIBUTE

WITHOUT PERMISSION OF THE AUTHORS
initial barriers to local adoption, including perceptions that low cost means low quality, that a
medical tourism institution would not serve locals, that Indian doctors weren’t as good as
Western doctors and might not speak English (the HCCI care team now has Spanish speakers,
too), and that the hospital would only offer telemedicine. To help address these misconceptions,
HCCI provided care to a few notable Caymanians, who then became local advocates for the
hospital.

As volume increases, HCCI plans to expand its specialties. New, diverse services have been
commissioned, including medical oncology, spine surgery, bariatric surgery, and a sleep lab;
sports medicine, radiation, and surgical oncology are coming soon. A cancer institute is expected
to be operational by mid-2016. The long-term plan also includes expansion to 2,000 hospital
beds within 15 years; a medical university; and a 1,500-unit assisted living facility, which will
serve people needing day-to-day medical supervision, as well as healthy retirees wanting health
care services nearby. Pharma-tourism—people willing to travel to purchase cheaper medicines—
is also seen as a potential growth area.

Most NH hospitals in India break even in 30 months. HCCI is expected to achieve positive
earnings before interest, taxes, depreciation, and amortization during the last quarter of 2016.
While any analysis of sustainability is speculative at this stage, HCCI is well-positioned both
geographically and as a brand to change the cost and process of surgery for the Americas and the
Caribbean. However, sustainability will depend on the company’s ability to drive up patient
volume in all clinical areas. To accomplish this, the hospital will need to gain significant traction
in the surrounding markets. It may introduce more diverse medical offerings outside of the NH
core service structure, as noted above. The staffing model is sustainable in the medium term, as
long as recruitment from India continues unabated.

EVIDENCE OF IMPACT
The NH model has been rigorously studied, and the impacts in clinical quality, health care
access, health outcomes, and efficiencies are well documented in peer-reviewed literature. In
2007, NH was responsible for 12 percent of all cardiac surgical procedures performed in India,
with 25 procedures completed daily, six days per week.v The high-volume model means that
each NH surgeon does 400 to 600 procedures annually, while U.S. surgeons perform 100 to
200.vi As noted above, surgeons quickly develop tremendous domain expertise, resulting in
excellent patient outcomes that rival those in the United States. For example, NH reports a 1.4
percent mortality rate within 30 days of coronary artery bypass graft surgery (CABG), compared
with 1.9 percent in the United States.vii

Although it’s too early to analyze data for HCCI’s health outcomes, the relevant cost advantage
is evident. At the time of writing, HCCI’s completed procedures are primarily in cardiology

7
 Attachment G5

WORKING PAPER - DO NOT CITE OR DISTRIBUTE

WITHOUT PERMISSION OF THE AUTHORS
(62%) and orthopedic surgery (23%), with 11 percent in cardiac surgery and 4 percent in other
specialties. HCCI’s bundled pricing structure is typically set at 30 percent to 50 percent of U.S.
fees for the same procedures; for example, CABG typically costs $100,000 or more in the United
States, while HCCI charges around $25,000. HCCI is focused on expanding services and
reducing costs further, with the ultimate goal of providing CABG for $15,000 and joint
replacement surgeries for $10,000.

Researchers at Stanford University are developing a time-driven, activity-based costing model

that allows them to measure the cost of each part of the patient encounter at NH, from walking in
the door through follow-up. Colleagues at Duke University are working with HCCI to develop a
similar model. This will allow HCCI to identify the cost drivers for each department and
procedure and will support efforts to measure and improve efficiency.

HOW CAN THE INNOVATION BE ADOPTED TO WORK IN THE UNITED STATES?

It is unlikely that the NH model could be replicated wholesale in the United States, due to the
regulatory and work culture changes that would be required. However, by replicating aspects of
the system-wide efficiencies of the model, U.S. hospitals could see significant cost savings. The
unrelenting focus of the NH and HCCI models to find efficiencies in every aspect of the
operating model could, with strong leadership, be adopted by U.S. health providers.

While U.S. regulations around licensure and scope-of-practice laws may inhibit the adoption of
many of NH’s efficiency strategies, there is opportunity to explore the cost-saving potential
related to task shifting. Advance-practice providers such as nurse practitioners can complete
nearly all aspects of the surgical process, including wound closure, and the surgeon’s time could
be used exclusively for tasks only a surgeon can conduct. This process, combined with an
assembly line approach to patient throughput, could clear bottlenecks in the surgical process and
lead to higher volumes, better quality outcomes, and cost reductions.

