TheSmartManager, SanjayPatro, Feb-Mar 08 - 475

27
DEVELOPI NG I NFRASTRUCTURE THROUGH MANAGEMENT I NNOVATI ONS

introduction by Nirmalya Kumar & Phanish Puranam
In this sixth anniversary issue, The Smart Manager is proud to
feature nine case studies which cover interesting problems in
management from a variety of sectors. These were developed
in the belief that innovations in management will play a key role
in overcoming Indias infrastructure shortfall.
developing infrastructure
through
management innovations
air india-indian: merging their way to success?
by Mala Srivastava, NMIMS, Mumbai
gujarat electricity boards turnaround
by Rakesh Mohan Joshi, Indian Institute of Foreign Trade, New Delhi
jalanidhi: success through participation
by Jeyavelu & Gopinath, Indian Institute of Management, Kozhikode
marg constructions (a)
by R S Veeravalli, Great Lakes Institue of Management, Chennai
state bank of india
by Narender L Ahuja, International Management Institute, New Delhi
reliance fresh stores in food retailing
by Debasis Pradhan & B K Mangaraj, XLRI Jamshedpur
the road less traveled?
by Munish Kumar Thakur, XLRI Jamshedpur
vasant scribes
by Sanjay Patro & Vinay Kumar, XLRI Jamshedpur
repositioning india post
by Monica Khanna, KJ SIMSR, Mumbai
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www.thesmartmanager.com T H E S MAR T MANAG E R Feb-Mar 08 28
DEVELOPI NG I NFRASTRUCTURE THROUGH MANAGEMENT I NNOVATI ONS
There is little doubt that several aspects of infrastructure
in India will have to improve dramatically for the country
to sustain its current stellar rates of growth. How will
these improvements come about? The case studies
you are reading in this issue of The Smart Manager
were developed in the belief that innovations in
management will play a key role in overcoming India's
infrastructure shortfalls; and in the optimism that some
of these innovations are already underway.
Early last year, the Aditya V Birla India Centre at
the London Business School invited proposals for case
studies about development and innovations in
infrastructure and the public sector in India, from faculty
at all the leading business schools in India. We received
an overwhelming response of more than a 120
proposals, of which the nine cases you see before you
are the result of multiple rounds of selection,
development and polishing.
These nine cases cover interesting problems in
management from a variety of sectors such as retailing,
telecom, post, banking, airlines, primary education,
rural electrification and water supply among others.
Two threads connect these cases. First, they are truly
representative of both the "hard" as well as the "soft"
infrastructure of the economy. Second, the management
challenges each case highlights are both mind
boggling, as well as capable of unleashing enormous
social value if solved competently.
Consider the problems of completing rural electrification, providing
safe drinking water and effective primary education in rural areas.
Few would dispute the critical importance of these aspects of the
economic infrastructure, as well as the immense challenges that we
face in resolving these problems in India Yet, as the cases you read
will show, headway is being made against even these daunting problems
through innovative management- whether practiced by the government,
the private sector or a combination of the two. Other cases in this
collection highlight the challenges that former state owned monopolies
in airlines, banking and postal services face in a brave new competitive
world, and perhaps surprisingly point to the strengths on which these
organizations are able to draw in their struggles. Finally, some of the
cases document exciting developments in areas like retail and telecom,
which are vital components of the broader economic infrastructure of
the economy, and where productivity improvements can have wide
ranging consequences.
The Aditya V Birla India Centre at London Business School was
launched in 1999 with the vision to be the leading centre outside India
of research and teaching that enables a mutually beneficial academic
exchange between Indian business and the global business community.
The case development initiative we launched last year fits well with
this mandate and we are hoping to make this case development program
a regular activity for the Centre. Our hope is that these cases will be
read with pride by students of management in India and with considerable
interest by those outside. While the cases and contexts are uniquely
Indian, the management problems they highlight as well as the innovative
solutions they describe are not necessarily bound to any particular
geography. We hope you agree.
phanish puranam
Assistant Professor, Strategic and Information
Management, and Co-Director for Aditya V Birla India
Centre at London Business School, Puranam's
research focuses on the organization of inter-firm
relationships: strategic partnerships, outsourcing/off
shoring arrangements and acquisitions. In particular,
his work seeks to highlight the importance of organi-
zation and coordination both within and between firms.
developing infrastructure through
management innovations
By Nirmalya Kumar & Phanish Puranam
nirmalya kumar
A Phd from Northwestern University, Kumar is currently
the Professor of Marketing, Director of Centre for
Marketing, and Co-Director for Aditya V Birla India
Centre at London Business School. He is passionate
about marketing and believes that for marketing to be
relevant to CEOs, it must become strategic, cross
functional, and bottom line oriented. In his leisure
time Kumar likes to travel, ski and write.
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www.thesmartmanager.com T H E S MAR T MANAG E R Feb-Mar 08 179
S M A R T E N T E R P R I S E
the management team at Vasant Scribes had just completed their
semi-annual meeting to review progress during the past six months
and plan for the future. Although the company had taken steps
to diversify into higher value added areas of medical billing
and marketing analytics, in line with its plans two years ago, there
had been very little achieved to speak about.
Vasant Scribes Limited was established in 1999 with a
primary objective of establishing ITES (IT enabled services) which
was then considered a sunrise business.
An IT enabled services firm company, faces the classic dilemma of growing its business organically
or by diversification.
i
t was May 2007, G K B Chowdary, Managing Director and
vasant scribes
by Sanjay Patro & Vinay Kumar
Founder, Datawise, Kumar has worked
both in India and abroad and has about
17 years of experience. His company
provides strategy and management
consulting to small and medium
companies. A graduate from IIM,
Ahmedabad, he is currently pursuing
his fellowship from XLRI Business
School, Jamshedpur.
Chairperson of Marketing Area at
XLRI Jamshedpur, Patro's areas
of interest are strategic marketing,
brand management, product manage-
ment and rural marketing. With
over twenty years of experience in
teaching, research and training, he
has conducted several training
programs on effective marketing,
industrial marketing, customer service,
brand management and rural marketing
to several MNCs and Indian firms.
www.thesmartmanager.com T H E S MAR T MANAG E R Feb -Mar 08 180
VASANT SCRIBES by Sanjay Patro & Vinay Kumar
exhibit 01 : medical transcription process overview
indian transcription process
doctor
transcriptionist
proof reader
doctor
transcriptionist
doctor dictates
audio file
doctor dictates
audio file
transcriptionist
transcribes the file and
transmits an electronic
file back to the doctor
transcriptionist
transcribes and
send electronic file
to proof reader
proof reader edits the
electronic file and
transmits back to the
doctor
the us transcription process
It had grown to figure among the top ten
medical transcription companies in India.
Among the leaders in the Indian medical
transcription companies were companies that
had headcounts of 1,000 plus and invariably had
a strong US base, such as CBay, Healthscribe,
Heartland, and Spryance. Second tier trans-
cription companies consisted of companies
which were primarily home-grown but had
come close to the first tier with headcounts
ranging from 500 to 1,000. These included
companies such as Acusis, Focus Infosys, and
Transdyne. Vasant Scribes was in the third tier.
One of the key decisions that was taken
at the time of setting up the medical transcription
business at Vasant Scribes was that the company
would not source business from third parties, that
is, it would not approach brokers or agents for
outsourcing business. It would be directly in touch with its
customers and deliver services to them. The Indian ITES sector had
witnessed a boom in recent years, with average growth of more
than 30% being posted by companies in this sector. With its large
base of English speaking people, and the advantage of a time zone
difference between India and the western world, growth was
expected to continue at a rapid rate even in the years to come.
G K B Chowdary was concerned with the lack of progress
on the diversification and was questioning whether to stick with it.
On the other hand, the transcription business of the company
had a breakthrough in the form of a new contract with MedQuist,
the worlds largest medical transcription service provider. This
contract alone was enough to catapult Vasant Scribes into one of
the biggest medical transcription companies in India. If the
company were to continue its efforts at growing the medical
billing and marketing analytics business, the management
would have to formulate a new mechanism to promote growth,
as previous efforts yielded minimal gains.
with its large base of ENGLISH speaking people and a TIME zone
difference, GROWTH was expected to continue at a RAPID rate
Chowdary needed to decide whether the
company should proceed with its earlier plan of
persevering with the new lines of business,
or concentrate on the new found thrust to
medical transcription business?
the medical transcription industry:
a background
Medical transcription was the process of
converting voice dictation (typically either
cassette or digital format) into a permanent
written record utilizing word processing
equipment and software. US legal system
demanded patients medical history be recorded
and maintained.
The doctor dictated those records in
audio form in his audio system. Medical
transcriptionists (MTs) listened to the audio
and transcribed into written formats. In India,
there was a further level of proofreaders who
would proofread these written documents.
Thereafter, the word files were uploaded
into the clients system.
Medical transcription was traditionally
carried out by secretaries in the US clinics
and hospitals. However, clinics and hospitals
realized that with their greater focus on
profitability, they could not afford to pay
high salaries to these secretaries. They also
realized that this was a non-core activity that
could easily be outsourced.
At the same time, the advent of Internet
made it easier for transcriptionists to work
out of remote locations. Whereas earlier
physical presence of the transcriptionists
at the workplace was considered a must,
now secretaries could receive voice files from
the hospitals or clinics and type out of
their homes.
This comfort in outsourcing gave rise to the outsourced medical
transcription industry. To begin with, secretaries to clinics and
hospitals decided to work from home, undertaking to work for
more than one physician or clinic, thus maximizing their own
revenues. This was a win-win situation for the transcription
secretaries as well as the clinics and hospitals.
Over time, there was consolidation of some of these companies
that resulted in the emergence of a few large medical transcription
companies in the US.
The biggest among these was MedQuist, a company that
had a relatively recent heritage. MedQuist, a company owned
by Royal Philips Electronics (71% of the shareholding vests
with it) claimed to have revenues of close to $500mn annually,
and had grown largely fueled by a series of acquisitions.
MedQuist employed about 6,500 medical transcriptionists.
However, MedQuist contracted transcriptionists out of their
homes, and did not have them as their employees (until recently:
MedQuist revised its policy recently to ensure that all its
transcriptionists compulsorily become its employees.).
Spheris was recognized as the second largest medical
transcription company in the world. Spheris had more than
6,000 direct employees, including more than 5,500 professional
medical transcriptionists. Spheris was headquartered in Franklin,
TN, with major operations in St Petersburg, FL; Sterling, VA;
Milpitas, CA. After the acquisition of Healthscribe in 2005,
Spheris got a presence in Bangalore and Coimbatore in India.
Spheris acquired Healthscribe at a price of $75mn. As on 31
December 2006, Spheris had net revenues of $207mn.
Barring these few giants the medical transcription industry
consisted of a number of small or home based transcription
companies; the medical transcription industry had remained
a cottage industry.
It was therefore difficult to determine an accurate estimate
of the exact market size of medical transcription market in
the US. According to a corporate spokesperson of Spheris, The
clinical documentation outsourcing industry is highly fragmented.
We estimate that the top ten firms in the industry account for
less than 10% of the total outsourcing market. There are several mid-
sized service providers with annual revenues between $10mn and
the MEDICAL transcription INDUSTRY
had REMAINED a COTTAGE industry
$40mn, and hundreds of smaller, independent
businesses. Most of the outsourcing providers are
US based, but there are several companies,
including us, that have a global presence.
We also compete with in-house medical
transcription departments of hospitals and group
practices. We believe that approximately 50%
of medical transcription services in our
addressable market currently are performed
in-house by healthcare facilities. To compete
with in-house medical transcription departments,
we must be able to providea cost effective
alternative to in-house transcription by offering
technology improvements, lower costs, faster
turnaround times, higher quality, a scalable
model and access to professional MLS.
In addition, as technology evolves, including
the continued refinement of speech recognition
technology, health information technology
providers are attempting to provide services
that replace, or reduce the need for, medical
transcription. Furthermore, companies that
provide services complementary to medical
transcription, such as electronic medical records,
coding and billing, may expand the services they
provide to include medical transcription, and
therefore, become competitors of ours.
According to US Bureau of Labor Statistics
(BLS), MTs held about 105,000 jobs in 2004.
About four out of ten worked in hospitals and
other three out of ten worked in offices of
physicians. Others worked for business support
services; medical and diagnostic laboratories;
outpatient care centers; and offices of physical,
occupational and speech therapists, and audio-
logists. Less than 15% were employed by
professional outsourcing service providers.
