tehelka article_no place to be sick

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20 MAY 2011 FRIDAY TEHELKAHINDI.COM TEHELKAFOUNDATION.ORG CRITICALFUTURES.ORG

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No place to be sick

Even if you could afford it, a private hospital may be the last place you would want to be in. SOPAN JOSHItracks theincreasing unease about private healthcare in India, and what the doctors say

ROHIT LUTHRA had heard stories of private hospitals fleecing patients. They seemed exaggerated, Rohit, the co-owner of an IT company in Delhi, says. He had recently taken two family members to corporate hospitals for cancer treatment, and was

fairly satisfied with the handling. Then, in June 2010, Gajanand Singh, 40, an employee in his firms purchase department, fell ill.Gajanand came from a poor family in Munger, Bihar, and had been with the company for about seven years. He went home to a wifeand three children. A dentist saw something unusual in Gajanands swollen jaw and recommended a biopsy. On 26 June, Gajanandfound he had non-Hodgkins lymphoma, a kind of blood cancer, in advanced stage. Two days later, his first stop was the All IndiaInstitute of Medical Sciences (AIIMS). Panicked by the crowds there, he went to the Max Super Speciality Hospital in Saket, SouthDelhi. His companys group health insurance covered him up to Rs. 8 lakh. The company also sent its employees to double up asattendants to Gajanand in hospital; he was a well-liked employee due to his quiet diligence and respectful conduct.

Doctors at Max suggested chemotherapy. Gajanand wanted to go to AIIMSbut feared the delay, so the Max doctors suggested he start the first courseof chemo at Max, and could later move to AIIMS. Gajanand was admittedon 13 July and chemo drugs were administered over three days. On 16 Julyhe developed well known side-effects of chemo: vomiting, dysentery andplunging blood counts. He did not recover. On 27 July, four days after thehospital had moved him to the isolation room of the intensive care unit,Gajanand died.

The cancer he had is typically detected at a late stage, when treatment isineffective. What did surprise Rohit and his colleagues, though, was howthe hospital handled the case. There was only one doctor taking thedecisions, not a panel or a team, even after we asked for it. Senior doctorswere not informed, says Rohit. After Gajanands death, oncologistselsewhere told Rohit chemo is not advised to a patient at such a late stage

of that cancer.

And then there was the bill for Gajanands treatment. Rs. 7.95 lakh, just ashade under the maximum insurance cover. Gajanands life had run outremarkably close to his insurance limit of Rs. 8 lakh.

We think the doctors knew Gajanand wouldnt survive. But they wanted tomaximise the hospitals revenues from the insurance company, says Rohit.When Gajanands company complained to the hospital about the treatmentoffered, the response left them very unhappy. When TEHELKA contactedthe Max Hospital authorities, they said, The patient and his family werebriefed about the patients condition, the prognosis and the estimated cost.They say another doctor examined the patient on the request of the family,and that a multi-disciplinary team of the hospitals tumour board as well asthe medical oncology team discussed the line of treatment in detail, which was communicated to the patient and his family, who signeda written consent. On the bill coming so close to the insurance amount, hospital authorities say the thirdparty assessor or the insurerdoes not disclose the coverage limit of the patient.

After all, Gajanand went to Max because AIIMS was too crowded. Most government hospitals have degraded to a point that theexperience is dehumanising. In comparison, private hospitals offer immediate care. Patients are pampered even, and attendants feelreassured.

Rohit says his confidence is shaken. He is now considering the only realrecourse: the consumer court. His chances are, however, slim.

Almost all cases of medical negligence under the Consumer Protection Actfail because it is impossible to get a doctor to testify against another doctor.They fear being ostracised, says Jehangir Gai of Mumbais ConsumerWelfare Association.

DELHIS CONSUMER activist Bejon Misra conducted a study in 2004 ofthe number of medical cases that go into redressal (for the World Bank andthe Union government). His finding: 1 percent. Consumer courts, though,deal only with cases of medical negligence. What can people do when theythink theyve been had overcharged or rushed into tests, procedures orhospital admissions? Nothing.

Most people have either experienced or heard of somebody feeling cheated

From Tehelka Magazine, Vol 8, Issue 5, Dated February 05, 2011

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by private health players the bigger hospitals get talked about more thanothers because of their size and presence, but almost all arms of theprivate sector healthcare are viewed with suspicion. India has created ahealth system it doesnt trust.

Says Namita Sharma, a government doctor in Pune, I had an ache in my knee, quite common at my age. I sought the opinion of aconsultant. He spoke to me like I were a novice, and in the blink of an eye suggested a knee replacement surgery.

Narendra Puri of Gurgaon went to a doctor after an attack of acidity. After an ECG test showed alarming spikes, he was told he had hada heart attack and needed a coronary stent. Before taking a decision, he consulted another doctor, who said there was nothing wrongwith his heart and the first doctor had placed the nodes of the ECG all wrong.We are unfortunate to be born in this country, says aretired high court judge who did not wish to be named. He developed a urine infection after he needed a catheter for treatment at a

prominent corporate hospital. I had told the doctor I needed preventive antibiotics because of my diabetes and vulnerability to urineinfection. He said I did not need it. I did get a urine infection and had to spend an extra 10 days there, he says, adding he saw no hopein going to consumer courts. Doctors are minting money. I feel defeated by the corruption in our society, he says.

The Indian government, regardless of the party in power, encourages private sector in healthcare. A World Health Organisation (WHO)survey ranked India 171 out of 175 countries in percentage of GDP spent in the public sector on health. India ranked 17 on healthspending in the private sector. About 80 percent of Indias total healthcare market is in the private sector.

The Centre has practically left healthcare to the private sector, which isbooming. The private healthcare industry in India benefits from lowgovernment interference. There are few regulations and, unlike manydeveloped nations, healthcare policies do not work on a reimbursementmodel, says Healthcare Services in India: 2012: The Path Ahead, a studyby YES Bank and ASSOCHAM.

Private healthcare has the status of infrastructure in India; 100 percentforeign direct investment is allowed under the automatic route, and thereare service tax exemptions. The government offers income tax exemptionsfor five years for setting up private hospitals in smaller cities.

There is no doubting, however, that the private sector has made a positivedifference. Private hospitals offer freedom from the crowding typical of

government hospitals. Patients have courteous attendants, hygienicsurroundings, higher chances of getting good treatment, and are affordedgreater dignity and privacy than government hospitals afford. The overallexperience is far superior. All this, though, is for those who can pay.

But the worry is that the medical regulation of the private sector is even more friendly than the financial regulation. State healthdepartments and medical councils are supposed to regulate the medical practices of private hospitals.

While the departments receive no complaints the Delhi Health Directorates nursing home cell said it had no complaints againstprivate hospitals state medical councils are infamous for being dysfunctional. The Maharashtra Medical Council, for instance, held itselection in April 2009. But the state government has still not constituted it; only one government official handles its work.

THE STATE councils are answerable to the Medical Council of India (MCI), which is charged, among other things, with the job ofensuring the ethical practice of medicine by all registered medical practitioners. In May 2010, its president Ketan Desai was arrestedon charges of corruption in granting approval to medical colleges, and later dismissed from the Council. The government brought in anordinance to suspend the Council and appointed a board of governors comprising six eminent doctors to oversee its functioning till it isoverhauled and reconstituted in May 2011.

Ranjit Roy Chaudhury, former director and dean of Chandigarhs Postgraduate Institute of Medical Education & Research, is one ofthem. The MCI and the state councils just do not have the investigative wings to catch unethical medical practices, he says.

So there is little monitoring of healthcare in India. This is a serious impediment to epidemiologicalresearch as data from private doctors, nursing homes and hospitals is not reported for mostdiseases. The effects are felt only when people go through bad experiences.

Pradip Saha, a filmmaker and designer in Delhi, saw this up close when his father was detectedwith an advanced stage of lung cancer nine years ago and taken from Kolkata to Mumbai.Doctors at the Tata Memorial Centre suggested palliative radiotherapy. But a young oncologist inHinduja Hospital differed. He said my father was going quickly, and that we should let him go inpeace and not interfere; that we should only manage his pain. He told Pradip palliativeradiotherapy would extend the patients life, but if he loved his father, he should think about the quality of time he could buy him. Herealised what the family faced, and offered to speak to the elder Saha. He counselled the patient and the family, taking them throughthe paces of what was likely to happen. It happened exactly how he had predicted, says Pradip. His father was quiet for two days,then angry for a few days, blaming the family for not doing enough. And then he accepted the truth.

The oncologist told me relatives typically fall at a doctors feet and request they do something, anything. And there are so many thingsto do, says Pradip. His father spent his last three days in an ICU. As he watched his fathers life ebb, Pradip saw relatives of otherpatients scrambling around, borrowing money in desperate attempts to save a loved one without any idea of the risks. He is still gratefulto the young oncologist for his decisiveness. It allowed his father dignity in his last days.

Not everybody, though, has the option of taking life and death decisions based on what they know. Sachin Kandhari, a neurosurgeon inDelhi, describes his travail. His cousin in Punjab, Anil Mahajan, 28, had discomfort in his chest and was taken to the Fortis EscortsHospital in Amritsar on 6 November 2009. An ECG and a rapid angiography later, he was told he urgently needed a coronary stent totackle a blocked artery. He had no risk factors like obesity, smoking or old age. So I asked the doctor attending him to send me thevideo CD of the blockage so I could show it to friends here and get a second opinion. They refused and told my cousins parents stuffthat got them worried, he says.

When TEHELKA asked Fortis Escorts about a patient not getting a CD, the hospital denied thecharge. At Fortis the practice of medicine is evidence-based, so the issue of having patientsundergo unnecessary tests is out of the question. All test results are given to the patient,including angiography, burnt on a duplicate CD, say hospital authorities. Jasdeep Singh, directorof the Amritsar hospital, says, There is barely anything that can be doubted with regards to theline of treatment and urgency in the manner it was done, viewing the criticality of the patient.

Mahajans family agreed, and he now walks around with a stent in his heart. Im a doctor and Icould not prevent one of my relatives from going through this. What chance do other people have? asks Kandhari. He doesnt believeMahajans situation was as critical as the hospital claims. A stent, he says, is a foreign body and poses risks, besides requiring lifelong

PHOTO:GETTY IMAGES

Agonising wait The infamous OPD

queue at AIIMS repels patients

PHOTO: SHAILENDRA PANDEY

Rs. 2 11 566 crINDIAS TOTAL HEALTHCARE EXPENDITURE

Narendra Puri of Gurgaonwent to a doctor after anacidity attack. He was told hehad had a heart attack. Asecond doctor said the firsthad placed the ECG nodeswrong

A WHO survey ranked India171 out of 175 countries inpercentage of GDP spent inthe public sector on health.The country ranks 17 onspending in the private sector




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medication; it should not be implanted unless it is absolutely necessary. And yet, he knows, the hospital would have had a logicalargument for suggesting the procedure. But even now, they have not given us the video of the angiography, their tall claims aside,Kandhari says.

INDIVIDUAL PATIENT complaints are, however, only one part of the story. Patients have become extremely demanding and customer-like; they shop for doctors now. A 56-year-old man I attended to was unhappy that I recommended tests worth only Rs. 200. He said hewas not coming back soon, and wanted a complete check-up done. I had to prescribe unwarranted tests worth Rs. 750 just to keep histrust.

There is a larger question: what is wrong with our healthcare system? The benefits of the private sector healthcare boom are at the costof the patient-doctor trust? We have no way to control or prevent a doctor from prescribing a more expensive drug or procedure from acheaper one. It boils down to a doctors judgement at that point and the Hippocratic oath, says MCI board member Roy Chaudhury. Imay think something is unethical, but another doctor may not see it like that, he says. This is a big grey area. What matters more thanstatistics and test results is a doctors judgement and experience, says a professor at AIIMS, who does not wish to be identified. Thereare arguments and counter arguments for every decision, and we do not deal with a machine but the highly dynamic human body.

What we have is a system that dumbs down a doctors instincts, makes them trust diagnostic tests rather than their instincts. Itdiscourages initiative, says the doctor who witnessed this. It is well known that most doctors especially general practitioners andthose working in smaller nursing homes get a cut of up to 40 per cent on diagnostic tests they recommend. The most common testdoctors suggest to milk patients is the MRI scan, say doctors.

Suraj Rajan, a doctor in a Thiruvanthapuram private hospital, is an outspoken critic of unethical medical practices. Doctors have a highlevel of commercial interests. They often suggest unnecessary tests and even surgeries, he says. Some doctors play a dirty trick: theyput a star mark against certain tests on the lab request form and tell the patient that these tests are important. This is actually a code.The lab guys make it a point to report these particular tests as abnormal. The doctor then tells the patient that this test has to be eitherrepeated in a few months, or more testing is necessary. The patient now becomes a permanent customer and thus both the doctor andthe lab gains. There are ultrasound scan centres where they report appendicitis similarly.

Renowned heart surgeon Naresh Trehan says there is a term in for it in the medical community: stretching the indication. RoyChaudhury says unscrupulous doctors conduct unnecessary hysterectomies, appendectomies and mastectomies across the world, and

that there is no way to stop this. Overtesting, though, has another side: the fear of getting sued under the Consumer Protection Act. Asour society gets more litigious, you will see the need for greater subjective (rather than objective) documentation, says Arun Bal, adoctor and consumer activist with 35 years experience in Mumbai.

This also explains at least a part of the reason so many negligence cases fail. We have dealt with more than 400 complaints of medicalnegligence. Not more than 4 percent did we find justiciable, says Bal. Many complaints have to do with patients feeling mistreated ordue to poor communication from doctors. That does not comprise negligence, he says.

FOR DOCTORS, the choice is between working either in the public sector, which is resource-poor and crowded with patients, or for theprivate sector, where the best of doctors in the best of hospitals have to make some adjustments with their conscience. It is not an easychoice. This is the only vocation in which by the time one is ready for an independent professional life, one is typically above 31-32years of age. And we watch our friends in other professions settle down into a career around the age of 25, says a doctor into his thirdyear of practice. An MBBS takes about six years, post-graduation for a specialisation takes another three, and they then have to workas senior residents for another three years. Super specialists often end up studying/training/interning for 14 years before they begin towork as independent professionals.

Besides, young doctors come through a system in which they do the workand their seniors get the money and the credit. In private hospitals, theseniors are like the portals that bring in the business. The world ofmedicine is highly feudal, hierarchical, says Rama Baru, professor atDelhis Jawaharlal Nehru Universitys Centre of Social Medicine andCommunity Health. A lot of close mentoring goes into making a doctor,which is why they stick to a code like the IAS officers do. What aggravatesthis is that junior doctors are paid a pittance, and have to work through thesystem to get to a stage where they are comfortable. The large capitationfees candidates have pay in private medical colleges only worsens this.

It is never easy to tell if a surgery or a diagnostic test is unindicated. Indiahas no clinical guidelines or national protocols on diseases and therapies,only textbooks, says Arun Bal. He as well as Naresh Trehan say it isimportant that the patients ask questions of doctors. That can happen onlywhen the patients are well informed. Or there is an insurance company thatasks questions about expenditure. But health insurance penetration in Indiais not even 5 per cent, Trehan points out.

Another concern is the nature of contracts by which private hospitals hiredoctors. Contracts are confidential, and their terms vary from hospital tohospital. There are three broad tiers of doctors. The younger doctors get afixed salary. There are associates and junior consultants who get a fixed salary and incentives based on the business they bring. And

there are senior consultants who are paid on the basis of the business they bring.

The revenues senior consultants generate in OPD go mostly to them, with a hospital typicallydeducting 15-30 percent for use of its premises. But when a doctors patient is admitted to ahospital for a procedure like a surgery, the senior consultants payment is often tied to the totalbill. Each private hospital has its own way of putting the onus of generating business on seniorconsultants. This is why I dread working in a private hospital, says an associate professor atAIIMS. I cannot stand the thought of having a manager asking me why the number of patientsIm bringing in is sagging. Next time I see a borderline case, Ill tend to admit the patient.

And its not just the business model; the medical model in private hospitals is also flawed. It makes doctors compete rather thanfunction as a cohesive unit, says Rama Baru. She has had government doctors who now work in private hospitals as consultants tellher that since remuneration is tied to the number of patients, it promotes competition and individualism, rather than collaboration.

RITU PRIYA, doctor and professor of community medicine at JNU, says in the current medical model, senior doctors are consultants oncall, specialists are brought in on request, and staff doctors are mostly junior. Several senior doctors, including Trehan and Roy

Rs.1,69,252 crWHAT PEOPLE SPEND ON OVERALL HEALTHCARE IN INDIA

Rs. 1,62,906 cr WHAT PRIVATE HEALTHCARE PROVIDERS EARN EVERY YEAR FROMPATIENTS

Loss of trust Gajanands familythought he was getting the bestpossible treatment. Not any more

PHOTO: TARUN SEHRAWAT

Younger doctors get a fixedsalary. Associates and juniorconsultants get a fixed salaryand incentives. Seniorconsultants are paid as perthe business they bring




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Chaudhury, say this is a common model of hiring doctors, and it is worrying.

A doctor recalls a case that illustrates Ritu Priyas concern. A young man came to his hospital for a bariatric surgery medical term for she felt social phobia because of his obesity. The senior consultant told him he did not need it, and that he should try other means of losincase and performed the procedure. Imagine what the first doctor would have felt for taking a tough decision. Next time he gets a similaraway.

In this regard, the Sitaram Bhatia Institute in Delhi has a good reputation; its doctors are organised in teams. Which is why it has sevedoes not pay us by the amount of money we earn for it, says a junior consultant. Even senior doctors are not paid by the number of patthe patient; their salaries are fixed and medical audits check the performance of doctors as a team. This allows research and collectilowered the rate of caesarean sections.

Such results depend on teamwork. Then again, at this hospital, a caesarean sectionno incentive to push women towards caesarean sections, unlike lots of other nursinmeanwhile, have no incentive to train and groom doctors. They have the money to bhas long been a good hunting ground. Sir Ganga Ram Hospital, run by a private chdecide on running the hospital. It is managed by a 22-member committee, of which 19

MEDANTA, RUN by Naresh Trehan, is trying to become a similar hospital that createsjury is out. Corporate hospitals dont allow this much. A doctors reputation cannot bethem is that of the hospital, says a surgeon who has worked at a government hospital

A doctor who worked in a corporate hospital summarises what several doctors sayrapidly. When there is commercialisation all around, it is outright hypocrisy to expect d

To be fair to private hospitals, there are more profitable avenues. The single mostsetting up hospitals, the long gestation period of such investment, and the relatively lhospitals by Rupa Chanda, professor of Economics and Social Sciences at the Indian

Several senior persons at leading corporatebusiness involving huge upfront capital-intensivto many, it takes 4-5 years to break even andsays, adding, Several hospitals noted that profother high growth sectors such as IT, finance, or

Rohit Luthra, whose IT business is a result ofcomparison: We need to discuss again the

hospitals use corporate jargon like KPIs (key performance indicators) for doctors, which includes the average billing that a doctor createis 70 percent variable on the revenue they generate for a hospital. Health and education have to be beyond commerce, they cannot ruGajanands death.

I have had physicians ask for commissions for sending patients to me. Thats how shameless people have b

Heart surgeon Naresh Trehan, chairman and managing director of Medanta: The Medicity, also heads the health committee of the Cinterview:

How does the private sector get to command 80 percent of Indias health market?Thats how it has always been. In villages, the local doctor or quack was the one providing the services. In smaller towns, adoctor would open a small nursing home with his wife or somebody else from the family. Metros had bigger nursing homes,built by doctors of a bigger stature. In the 1970s, Mumbai saw some large trust hospitals supported by business houses. In the1980s came the first corporate hospital, Dr Prathap Reddys Apollo Hospital. Max then took a trust hospital and gave it theflavour of a corporate hospital. In 2000, the Confederation of Indian Industry formed a health committee, with a powerfulsecretariat. It tried to bring the stakeholders together and build a healthcare sector in India, rather than everybody being ontheir own. Thats when we realised we had no idea what was going on. We commissioned McKinsey to figure out the healthsector. We found India and 134 countries had signed the Alma Ata Declaration in 1978. It said we shall commit to provide aminimum standard of health prescribed by the WHO. McKinseys data showed India was 40 percent of where we wanted to beand that we need to double the sector. That $25 billion incremental investment was required. And at the current rate, we wouldbe spending only about $10-15 billion. The corporate sector saw the opportunity and got excited. Thats when a lot of activitystarted like buying up of trust hospitals. That is why this mad race of how many beds you own and what not.

How do you view the governments regulation of private healthcare?The government is not regulating. And the private sector, too, is at fault. Some of us took land in the old days with the promiseof offering free services, which most of the hospitals are not providing. The problem is also the definition of free. Thegovernment realises it must advance healthcare, and that the private sector will play a larger role in it. But the expectation ofthe government is also that the private players will have a sense of social responsibility.

How responsive have you been?We have almost finalised PPP (public private partnership) model and we are saying we can build good quality secondary care hospitals ito 40 percent of the capital costs. In return, the private partners will offer the first 30 percent of the beds to people below the poverty line,Another idea is that private players adopt a district each and develop the health infrastructure there. The pilot project will be Jhajjar in Ha

Why do private hospitals push patients to expensive options?The cost is high from a patients point of view. But a hospital cannot do it cheaper. Hospitals operate on small profit margins; it is difficuthe stock market frenzy, I dont know what they do but nobody is breaking the bank here. A hospital is the hardest way to do businsurgeries of the same standard as in the US for a tenth of the price. But if hospitals resort to practices that inflate the bills, that is wrong.greedy people who are doing bad things.

Corporate hospitals make doctors compete with each other. Does that worry you?Yes it does, and that is why at Medanta we are doing the opposite. That is the difference between a housewife and a whore. We aorthopaedic surgery unit. A doctor heads a team of doctors who work on different things. We have full teams with different parts workidoctors knowledge, year by year, as well as research.

Is a doctors income linked to the number of procedures/total billing that they bring in?Yes, that does happen; most of them are veering to a model like that. It is worrisome; a doctors pay should not be linked to the numbersMedanta. Almost all our doctors are full-time staff. Their pay depends on the quality of healthcare delivered to the patients, determined b

Wary and wise Rohit Luthra sayshealth and education cannot run onthe profit motive alone


PRIVATE SECTOR SHARE OF INDIAN H

60% HOSPITALS 75% DISPENSARIES

Several hospitals noted thatprofit rates are around 13percent, lower than that inother high growth sectorssuch as IT, finance or retail,says an IIM study

PHOT




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We brought down caesarean deliveries from 70 to 46 percent

Dr Sonia Naikof the obstetrics unit of Delhis Sitaram Bhartia Institute talks about aprogramme that reduces caesarean deliveries. Excerpts from an interview:

Why are caesarean deliveries so common in private hospitals?They are more common in private hospitals than in public hospitals. One reason isricher patients with sedentary lifestyles. Another is better food availability, which,combined with a sedentary lifestyle, is leading to higher baby weight. Yet another is

that women are having babies later, after the age of 30, which is more risky.

Do hospitals have a role in this?Most private set-ups have individual doctors and not a group of doctors or unitsworking together. The entire responsibility is on that one doctor, who typically doesnot want to take risks regarding the mother or the baby. She goes for a Csection ifthere are signs of distress to the baby. A C-section in a later stage of labourincreases distress to the mother (more blood loss, injury to the bladder). Individualresponsibility also means the doctor is not available 24x7. Caesarean gives theoption of conducting deliveries at her convenience and availability.

Who decided to reduce the C-sections?It came about when we started the integrated mother and child programme. Thehospital director was keen on it. From more than 70 percent, it came down to 46percent.

But dont hospitals earn more from C-sections?C-sections involve an anaesthetist and operation theatre, and more drugs. I reallydont think it is more profitable for the hospital overall. In the long term, more patientscome to a hospital that will not do unnecessary interventions. The surgeons fee for anormal delivery and C-section does not differ that much in our hospital. And asurgeon needs to give far more time to a normal delivery; she may have to wait for

hours, whereas C-section is over in an hour.

How can a hospital reduce the C-section rate?One, doctors need to be sensitised. Two, they need to work in a team; visiting consultants will not make such an effort. