Today we advertise ourselves, employ touts to bring patients, perform unnecessary and expensive tests and even demand cut-backs from diagnostic laboratories. – Renowned nephrologist Dr M K Mani
In 1979, Dr P C Reddy with great enthusiasm presented details of his corporate hospital project to then Prime Minister Charan Singh, only to be angrily retorted with a “you want to monetise people’s misery?” and saw the report thrown to the trashcan.
Dr Reddy (PC), the harbinger, force-major and grand-daddy of the corporate hospital era in India, used to narrate frequently this incidence with dramatic impact.
Luck, however, favoured India’s original medical-entrepreneur. The Chaudhry demitted office without facing Parliament and in 1980 Mrs. Indira Gandhi returned to power. In a chance meeting with civil servant B Venkataraman (IAS) at his brother B Natarajan’s house, PC narrated this experience. Soon BV provided the doctor access to the later day President, Pranab Mukherjee who, in turn, set up a meeting with Mrs Gandhi. Chastened by the original rebuff, PC re-formulated his submission, stressing on broader healthcare. He readily agreed to the prime minister’s condition that 10 per cent of the treatment should be offered free to the poor and weaker sections. Today, this charity is neither publicised nor reported. Instead, we hear of several patients losing their shirt and even under-garments, thanks to the predatory practices of corporate hospitals.
Tn becomes the cardiac care capital…
It is true there is a phenomenal improvement in the quality of medical care. The rush to Dr Denton Cooley’s at Houston for bypass surgeries abated soon after the advent of Apollo. Dr M R Girinath and Dr D K Mishra at Apollo, Dr T J Cherian of the Railway Hospital and Dr K M Cherian (Frontier Lifeline) soon made Chennai the cardiac care capital of India. A great deal of the credit must go to PC whose exposure to the American way of working helped set up state-of-the-art medical equipment and practices. Many of his prosperous Telugu friends liberally contributed to the initial costs. I remember the glittering diagnostic equipment – ultrasounds, treadmills, autoclaves, ECGs, radiographic equipment, CT and MRI scanners… seen for the first time in Chennai.
Incidentally, it was a struggle to keep these utilised, both optimally and gainfully. PC had innovative ideas. He offered a fee of Rs 150 that entitled getting any test done at 10 per cent of the cost. He also provided, perhaps for the first time in large numbers, a master health check-up facility. The custom expanded in quick time and Apollo soon withdrew the offer! For over a decade, Apollo did not see much profit. However, once India opened its economy in the 1990s and incomes of the middle class shot through the roof, health-awareness rose. Then came the opening of the insurance sector. The rapid growth of the economy post-2000, a booming middle class and corporate prosperity contributed to a spectacular expansion of corporate medical care.
THE GOD THAT FAILED…
The Mahavishnu of Mount Road, The Hindu, organised a discussion programme moderated by the celebrated journalist, N Ram. Three famous doctors, Samiran Nundy, M K Mani and George Thomas, along with former health secretary, Keshav Desiraju tore into the unsavoury practices of the medical profession. They referred to several predatory practices of the present healthcare system. The experts with rich experience expressed anguish at pervasive corruption. These extended to medical education, primary, secondary and tertiary care hospitals, healthcare apathy, the indifference of personnel, massive leakages of allotted amounts and the shenanigans of pharmaceutical companies.
Privatisation of medical education contributed significantly to corruption and a steep deterioration in the quality of healthcare professionals. IE had written on how Annamalai University heralded this decline decades ago: allotment of seats for the progeny of politicians, civil servants, fat-cat business people and scions of doctors, compromised merit. With that hefty capitation fees, it dealt the first significant blow to the healthcare profession. The poor calibre of intake had to be nourished by manipulation of marks.
Of course, this ‘technology’ was quickly transferred to the other private medical colleges that surfaced soon. The Times of India presented an expose of this pernicious practice of charging hefty capitation fees by TN’s two leading medical colleges. A politician, who was then elevated by his party to the position of a Union minister just winning his first election to the Lok Sabha, founded one of these colleges. Nothing much came out of it, and the pernicious practice of such private medical colleges setting up large hospitals and other businesses continue unabated.
The lack of appreciation by the policymakers to acknowledge that quality medical education was expensive and needs hefty fees, also made its contribution to mindless, illegal capitation.
The learned speakers pointed to the inevitability of corruption. Doctors coming out of these colleges need to recover their investment (!). The introduction of the National Eligibility cum Entrance Test (NEET) is bringing about much-needed change. There is hope on ending capitation fees, recognising merit and imparting uniform standards across India.
THE ‘CUT’ FOR REFERRALS
The second level of corruption is in hospitals. It happens in several ways.
Samiran Nundy described a ‘cut’ for the prescribing doctor as common in diagnostic laboratories. He said that a Rs 3000 fee for Rs 10,000 scan involves an increase in cost by around 50 per cent. Look at the change in a matter of just a few decades of the cost of a simple x-ray. It has shot up from Rs 10 in the 1970s to over Rs 400 today in corporate hospitals. There is a tendency to go for equipment of ever-increasing sophistication and cost and there is the urgency to recover it in quick time to invest in the next state-of-the-art machine. Plus there is the compulsion to show increased profits every quarter for maintaining the health of the company’s share price. Result: apart from the high cost, the tendency to prescribe expensive diagnostic tests, whether needed or not, is now a norm.
Look at the chain of such practices. You go for a master health check-up for a fat fee; with each one of the results on blood tests, ECG, ultrasound, doppler… you are directed to specialists who prescribe additional tests, taking new consultation fees. With increasing age, morbidities are bound to increase. There is also the other pernicious practice of each large hospital insisting on going for the tests all over again even if these had already been done in another large hospital only a few days ago. I once flagged this to PC and suggested an agreement among hospitals of comparable size to agree on the reports of one by the other. He was evasive and said they were waiting for common standards to be prescribed by the government. I wonder why as a pioneer and leader he shouldn’t work on such a collective agreement. Of course, this will impact custom for the equipment in each one of these hospitals.
THE DRUG DACOITS
There is corruption in the pricing of drugs. At the meeting, puritan Dr Mani referred to the practice of pharmaceutical companies making a stellar contribution to corrupting doctors. Well-heeled pharmaceutical reps troop into consulting rooms requesting busy doctors to prescribe costly drugs introduced by their companies. These may range from simple antibiotics to placebos to vitamins and other OTC products. In most cases, the doctors prescribe the more expensive branded drugs even while cheaper generics are available. In a leading hospital in Chennai, I noticed it continuing to charge VAT long after the government stipulated MRP as inclusive of taxes.
There are other paradoxes: should such hospitals, as large buyers of drugs, charge the patient the MRP? Undoubtedly, they should be enjoying hefty discounts on the MRP. But then, their concern is for the investor and not for the patient.
E-commerce promises competition and handsome discounts on MRP. Amazon and several others offer drugs at lower prices. Understandably drug stores raise a hue and cry questioning the competence of e-commerce companies offering prescription drugs and the scope for abuse! One knows only well that mose of these shops have a registered pharmacist only for the law! It is common for a drug store assistant to deliver available equivalent of the drug prescribed without even informing the patient.
A recent practice relates to wastages in post-operative prescriptions of drugs. It’s a simple practice to prescribe large numbers of full strips of tablets/capsules, say, 20 or 30. Many of these are expensive, and in several cases, you need only a few of these; the rest go waste. The hospital-owned pharmacy does not accept returns. Remember, patients are forced to suffer these losses at knifepoint.
Dr Mani also pointed to expensive sojourns offered by pharma companies for attending conferences in distant countries and their liberal support to the numerous medical meets.
Why not ethical officers?
Hospitals must have ethical officers who should render proper advice on retaining terminally ill patients as in-patients and for humane billing. I cite a recent instance of a senior executive who retired from a leading engineering company: he was admitted into a top Chennai hospital for treatment of a lung infection. He had other complications like Alzheimer’s. In a few days, the virus was cleared, but hospital-related infections affected the other lung. Breathing difficulties followed and more tests were prescribed. The patient was retained at the ICU for close to four weeks. With no significant improvements, he returned home. The bill ran into several lakhs. Another instance relates to a road accident, where the hospital collected in advance Rs 50,000 at the trauma care centre and in the next two hours another Rs 50,000 for transferring him to the ICU. A couple of hours later the patient died, leaving the family poorer by Rs 100,000. Often the usurious hospital bill is more traumatic than the loss of the near one.
Large business houses like the Tata Group have ethical officers to ensure that their practices are ethical. More than other sectors, corporate hospitals need such ethical officers. There is also the need for a robust regulatory mechanism with reputed individuals to review such practices. Remember, unlike other professions, medicine is considered divine and should not turn devilish.
MEDICAL INSURANCE
Wide recourse to medical insurance has been a recent development. In quick time this has registered good expansion though it is still confined to a miniscule section of the population. Despite claims of cashless settlement, hospitals do not always see eye to eye with insurance companies. There is the widespread practice on the part of the hospitals to inflate charges and on the part of the insurance companies to disallow a good portion of these. The patient, in most cases, is not aware of their entitlements or the co-pay obligations. Here too we need urgently independent regulation.
Until the advent of the corporate hospital, Tamil Nadu had doctors committed to public service, and the government-owned hospitals did deliver top quality healthcare. I remember numerous such dispensaries run by the Corporation of Chennai offering effective treatment, for free. Stanley Medical, Royapettah, the General Hospital, Kilpauk Medical, the Railway Hospital at Perambur and the Egmore Eye Hospital had legends manning them.
THE MODICARE OPPORTUNITY
IE has been admiring the TN Chief Minister’s Health Insurance Scheme. Under this, nearly 60 per cent of the population is provided surgery that costs up to a value of Rs. 2.25 lakh each. A long list of surgeries eligible for free treatment is published and the patient has the choice of the hospital. This scheme is emulated by the Centre in the more ambitious Ayushman Bharat scheme to give a healthcare cover up to Rs.5 lakh per person per annum covering 50 crore of the population. We believe this is a welcome measure to offer an essential service to the teeming millions.
The learned doctors at the seminar didn’t seem to be impressed by the Ayushman Bharat initiative of the Central government. They felt that the primary beneficiary would be private hospitals as government hospitals cannot handle such large numbers of patients who would be asking for the facility. Mushrooming private hospitals will, of course, be salivating over the Modicare opportunity.
It’s a welcome augury that a specialist like Dr M K Mani who had worked closely with the government and leading private hospitals like Jaslok and Apollo, should firmly believe that healthcare delivery can be effective only in well-run government hospitals.
Mani said public health should be the concern of the government. His suggestion for making it obligatory for ministers and government officials to get treatment only at government hospitals for availing reimbursement of costs, has the prospect of improving the quality of healthcare delivery of these hospitals. Until the advent of corporate hospitals even such celebrities like Rajaji, EVR and M Bakthavatsalam used to be treated at the GH. I admired the conviction of the TN Health Secretary, Dr J Radhakrishnan who has been contributing so richly to the reputation of Tamil Nadu for its lead in healthcare, preferring the government’s super speciality hospital for the treatment of his mother’s illness. She returned to health in quick time and was discharged.
– With inputs from V Pattabhi Ram and Vijaya Durga