Another example is transparency of costs across the organization. At NH, each receptionist,
billing specialist, nurse, lab technician, and physician knows the cost of every material they use
and every procedure they recommend. With the time-based activity costing model being
developed at HCCI, staff will also soon be able to know the cost of each aspect of the patient
encounter and how they can reduce that cost through simple efficiencies. There is growing
interest in bringing greater transparency to U.S. health care pricing, and these efforts could be
informed by the NH and HCCI models. Cost data could motivate members of U.S. care teams to
participate in cost-reduction strategies, particularly if aligned with a service mission, as it is at
NH: reducing cost of care means that more people can receive high-quality care.

8
 Attachment G5

WORKING PAPER - DO NOT CITE OR DISTRIBUTE

WITHOUT PERMISSION OF THE AUTHORS
HCCI brings the NH model of high-quality, low-cost specialty care within a few hours of U.S.
patients and offers a dramatically frugal alternative to U.S.-based care. Surgical treatment of
cardiovascular disease, cancer, and orthopedic conditions (including joint replacements) are top
drivers of health care expenditures in the United States, and demand will increase with the
growing aging population. A U.S. insurer could offer to cover the entire cost of travel for the
patient and a companion to Grand Cayman, surgery at HCCI, and postoperative care at home,
and still save half the average fees of the procedure in the United States. If U.S. providers don’t
become more efficient and less costly, payers will be tempted to send insured patients to the
Cayman Islands, putting competitive pressure on U.S. hospitals.

U.S. health insurers and consumers are clearly interested, if tentative, and medical tourism
companies are emerging to facilitate cost-saving surgeries at HCCI and other global locations.
Self-insured companies are likely to test the model first, because they have the clearest financial
incentives, but other payers may follow as payment structures and incentives shift toward a focus
on reimbursement for outcomes versus fee-for-service models.

9
 Attachment G5

WORKING PAPER - DO NOT CITE OR DISTRIBUTE

WITHOUT PERMISSION OF THE AUTHORS
APPENDIX
ADDITIONAL DETAIL ON THE HEALTH CITY CAYMAN ISLANDS MODEL

Business Model
The mission-driven approach of NH to serve all patients, regardless of ability to pay, is made sustainable
by driving operational costs down through unique process efficiencies, ensuring high patient volumes at
all times, and attracting a high proportion of full-pay patients through quality outcomes and low cost. The
HCCI venture seeks to replicate this success, but adjustments to the business model were necessary to
meet the different target population, payer mix, and operating environment.

The cost of building and launching the HCCI hospital was $70 million, funded through a mix of debt and
equity; this does not include the cost of future stages. The model’s major cost drivers are personnel,
supplies, and overhead. Compared to India, the cost of utilities, personnel, and supplies are far higher in
Grand Cayman, and many of these costs will remain higher. Some operating costs, however, will be
reduced over time by economies of scale and development of more efficient supply chains.

Because the cost of the most expensive personnel (managers and surgeons) is fixed regardless of surgery
volume, staff is the primary cost driver for HCCI. To keep staff as lean as possible during the start-up
phase while patient volumes are low, senior-level clinical and managerial staff are expected to hold
multiple roles.

NH has built reliable low-cost supply chains in India over the past decade and leverages economies of
scale to drive prices down further. HCCI has capitalized on this and procures most supplies directly from
India. The added time and unpredictable nature of sea transport complicates inventory management but,
even with transport costs, the price is a fraction of what comparable supplies would cost from other
markets. Medicines are procured from FDA-approved companies in India when possible, and the
remainder come from the United States or the United Kingdom, through NH’s existing supplier
relationships. As patient volumes increase, HCCI expects to shift from on-demand orders to streamlined
bulk orders, improving efficiency. True to the NH model, HCCI doctors are aware of supply costs and are
involved in the acquisition process to ensure they include cost in their decisions and avoid unnecessary
expenses.

Utilities, such as water and electricity, are another major cost for HCCI; they are far more expensive in
the Cayman Islands than in India. To address this, HCCI recycles water for reuse and is planning a solar
farm.

The NH business model is designed for the Indian context in which the majority of health expenditures
are out of pocket (58 percent of total health expenditure) and the majority of patients self-finance their
care.1 To serve the Cayman Islands and Latin American markets, where the majority of people are
insured, HCCI must adjust its pricing, billing, and marketing strategies to the preferences of insurance
payers. Whereas NH pricing is transparent, HCCI does not publish prices because it needs to allow for
negotiation with insurance companies. HCCI uses bundled, fixed pricing, rather than billing by codes, and
1
World Health Organization Global Health Expenditure Database.

10
 Attachment G5

WORKING PAPER - DO NOT CITE OR DISTRIBUTE

WITHOUT PERMISSION OF THE AUTHORS
typically sets prices at one-third to half of average U.S. prices. Eschewing current procedural terminology
(CPT) codes in favor of bundled pricing for procedures results in significant efficiencies for HCCI (it
employs only two billing staff for the entire hospital) and caps risk for insurance companies. The bundled
procedure price includes consultations, preoperative and postoperative investigations, admission charges,
surgical fees, operating room fees, anesthesia, implant costs, room and food charges, medications and
surgical consumables, transportation, and all physician visits up to two weeks post-op.

While bundled pricing is attractive in theory to U.S. insurance companies, HCCI has learned that, in
reality, most insurance companies still want to receive itemized bills to match U.S. billing codes. Another
challenge that HCCI faces in dealing with insurance payers is long wait times for payments. NH reports
that the current average for NH Cardiac Hospital is over 70 percent cash payments directly from patients,
with payments received at the time of service. However, HCCI faces 45- to 50-day waits to receive
payment after billing insurance companies, making cash-flow management more difficult. A key question
for patients and insurance companies that HCCI must address is postoperative support for medical
tourists. HCCI helps insurance companies and patients find resources near their homes.

Staffing Model
Like NH, HCCI utilizes lean management principles, and staffing is planned according to minimum
requirements based on patient volume. The HCCI staff typically wear multiple hats (e.g., head of internal
medicine also heads pharmacy and a pulmonologist also heads infection control), which is partly a
function of current volume, but also reflects a cultural ethos HCCI sought to replicate by bringing teams
from India. A willingness to do what is asked of you, regardless of your formal role, is a key component
of NH culture and is familiar to the Indian staff, most of whom trained at NH in India. Ability to balance
multiple tasks is a key criterion in selecting candidates for HCCI. Internal hiring is also prioritized, to
maintain the strong organizational culture.

There are currently 163

Employee Category Caymanian Indian Others Total
employees at HCCI, with 107
Administration 18 24 4 46 (about two-thirds) recruited from
Doctor 1 21 0 22 India (see table). All clinical staff
Nursing 3 33 0 36 are currently recruited from India,
Paramedics 3 29 2 34 in part because there is not
Support Services 24 0 1 25 sufficient local capacity for the
Total 49 107 7 163 high-end, specialized care that
HCCI offers, and also to ensure
brand fidelity and work culture in the replication. HCCI has an agreement with the Caymanian
government allowing them to source clinical staff from India, providing flexibility to draw from a large
labor pool in India and to structure agreements based on needs. For example, HCCI can set up short-term
agreements to meet demand predictions. Most contracts are renewable two-year terms, which staff prefer.
Being recruited to HCCI is viewed as an excellent professional development opportunity.

HCCI has committed to the Caymanian government to maintain a minimum of 25 percent to 30 percent
local employees (currently at 30 percent). To meet this goal long term, HCCI has implemented an

11
 Attachment G5

WORKING PAPER - DO NOT CITE OR DISTRIBUTE

WITHOUT PERMISSION OF THE AUTHORS
aggressive student intern program with 199 student interns this year and an anticipated 300 next year.
Historically, the primary industries on the island are banking and tourism, with little emphasis on
sciences. HCCI is working with the government to develop a long-term strategy to increase science
curriculum and exposure to health care professions. In 15 years, HCCI plans for one-third of its staff
across all categories, including clinical, to be Caymanian.

Policy and Regulatory Changes Made to Enable HCCI’s Model

The Caymanian government worked with NH and Ascension to change laws and regulations to enable the
adaptation of the NH model to the Caymans. Changes were made to the following nine laws, which were
implemented through changes to 13 regulations.

1. Health Practice Law

2. Tort Reform Law
3. Organ Transplant Law
4. Organ Importation Law
5. Planning Law
6. Customs Law
7. Immigration Law
8. Registered Land Law
9. Local Companies Control Law

12
 Attachment G5

WORKING PAPER - DO NOT CITE OR DISTRIBUTE

WITHOUT PERMISSION OF THE AUTHORS
Notes

i
Khanna, T., Rangan, V. K., and Manocaran, M., "Narayana Hrudayalaya Heart Hospital: Cardiac Care
for the Poor." Harvard Business School 20, revised April 2006.
ii
Richman, B. D., Udayakumar, K., Mitchell, W., and Schulman, K. A., "Lessons from India in
Organizational Innovation: A Tale of Two Heart Hospitals." Health Affairs, Sept. 2008 27(5):1260-70.
iii
Govindarajan, V., and Ramamurti, R., "Delivering World-Class Health Care, Affordably." Harvard
Business Review, Nov. 2013 91(11):117-22.
iv
Khanna, T., and Gupta, B., "Health City Cayman Islands." Harvard Business School Case, May 2014
714-510.
v
Kothandaraman, P., and Mookerjee, S., "Healthcare for All: Narayana Hrudayalaya, Bangalore."
Growing Inclusive Markets (2007).
vi
Govindarajan and Ramamurti, "Delivering World-Class Health Care, Affordably," 2013.
vii
Anand, G. "The Henry Ford of Heart Surgery." The Wall Street Journal, Nov. 21, 2009.

13