Medicine: The God that failed

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

Bala Swaminathan, an insurance expert based in Hong Kong and familiar with insurance business in the US, Europe and Asia, rates the healthcare system of Taiwan as among the best.

Taiwan … total coverage

The National Health Insurance (NHI), the healthcare system in Taiwan is a compulsory social insurance plan centralising the disbursement of healthcare funds, modelled after the US. The system promises universal healthcare for all unlike covering only the elderly in the US. The working population pays premiums shared by their employers; others pay a flat rate with government help and the poor are fully subsidised.

Citizens are free to choose hospitals and physicians and need not worry about waiting lists. NHI offers comprehensive benefit package covering preventive medical services, prescription drugs, dental services, Chinese medicine and home visits. Change or loss of jobs does not affect the insurance of the employed. Annual medical check-ups, maternal, child-care and most preventive services are provided free.

Every citizen is provided a health smart card that includes provider and patient profiles (including his medical history), to identify and reduce insurance fraud, overcharges, duplication of services and tests. The insurer is billed for the medical costs and it is paid automatically. The insurer monitors the use and quality of treatment for diagnosis and the medical provider is required to submit a full report every day, thus improving the quality of treatment, limits physicians from over-prescribing medications and prevents patients from abusing the system.

The principal strengths of NHI are good accessibility, comprehensive coverage, short waiting times, low cost, high coverage rate and nationwide research databank.

When hearing aid cartels make a deafening noise

At a public discussion organised by The Hindu Centre for Politics and Public Policy and Oxford University Press on the book Healers or Predators? I narrated my experience relating to the unfair trade practices in hearing aids.

Loss of hearing is common with aging. A study on in the US mentions: “older individuals with hearing loss are significantly more likely to develop Alzheimer’s and dementia.”

A famous ENT specialist of Chennai referred me to a hearing aid centre. A couple of young audiologists carried elaborate tests and assessed the extent of hearing loss. They suggested my going for the Phonak brand, each aid costing around Rs 52,000. My children from the US who took me to the shop, took photos of the hearing aids and checked the price on Amazon. We found it to cost Rs 19,000 each.

The company said they couldn’t tune the equipment bought outside. I checked with another brand, Starkey. The prices were even higher. I took up the matter with the distributor in Delhi. He mentioned that such medical products cannot be bought from e-commerce companies and that the audiology companies would not tune or service them. There are just a handful of global manufacturers – German, Amercian and Swiss. Their dealers have formed a powerful cartel. After battling for a while, I had no alternative to ordering at prices charged by the cartel.

The government has succeeded in substantially reducing the costs of stents and implants. However, the benefits of this are not entirely passed on to the patients. Even while the hospitals ostensibly complied with the mandate and showed a reduction in the prices of these, they had increased the doctors’ fees and other charges. There should be some regulation on the charges made by hospitals and for greater transparency.
After the crackdown of the government on the pricing of stents at least one of the leading hearing aid manufacturers, the American company Starkey, has been offering hefty discounts, buy back facilities and extended warranties.

Recently I came across an interesting advertisement in an American journal with the caption Advanced hearing aid technology for less than $ 200. MD Hearing Aid mentions its product as doctor-designed, audiologist-tested and FDI registered. It also offers free batteries for one year plus free shipping as even a full refund for return within 45 day. – SV

Cancerous corruption in healthcare

‘Healers or Predators, a collection of essays, boldly talks about the ongoing issues in the healthcare industry.

A nation can flourish only if health grows alongside wealth. Health is an essential determinant of standard of living, and it depends on the guardian angels, the doctors. Alas, the quality of doctors is deteriorating. The book talks about the dangerous threats to society caused by corruption in the healthcare sector and suggests possible solutions.

During Independence, it was promised that healthcare would be provided to all irrespective of ability to pay. After that, a large proportion of doctors started moving to private practice and during 1980s individual players explored the whole arena, setting up and managing medical colleges. Even though the turnout of doctors was increasing because of the private sector, it sowed the seed for corruption.

Different layers of corruption

First: From Admission to Graduation: private institutions bridged the gap between the demand and supply of doctors. Understanding the market, they started charging exorbitantly. Aspirants had no choice but to choose that path as the seats allocated by government medical colleges was just 15 per cent and the rest 85 per cent was reserved for other than general category people. Today a medical place would cost anywhere up to Rs 5 crore. Parents mostly through black money made the so-called ‘Investment,’ and after such ‘Investment’ one would naturally desire a return.