What was most noteworthy was the fact that
between 1999 and 2004, the overall employment
of MTs in the US increased by only 1.5% per annum. This was
despite the fact that the Bureau had predicted an employment
demand growth for MTs faster than the average growth for all
occupation.
The sluggish growth in MTs in the US was triggered by
a number of reasons:
American transcriptionists were aging; most were aged between
47 and 51 years
IT vendors were providing new technology including EHR
(electronic health records) and speech recognition technologies
which were increasingly reducing the need for transcriptionists
medical transcription was no longer considered a paying career
in the US, and transcriptionists had to remain content with
low salaries
the ITES industry in india
According to NASSCOM (National Association of Software
and Service Companies), Indias ITES sector, the primary destination
of business services outsourcing from Western countries,
employed over 400,000 people with revenues expected to exceed
$8.3bn, of which over 70% were to the US. While the sector was
still small it was growing at a rate of more than 30% per annum.
NASSCOM forecasted that exports would hit the $50bn mark
in five years. By that time, the business process/business services
outsourcing segment would employ over 2mn people, and the
total exports of the IT industry would support over 8mn jobs.
India offered many advantages to serving as an ITES
destination for major global companies. These included:
a virtual twelve hour time zone difference with US and other
major markets for ITES
a huge pool of English speaking and computer literate man-
power that continued to cater to the growing demand for
professionals for ITES. These professionals were skilled as
well as quality conscious
cost of qualified personnel was amongst the lowest in the world
stable legislative and economic framework
many state governments in India offered special incentives
and infrastructure for setting up ITES
thrust by Government of India to make India an IT driven
while the SECTOR was still small it was GROWING
at a RATE of more than 30% per ANNUM
nation with a focus on the services sector where
potential for value addition and thus premium
was higher.
India enjoyed very strong brand equity in
major markets, thanks to its growing and
globally competitive software industry. The
proliferation of ITES and its continuing demand
led growth had become a strong opportunity
for India, both in terms of generating employment
and export.
medical transcription in india
In 1993, Healthscribe became the first medical
transcription company to be set up in India. The
companys base was in Delaware, US which
controlled all its marketing efforts while
transcription was carried out of Bangalore, India.
As a pioneer in offshoring, Healthscribe
found it difficult to break into the American
medical transcription market and to convince
its first customers to send transcription work to
India. Typical concerns were data security and
uncertainty whether Indians could transcribe at
all. Countering these concerns were some big advant-
ages that Indian off shoring companies offered:
the rates charged by Indian companies were
significantly lower than those charged by US
based transcription companies or trans-
criptionists. Sometimes, the difference in
rates was as high as 40%-50%, a high incentive
for clients to consider shifting business to India.
The huge English speaking workforce gave
India the advantage of being able to offer
these services at competitive rates.
india, with its unique geographical position,
was able to offer transcription services during
the American night (the time difference between
US and India was approximately twelve hours).
As a result, while corporate America was asleep,
the transcriptionists in India would transcribe
the dictations during the Indian day, and
transmit the transcriptions back in time for
the clients in the US.
Once Healthscribe managed to break the barriers of offshoring
medical transcription work to India, a number of companies followed
suit; some of the early pioneers included, Heartland, and CBay. As
a result, by the late 90s there was a proliferation of medical
exhibit 02: the top six medical
transcription companies in india
company ceo no. of current
employees status
C-bay v raman 3,500 -
own centers kumar
and franchisees
Heartland bryan 1,500 merged with
own center, jv black Spryance
Healthscribe suresh 1,350 acquired by Spheris,
own center and nair the second largest
hbt medical transcription
company in the
world
Spryance raj 1,000 merged with
own centers/hbts malhotra Heartland
Acusis coo: kb 550 -
own center/hbts anand
Focus Infosys jayesh 4,500 acquired by nuance,
own centers nagda a company
specializing in
speech recognition
technology (owned
by Dictaphone)
50,000
jan05 feb05 mar05 apr05 may05 jun05 jul05 aug05 sep05 oct05 nov05
60,000
70,000
80,000
90,000
100,000
110,000
exhibit 03: the overall business
volume of vasant scribes in 2005
average lines per day
IT services
exports
ITES-BPO
exports
ES+
product
exports
domestic
market
fy 07
fy 06
NASSCOM July 2007
6.7
8.2
4.0
4.9
6.3
8.4
13.3
18.0
Some of the key trends in the medical transcription industry were as follows:
the demand for offshore MT outsourcing services in the US was growing at about 20% per year.
there had been a steady 10% decline in the number of transcriptionists in the US every year.
American transcriptionists were aging (most were aged between 47 and 51)
the US MT industry calculated that it needed at least 25,000 medical transcriptionists per year for it to grow at the same rate at
which it has grown in the past
according to IDC, US spending on medical outsourcing services totaled $2.3bn in 2004
IDC's research further showed that although MT was still being performed with antiquated technology, IT vendors were providing
new technology including Electronic Health Records (EHR) and speech recognition technologies.
forecasts showed that the market would increase to $4.2bn in 2008 with a five year CAGR (compound annual growth rate)
of 16.1%
US industry medical transcription
employment breakup
US states with highest medical
transcription employment
industry employment (%)
general medical and 40.2
surgical hospitals
offices of physicians 33.2
business support services 12.5
offices of other health 2.3
practitioners
medical and diagnostic 2.0
laboratories
others 9.8
state employment (%)
Michigan 5,590
Wisconsin 3,830
West Virginia 980
South Dakota 780
North Dakota 520
may 2003 figure. source: US Bureau of Labor Statistics
figures in $bn
exhibit 04: medical transcription industry statistics
Indian IT software and
services revenues
transcription companies in India, all eager
to cater to the US markets. Most of them
were drawn by the lure of easy money. The
barriers to entry into medical transcription
were very low. According to Ramakrishna, the owner of WorldTech,
Every proof reader considered himself capable of starting
his own unit. He would break away and take another twenty
trained people with him and start a transcription centre.
exhibit 05: the top six medical transcription companies in India
It was estimated that the medical transcription market would continue to grow year on year, as shown in the table below:
year us medical outsourced #mts projected total value of gap between
transcription market for mt employed by value of the output of us demand for
market @10% @13% mtsos productivity mts employed services and
growth/yr growth/yr (declining increase of us by us mtsos supply of mts
(in bn) (in bn) @ 5%/yr) mtsos @3%/yr (in bn)
2000 $10.00 $4.60 178,000 $33,000 $5.87 sufficient supply
2002 $12.10 $5.87 161,000 $35,000 $5.64 $0.24
2004 $14.64 $7.50 145,000 $37,100 $5.38 $2.12
2006 $17.72 $9.58 131,000 $39,400 $5.16 $4.42
2008 $21.44 $12.23 119,000 $41,800 $4.97 $7.25
Larger companies required large infrastructure
such as servers, security systems, bandwidth,
power back-up systems, etc. They also invested
more in senior management who were capable
of managing operations.
In contrast, smaller transcription outfits
operated with a proof reader-owner who
doubled up as the manager for all allied
functions (personnel, administration, finance,
and IT). Such companies were therefore able
to keep overheads low. Since the key deliver-
able requirements (quality and turnaround)
were largely independent of these over-
heads, customers, especially the physician
practices did not insist on specific standards
in this regard. Smaller transcription companies
therefore managed to have much better
profitability than larger transcription companies.
Even in the US, it is interesting to note that
none of the top ten medical transcription
companies makes profit, says Ravi Rajagopal,
COO, Elico, a medium sized medical trans-
cription company based in Hyderabad. Elico
had moved into medical billing business and
was providing services to its US based partner who maintained
the interface with the clients.
The top six transcription companies (refer exhibits 02, 03, 04,
05, 06 and 07) accounted for 75% of the revenue and close
to 70% of the employment. There were another five to six
companies that had hundred or more people. In that sense,
the average employees per company among the rest turns out
to be less than twenty. Medical transcription had assumed the
form of a cottage industry in India, not very different from
that in the US.
In spite of this rapid increase in the number of companies,
in reality, Indian transcription companies found it difficult to
survive because they miscalculated a number of factors:
offshoring was seen as attractive only when the price differential
was high. As a result, most outsourcing contracts were at rates
significantly lower than what they were worth in the US. Medical
transcription contracts were typically based on a payment per
line of transcription. In the US, these payments ranged between
14-15 per line. In India, transcription companies started
with quotes at a 40%-50% discount to the US rates, but under-cutting
resulted in prices in the range of 2-3 per line in many cases.
Clearly, transcription business was not viable at these rates.
quality of the transcription was paramount, and even with
good english speaking graduates recruited for the job, transcription
smaller TRANSCRIPTION companies therefore MANAGED to have
much better PROFITABILITY than larger transcription COMPANIES
category no. of share of indias performance
players total it/bpo export
revenues
IT services 10.4 13.5 17.5
tier i players 04 march 45% of IT services revenues greater than $1bn
4-5% of BPO
tier ii IT players 10 july 25% of IT services revenues $100mn-$1bn
4-5% of BPO
offshore operations of global 20-30 10-15% of IT services revenues $10mn- $500mn
IT majors 10-15% of BPO
pure play BPO providers 40-50 20% of BPO revenues $10mn- $200mn
(excluding top provider with $500mn)

captive BPO units 150 50% of BPO revenues $25mn- $150mn
(top ten units)
emerging players >3000 10-15% of IT services revenues less than $100mn (IT)
5% of BPO revenues less than $10mn (BPO)
* based on last comparable annual report
** earnings before interest, tax, and depreciation and amortization margins (last reported)
*** including captive centres for independent software vendors (for example, Microsoft, Oracle)
source: nasscom mckinsey report 2005
employment trends
the total direct employment in the Indian IT-ITES sector was estimated to have grown by over a million, from 284,000 in FY 99-00
to a projected 1287,000 in the current fiscal (2005-06)
in addition to the nearly 1.3mn strong workforce employed directly in the industry, Indian IT-ITES was estimated to have helped
create an additional 3mn job opportunities through indirect and induced employment. Indirect employment included expenditure on
vendors including telecom, power, construction, facility management, IT, transportation, catering and other services. Induced employment
is driven by consumption expenditure of employees on food, clothing, utilities, recreation, health and other services.
key industry highlights:
the leading publicly- listed players have reported a top line year-on-year growth of nearly 34%, over the first half of the current
fiscal.
multi national company owned captive units have been scaling up their operations steadily with the headcount forecast to grow
by at least 30% this year.
IT-ITES activity in the domestic market is also witnessing steady growth with the services segment coming into its own reflecting
sound optimism for the year end results.
India based service provider landscape
exhibit 06: medical transcription industry statistics
companies quickly realized that it was not easy
to transcribe. Doctors demanded accuracy levels
of 98.5% and more, which companies failed
to achieve. Quality in transcription had
been a much debated concept. The AAMT
(American Association of Medical Trans-
criptionists) had evolved definitions and standards
for quality, and most customers agreed that 98%
and above accuracies were acceptable. In reality, though even
one simple mistake could irritate the customer on a bad day.
Some doctors insisted on transcriptions without any form of
editing whereas others encouraged edits and grammar corrections.
in order to achieve the required levels of accuracy, companies
had to pass each transcript through two levels: a transcriptionist
and a proof reader, a concept alien to the US markets. This
immediately doubled the costs of transcription companies in India.
a typical American transcription could produce
about 1,000 lines per day of work. Indian
companies assumed that they could achieve
similar productivity with transcriptionists in
India. In reality, the productivity of Indian
transcriptionists was typically about half of that
of American transcriptionists. On top of it,
whereas American transcriptionists were
accustomed to working eight hour day shifts,
Indian transcriptionists typically worked based
on flexible timings. Productive time rarely
exceeded four to five hours. Very often, when
work was not available to keep the pool
of transcriptionists, their employers would
let them off.
marketing their services proved to be a big
hurdle, especially since most companies did not
have an established US presence. Credibility of these
companies and the scare of data security
kept large clinics and hospitals away.
According to Ramakrishna of WorldTech, a
pioneering Indian MT firm, We have to
constantly keep managing supply and demand
continued BUSINESS came through the US based INVESTORS,
whereas the Indian INVESTORS were incharge of OPERATIONAL control
situations. Work may suddenly come in one day without any
notice and it is not possible to postpone or decline it. On other
days, there would be no work at all. Planning for the ups and downs
of work becomes very crucial. We have to maintain a buffer of at least
15% excess transcriptionists at any time.
The transcription industry in India had evolved different
models to counter the fluctuating demand and supply patterns.
the joint venture model: a number of companies were grown
based on the investments made into a transcription company by
an interested US based entity (either a hospital, clinic or group
of physicians). The assurance of continued business came through
the US based investors, whereas the Indian investors were
incharge of operational control.
the sub-contracted model: another model was that of a sub-
contract. Indian transcription companies sub-contracted either
with US or India based transcription companies. This was typically
a win-win for both entities. The provider of the contract did
not have to worry about maintenance of adequate manpower and
issues of operational control and the transcribing company was
assured of a steady source of revenue. Elico, a mid-tier transcription
company in India had opted for this model. In a sub-contracted
model, the transcription company did not have direct contact with
the end-customer. Also, the rates that were offered were
exhibit 07: medical billing process
The typical stages involved in a medical billing process were as follows:
charge entry, which consisted of entering the details related to a patient's visit, upon completion of the visit, in a billing software.
verification, which was typically done by a senior level resource to ensure that the entries were made correctly in the software.
coding, which consisted of entering appropriate codes based on the pre-designated codes depending on the type of medical service
provided to the patient. Depending on the nature of the billing, the abilities of the software and the insurance company that a patient
had subscribed to, either electronic or paper bills were generated. Electronic bills were directly received by the insurance provider
whereas paper bills needed to be printed and dispatched by another intermediary process.
denial management, which consisted of reconciling the amounts billed to the insurance companies and the amounts accepted, and
accounting for the differences based on billing errors or other established protocol.
accounts receivable follow-up, which consisted of following up with the insurance provider for payments. This was usually done
through voice calls and required a VOIP (voice over internet protocol) or similar telephonic set-up.
finally, depending on the arrangements with the client, payments were either received directly by the billing service provider and
credited to the client after deducting the service charges, or were arranged through a lock-box facility, where the service provider had
the ability to 'view' the account.
significantly lower than what the transcription
company could make through a direct contract.
the partnership model: in a partnership
model, there were two separate entities, a
US based company which was only in the
business of marketing transcription services,
and the India based company, which was
only in the business of transcription operations.
Each company had core competencies related
to its area of specialization, and it was a
win-win. However, unless there were any
binding or exclusivity arrangements, there was
a risk of each of them losing the support
of the other, should the relationship not
work out.
build-operate-transfers (BOTs) and acquisitions:
a number of companies had adopted a
strategy where either a US transcription
company decided to enter the Indian tran-
scription industry through an acquisition
or a build-operate-transfers route, to
combat increasing difficulties in hiring
transcription talent in the US. Indian
companies too had explored the possibility
of acquiring US based transcription companies
to increase their customer base.
There had been failures and successes
with each of the above models as companies
in India and the US continued to explore
various possibilities.
recent developments in the medical
transcription industry in india
The main domestic players in the medical
transcription industry in India had recently seen
significant changes:
Healthscribe: the pioneer in the medical
transcription market in India was acquired by
Avicis, which was subsequently acquired by
Spheris in 2005.
Focus Infosys: viewed by many to be one of the largest medical
transcription companies in India (transcribed about 1mn lines per
day) was acquired by Nuance Communications in late 2006.
C-Bay Systems: a company that had rapidly become one of
the largest medical transcription companies in the world, was
rumored to be planning a public issue which would enable the
existing promoters to exit. It had, over the past few years,
been acquiring some of its sub-contractors (at one time, it
had 28 sub-contactors, many of whom were now acquired by C-Bay).
MedQuist: which had earlier tied up with Spryance (a medical
transcription company with a base in India), was scouting for
new partners in India to outsource its work. Medquist had
recently established an ILP (international labour partner)
program with this in mind.
history of vasant scribes limited
Vasant Chemicals Limited was the flagship company of the
Vasant Group. After being in the bulk chemical category for about
25 years, Chowdary, wanted to move into a new economy
business. Vasant Scribes Limited (VSL) was the outcome of
a brainstorming by the promoter of Vasant Scribes, who had a
desire to make a foray into the IT services sector. With the help of
consultants and internal reviews, the group narrowed down on
medical transcription services as the main focus area to enter
the services business.
Vasant Scribes transcribed about 100,000 lines of transcription
per day. It had about 320 employees spread over three locations
in Hyderabad. The company also outsourced some transcription
work to franchisees in Vijayawada, Coimbatore and Kolkata.
Vasant Scribes was a closely held company with a majority of
its shares held by Vasant Chemicals and the directors of
Vasant Scribes and their family members. The shareholding pattern
of VSL was as follows:
management team
The managing director of VSL was G K B Chowdary, a
seasoned entrepreneur with more than 25 years of successful
experience in running businesses. Although Chowdary was
a lawyer by profession, he had mastered the ability to manage
unless there were any BINDING or exclusivity ARRANGEMENTS,
there was a RISK of each of them losing the SUPPORT of the other
businesses in which he had little or no
knowledge to begin with. The companys
operations were led by Alok Singh, an MBA
from the Indian Institute of Management,
Ahmedabad, a reputed business school in India.
He was instrumental in setting up the initial
processes and procedures in the firm.
In the US, Vasant Scribes was led by
Jagannathan an alumnus of an US Ivy League
Business School. Jagannathan was also a
professor of marketing in the University of
Wisconsin and was on the board of Vasant
Scribes Limited.
About two and a half years ago, the company
inducted Vinay Kumar as the Chief Executive
Officer. Kumar was also an alumnus of the
Indian Institute of Management, Ahmedabad
and had about fifteen years of experience in
various companies in India and abroad.
Vasants second line of leadership comprised
of technical graduates and was entirely home-
grown. Most of the senior staff with Vasant
started their medical transcription careers with
the company. Most of them had no prior
corporate experience. About three years ago,
some of the senior proof readers were promoted
to supervisory level both as a career enhance-
ment and retention mechanism. Supervisory
positions were felt necessary to create optimum
team size for management and control.
Barring a couple, none of the second line
of management had any professional manage-
ment exposure. In the transcription industry
in India, this was common to a number
of companies. Often Kumar had to spend
long hours on day to day functioning of the
firm. He had strengthened the process driven
focus and was proud of the systems driven
approach of VSL.
phase 01: initial years and growth pangs (1999-2001)
In the initial years, the company decided to target known doctors
of US who were either known or related to the promoter.
Companys key management made a number of visits to these
clinics/doctors. However, after showing initial willingness to
try the services of Vasant Scribes, most of the doctors shied away.
The most often quoted reason was a lack of credibility.
All of Vasant Scribes medical transcription staff was fresh
graduates who were trained. The process of recruiting talent
was relatively easy since there was availability of unemployed
graduates. Each training program consisted of six months of
rigorous class room training where staff was imparted knowledge
in the language of medicine, and basic english grammar.
By 2000, the company was able to build a transcription team
that had the capabilities to handle about 15,000 lines of
transcription per day.
The period from 1999-2001 was of loss and consolidation for
most companies and Vasant was no exception. Transcription
companies that had survived the initial period continued to
incur losses for the first 2-3 years when capabilities were
established and yet business did not pour in as initially anticipated.
If one company starts a new business all others will
follow blindly in the next six months says Ramakrishna,
CEO, WorldTech. However, a number of companies that had
mushroomed during the first wave of medical transcription
and which did not have the financial backing to survive
quickly died. Some of the more persevering companies dug
into clinics which were run by their friends and family (Indian
doctors who had settled in the US).
Most of the smaller companies decided to outsource work from
agents who would offer work to the lowest bidders. Prices of
transcription services plummeted to as low as 2-3 per line
and companies quickly realized that it was not possible to run
a financially viable business at these rates.
With the surviving companies seeing a stabilization of their
revenues and profits, a number of companies started entertaining
thoughts of diversification during this period (2001-04).
Vasant Scribes also took a decision to establish a US subsidiary
in the same year on the premise that clinics and hospitals would
TRANSCRIPTION companies that had SURVIVED
the INITIAL period continued to incur LOSSES
be more comfortable working with a US based
entity rather than with an Indian company.
In August 2000, the company started its own
marketing efforts by setting up a US based
subsidiary, Vasant Scribes Inc, with a president
and a COO (chief operating officer). The COO
was sent from India, whereas the president
was an Indian who had been working in the
US for the past 25 years.
In addition, the company also sent a couple
of people as marketing staff from India to the
US. However, they could not win any accounts
partly because of their poor knowledge of the
American cultural nuances, and partly because
of their poor knowledge of the medical transcrip-
tion industry. They soon left the company.
The company achieved its first nominal
revenues of about Rs1500,000 ($37,736.80) in
the 2000-01 while incurring a loss of about
Rs700,000 ($17,610.51). By the end of 2001,
the company had built transcription capacities
of 50,000 lines per day. However, the volume
of contracted work was not adequate to fill
the capacities. Vasant had created production
capacities in anticipation of work volumes.
These work volumes continued to come in a
trickle, thereby creating a huge pressure on
maintaining high redundant manpower costs.
In early 2001, Vasant Scribes had to take the
harsh decision of releasing some of the staff since
the company was not able to gain enough
business to keep all staff busy. The key challenges
that the company faced during this phase were:
01 establishing credibility in the US transcription
market
02 winning its first clients
03 managing manpower and maintaining a
redundant workforce.
phase 02: the years of rapid growth
(2001-2004)
In 2001, the company initiated a number of
measures to improve marketing efforts,
including engaging the services of a US telemarketing services
company. This strategy started showing results in the second half
of the 2001. At the same time, the efforts in establishing a US based
subsidiary and sending the COO to the US started paying off.
Business had started growing at the rate of 5,000 lines per day
per month from October 2001, and most of the staff who were
earlier let go were recalled. In the 2001-02, the company
achieved revenues of about Rs6600,000 ($166,058.63) and yet
incurred a loss of about Rs12,000,000 ($301,924.77). It built
capacities of 50,000 lines per day.
While the company continued to gain clients in a trickle,
the first major break-through for the company came in 2002.
An account that was being sub-contracted from one of the
Indian Medical Transcription company decided to seek new
bids. Vasant Scribes was one of the bidders, and was viewed
favorably in view of its previous track record with the client.
This account catapulted Vasant Scribes from a small company
to a medium sized company. At the same time, some of the early
clients of Vasant Scribes also started referring other clients
to the company.
In order to further strengthen its production capabilities
without taking on the burden of additional manpower, the
company decided to enter into a sub-contracting relationship
with two smaller companies, a Vijayawada based medical
transcription company and another Hyderabad based medical
transcription company. Both these companies were initially
entrusted with small transcription volumes that could engage
around twenty to thirty transcriptionists.
2,000
oct 00
t
h
o
u
s
a
n
d
s
apr 01 oct 01 apr 02 oct 02 apr 03 oct 03 apr 04
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
20,000
exhibit 08: growth in
transcription volumes
Some of the key achievements of the
company in this phase were as follows:
01 wins of some medium sized clinic accounts.
Most of the initial clients were a result of door-
to-door campaigns. Subsequent wins were a
result of references from these clients.
02 winning a large account due to previous
relationship and experience with the client.
03 establishing sub-contractors in order to
increase capacities without risk of redundant
manpower.
In the year 2002-03, the company also
took a decision to increase price to some
of its long-standing customers by about 10%.
By the April 2004, the growth in trans-
cription volumes of the company, in terms
of lines per day (see exhibit 08).
The year 2004 was a defining year in
the history of Vasant Scribes. It won
two large clients. In addition, as a result of its
telemarketing efforts, the company was able to
sign a contract with a large clinic, which was
equivalent to about 40% of the total business
of the company.
marketing of medical transcription
in the us
By 2004, the company had already exhausted most
of its business leads in medical transcription.
Telemarketing did not yield any additional
business. Also, the sales efforts of the COO
were bearing no fruit. It was decided by the
management to engage the services of native
Americans as sales persons. The decision was based
on the premise that native Americans could
relate better to the Americans and therefore
could close sales faster.
According to Ramakrishna, When an Indian
salesman approaches a potential client, the
first question that is asked is regarding the price of the offering,
whereas when a native American salesman approaches a potential
client, the main area of interest revolves around the more
important factors of quality and turnaround time.
However, despite efforts from the new salesmen, most of
the business continued to come primarily from references only.
Since these references consisted of low volume small accounts,
the earlier high volume growth of the company started to peter
out. The breakdown of business gained during this period from
various sources is given in exhibit 09. Through this entire period,
there were no significant additions to the transcription volumes.
Most of the staff who had joined the company at the time
of incorporation also started to look for other avenues. As a result,
the company was once again faced with a dilemma of retention
of manpower. Whereas in the first phase of growth, the company
had excess manpower without adequate work, by the mid-2005,
the company had a steady stream of attrition which was
compounded by increasing trainee recruitments.
Vasants clients could broadly be divided into the following
three segments: those who generally gave consistent and high
work volumes and were prompt on payments, those who were
inconsistent on work volumes as well as payments, and those
who gave work only sporadically and were delinquent on payments.
Almost 70% of the business came from about 20% of the customers
who belonged to the first segment and the worst 20% of the business
came from a large number of customers from the third segment.
despite EFFORTS from the new SALESMEN, most of
the business CONTINUED to come primarily from REFERENCES only
exhibit 09: breakdown of business
sources total converted %
leads leads conversion
current customers 8 5 62.50%
references 31 14 45%
associates 8 4 50%
telemarketing 60 0 0%
advertising 3 0 0%
exhibitions 3 0 0%
sales persons 17 0 0%
In 2004-05, the company once again
proposed a fee increase to some of its customers.
The company performed a customer analysis
using parameters such as volume of business,
consistency, frequency and payment track
record and identified 49 customers who
contributed about 5% of the total revenues. Only
five of the customers dropped out as a result
of this exercise. At the end of this exercise,
Vasant was able to gain some additional
revenues while maintaining business volumes.
diversification dilemma
Based on these successes, and the hope of
continued business success, the company also
decided to pursue diversification. The idea to
diversify was fueled by the desire to continue
to grow rapidly while at the same time not
exposing the company to the risks of continuing
to operate in a single sector. There have been
continuing discussions amongst industry players
about the changing face of medical transcription
including the role of technology.
Also, the management felt that medical
transcription, by nature was a low skill business,
and sustaining the business operations would
prove to be difficult in the long run, since
costs of operations were expected to continue
to increase while the US dollar to Indian rupee
rates would remain steady at best. A natural
corollary to growth was therefore seen to be
to diversify into areas that offered higher
value. Some of the key areas that were
considered for diversification included:
appraisal transcription (being similar in nature
to medical transcription)
medical billing and coding (being a natural
forward integration into a high end outsourcing
business)
legal transcription/outsourcing (unrelated business)
voice mail transcription (being a natural extension to
medical transcription)
marketing analytics (unrelated business)
Among these, the company decided to pursue appraisal
transcription. While there were some differences in the delivery
requirements, the client company agreed to provide all the
technical support and training to start this business.
While the desire to diversify was clear, the actual decision
to expand and diversify was primarily driven by client requests.
In some cases, clients specifically asked for these services from
Vasant Scribes. Since no market studies or surveys were conducted,
this was identified as the first step leading towards starting these
new businesses.
Marketing analytics was identified as a growing industry
(commonly referred to as the knowledge process outsourcing,
or the KPO business), and was identified as a potential
area for growth. This was supported by the fact that
Jagannathan was an expert in the area of marketing and had
considerable expertise to lead this business. However, the
company decided to defer the plans for growth in marketing
analytics since it would not be possible to handle too many
new growth areas at the same time.
The idea of pursuing the legal transcription/outsourcing
business was dropped since it entailed gaining expertise in a
new area, and would call for significant investment of time
and effort. The company did not believe that it could afford
to dilute management attention, nor could it afford to hire
additional management talent.
phase 03: challenges of diversification (2005-2007)
In late 2004, a decision was finally taken to pursue medical
billing business. It was viewed as a natural forward integration
of existing medical transcription business. Also, based on a
preliminary feedback from existing medial transcription clients,
it appeared that the company could expect a few quick wins.
The company set up a medical billing operations team in
India. Deviating from its policy of recruiting only fresh graduates
as in the case of transcriptionists, the company decided to hire
COMPANY decided to defer plans for growth in marketing ANALYTICS
as it will not be POSSIBLE to handle too many new GROWTH areas
experienced talent. This was possible since
in the meanwhile the medical billing
outsourcing industry had also matured in India,
and talent was available. It was also felt
necessary to hire such talent to cut short the
learning curve in establishing a medical
billing business.
The medical billing business was inaugurat-
ed in early 2005, with the win of one client.
This client was already a medical transcription
client who moved out of its existing service
provider relationship in medical billing to sign
up Vasant Scribes.
The medical billing services were offered
under a different brand name of Vantage Villing
Services to distinguish it from Vasant Scribes,
which had already gained repute as a medical
transcription client.
medical billing industry overview
The medical billing industry was mainly divided
into the payer side billing (providing services to
the health insurance companies) and the provider
side billing (providing services to the clinics
and hospitals). Vasant Scribes has decided to offer
provider side billing services only.
Medical billing consisted of taking care of
the revenue cycle management of the clinics
and hospitals. Unlike medical transcription,
which was viewed as secretarial activity, medical
billing was a function that was typically
controlled by the CFOs or directly by the doctors
(in the case of smaller practices). Also, since
medical billing involved the money purses of the
facilities, clinics and hospitals were less keen to
change service providers.
Medical billing processes were more
complex as compared to medical transcription
and required registration of a billing software
in the state of the US where the service was provided, and
establishment of specialized back end processes which
were technology dependent.
Unlike in the case of medical transcription, where payments
were on a flat basis of cents for every line of transcription, in
the case of medical billing, there were two broadly accepted
industry practices:
in cases of companies that offered manpower irrespective and
not based on the actual degree of claims submitted, a flat rate
per employee was agreed.
in other, and more typical cases, fees were a percentage of the
amount billed and received from the insurance companies.
These percentages ranged from 2% to 5% depending upon
the complexity of the physician practice and therefore the
expected amount per patient.
Most medical billing companies in India continued to
source work from existing medical billing companies in the
US, and did not have any direct relationships with clinics
or hospitals, and were agreeable to either of the above basis
of payments.
Relative to medical transcription, medical billing was
also viewed as a relatively high risk area, since an incorrect
billing could make a company liable to damages and legal
suits. To de-risk their businesses, a number of medical billing
companies refused to do the coding. The coding, in such cases,
was done directly by the physician practice. Since it involved
revenues to the practice, the decision to outsource was
taken at the CFO or CEO levels of hospitals or healthcare
facilities, as opposed to administrative incharges in the case of
medical transcription.
Just as in the case of the medical transcription industry, the medical
billing industry in the US was also highly fragmented. No clear
estimates were available as to the size of the industry or
the number of people employed.
The BLS classified information about medical billing
employment under the heading medical records and health
informatics technicians. According to the BLS, in 2004, there
were about 159,000 staff who were employed in this profession
in the US. About two out of five jobs were in hospitals. The rest
MEDICAL billing consisted of taking CARE of the
REVENUE cycle management of the clinics and HOSPITALS
were mostly in offices of physicians, nursing care
facilities, outpatient care centers, and home health
care services. Insurance firms that dealt in health
matters employed a small number of health
information technicians to tabulate and analyze
health information.
Even in India, the information on the
medical billing industry was scarce. Some of
the major players in the medical billing
industry in India were:
Nittany: was one of the first companies in
India to start medical billing practice. It had
gradually lost clients as well as people to other
smaller medical billing companies in India.
Vision Health: a dominant player in the
Medical Billing industry in India was recently
acquired by Perot Systems, one of the largest
outsourcing companies in the US.
Ajuba: employed around 1,500 staff out of its
office in Chennai and concentrated on a few
medical specialties. Ajubas owners were based
in the US and assisted in sourcing new business
for the company.
Apollo Healthstreet: was a part of the Apollo
Hospitals Group in India and had grown rapidly
since late 1990s, and had about 1,000 staff on its
rolls. Apollo Healthstreet acquired a US based
medical billing company with a view to move
the billing business to India. It had proposed
to acquire other similar companies in the future.
marketing analytics business
overview
Marketing analytics was an emerging area of
analytics where companies attempted to use
analytical applications in the area of marketing.
Services could range from data cleansing
and data entry (at the low end) to high end
marketing analytics, including blog analytics.
Specifically, the following areas were required
to be addressed in the case of any analytics
assignment:
01 data collection
exhibit 10: india (offshore) marketing
analytics services market size and
forecast, 2003-06
100
2003 2004 2005
i
n

u
s
$

m
n
2006 2007 2008
200
300
400
500
0
43
82
169
279
384
456
02 generation (and storage) of unique identifiers. In order
to help merge information from several records and remove
duplicate records, systems needed to generate unique keys
to join data and store them.
03 integration with multiple data sources. Analysis was more
effective when data was available from multiple sources.
04 hardware sizing. Analysis required significant hardware to deal
with large amounts of data. Companies had traditionally
underestimated the need for sophisticated IT infrastructure
and powerful hardware to make analysis feasible in a timely manner
Marketing analytics companies could broadly be divided
into Analytics product companies (such as SAS and SPSS), IT
Consulting firms (such as Accenture), Large service providers
(such as EDS and IBM), Specialist Marketing analytics
companies (such as GE Analytics, eXelligent), global advertising
groups (such as WPP-Kantat, Interpublic) and market research
companies such as Ipsos and VNU. The overall market was
estimated at around $2.1bn in 2003 by Ernst &Young. Ernst&
Young had further estimated that the marketing analytics
offshoring market would grow rapidly in the next few years and
this was estimated at more than $450mn by 2008. Unlike
medical transcription or medical billing, in marketing analytics, the
key decision maker was the chief marketing officer of an
organization. However, since the decisions typically also involved
significant budgets, the CFO was a key influencer.
Also, unlike in the case of medical transcription and medical
billing where the need already existed, in marketing analytics,
mostly the onus of identifying a need rested with the service provider.
In the case of marketing analytics, typically a
project with a customer was likely to result in
benefits (and potential savings) to the customer
far in excess of the required investment. The job
of a service provider was therefore two fold: to
demonstrate that they had the capabilities and to
show the potential client that there was a need.
Not only did the provision of marketing
analytics services require a highly skilled
sales force, even the operations team requires
highly qualified resources, typically consisting
of experienced people with a background
in statistics and proficiency in some of the
analytics packages.
According to Chowdary, MD, VSL, If in
medical transcription, we make say, $1 per person
per hour, we make $5 per person per hour
in the case of medical billing and nearly four
times as much in marketing analytics. We believe
that the company must continue to grow on the
value chain for growth and survival.
vasant scribes today
The medical billing business continued to
remain where it was last year. While the business
was not making losses, it failed to gain any new
clients since its first client gained in early 2005.
The company had pursued a number of measures
including hiring a team of marketing experts in
the US, but they failed to yield any results.
Early in 2007, VSL signed a contract with
MedQuist to provide medical transcription
services to its clients in the US. This deal was
one of the largest of its kind and had the
potential to treble the revenues of the company
in the next two years. This was however not
in line with the policy of direct acquisition of
clients and was mainly a result of the marketing
efforts of one of the marketing staff in the US.
The company also decided to launch its marketing analytics
initiative and actively started canvassing for business in the
US. A salesperson was recruited specifically for market analytics
services to companies in the US. He would make calls
to companies based on requirements identified by him. A number
of demonstrations were made to reputed companies in the US.
In early 2007, a Fortune 100 company engaged Vasant to conduct
a pilot study for them. However, there continued to be a
dearth of clients for the company.
While the business development efforts continued in the
US, staff in India, hired for medical billing and marketing analytics
areas was getting restless. Retention of staff, always a difficult
issue, was getting more difficult to manage.
With the issue of continued sustenance in medical transcription
temporarily put away, the company was now gripped with the
challenges of growing the medical billing and marketing analytics
businesses. Some of the key issues before the management were:
01 should the company continue to pursue the medical billing
business? If so, how should it attempt to grow it? In the past,
the company had looked at potential acquisition of companies
to gain initial credibility. Should the company pursue this option?
Or, alternately, should the company look to tie-up with a reputed
medical billing company in the US (essentially repeat the same
trick as with medical transcription)?
02 should the company continue to look to grow in marketing
analytics, or should it temporarily defer the plans until the
establishment of the medical billing business? If the company were
to aggressively pursue the marketing analytics business, what
should be the strategy?
03 finally, since medical transcription had become a very large
and profitable business, should the company concentrate all
its energies on this, and de-emphasize the growth and
diversification plans?
Post your vi ews on thi s arti cl e at www.thesmartmanager.com
while the BUSINESS development efforts CONTINUED
in the US, STAFF in India was getting RESTLESS
For a compl i mentary copy of the teachi ng notes send a request to
sonia@thesmartmanager.com. The case study was supported by the Aditya
Birla India Centre at London Business School.

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27

DEVELOPI NG I NFRASTRUCTURE THROUGH MANAGEMENT I NNOVATI ONS

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