Care-taker to care-seller…

Second: Care Takers vs. Care Sellers: Entry of corporates into the medical sector started during 1980 pioneered by Apollo. Such a paradigm shift made the doctors’ concentration turn towards employment in such hospitals rather than being content with modest private practice. Most of the corporate hospitals were owned and managed by the management professionals who had the motive of profit rather than providing service. Doctors were treated as employees and forced to achieve targets. From then onwards the doctor-patient relationship shifted to a consultant-client. The paradigm of the profession shifted from being a care-taker to care-seller.

Third: The unholy nexus between pharmaceutical companies and medical profession: pharmaceutical companies seduced doctors with various offers to prescribe their products even though their substitutes of such would be much cheaper and affordable. The same case happened with regard to diagnostic and testing centres. Doctors were paid for referring to those centres. Consultation fees paid by the patients was less compared to the amount paid by pharmaceutical companies and the amount earned by the doctors through referrals. Most of the doctors abused power entrusted to them for a private gain.

Is Consumer the real ‘King’?

In the healthcare sector there is little the consumer, can protect himself. Consumer protection applies to healthcare to protect the interest of the patient by making doctors liable for their deficiency in the services provided. For instance, take a doctor appointed by the public health systems expected to serve and provide care and at the same time allowed private clinical practice. Certain physicians of that genre advise their patient to visit them in their private facility for better services. This is consumer exploitation and happens throughout, but barely few complaints get registered and doctors were able to get themselves out of it through bribing or paying off the penalty.

The bases of most of the corruption are: industry being alienated from the rest, high and biased regulatory authority. Medical Council of India had members who are either part of corporate hospitals or private practitioners. A solution is there should be three statutory bodies in place of Medical Council of India, to oversee ethical medical practices, to accredit hospitals and audit their functioning and to regulate standards of medical education. Most importantly, there should be a system of levying luxury tax over the private hospitals to upgrade facilities in state government-run medical colleges and district hospitals. Not just discouraging the people from visiting corporate hospitals, quality of the services provided by the government hospitals will increase if the fund flow from corporate to government hospitals through this luxury tax.

On a personal note

This book scares and makes us doubt the treatments what we, or our closed ones, have gone through in our past. Hope this book creates an impact in the minds of the guilty. Such disruption may not have an immediate effect, but separation starts from an individual, doesn’t it? – Ramanathan Prasanna

Excerpts of the book

M K Mani

Profession has sunk from heights where aim of most doctors was to fight disease and end suffering, to tremendous lows where most of us, above all, to enrich ourselves.

Today we advertise ourselves, we employ touts to bring patients to us, we perform unnecessary and expensive tests and even demand cut-backs from diagnostic laboratories.

Students are spending lakhs, even crores to get a seat, as only 16 per cent of the seats are open for open competition. The amount spent will be almost black money. So, the entry itself starts with corruption. These parents expect return for their investment, pressurising young doctors to make money. If one can pay so much to get a medical seat, then he can also pay a lot to get a medical degree.

George Thomas

Consequences of corruption in healthcare are:

• Denying medical care to many, impoverishing the already poor.
• Assaulting patient’s body if he/she has to undergo unnecessary procedure.
• Causes conflict in doctor’s mind between what should be done scientifically in patient’s interest or in doctor’s interest.
• It causes a trust deficit between patient and a doctor.

Samiran Nundy, Keshav Desiraju, and Sanjay NAGRAL

Denial of healthcare are symptomatic of a deep-rooted crisis, and at a time when the trust deficit between healthcare and ordinary citizens is at an all-time low, it is crucial to go beyond the headlines and dispassionately analyze one of the key drivers of the problem – healthcare corruption.
India’s shocking child sex ratio statistics reflects that this situation which could not have arisen without the active connivance of doctors and other healthcare staff.

The study of medical ethics is not given enough importance in undergraduate study and the MCI does not have a strong record in the matter of taking action against its members.

By no means had the case that it is only medical profession that has been so affected. The civil services, the world of universities and higher education, the world of lawyers and the courts, the world of politics and public representation, all have been so affected, but healthcare is a critical and universal need.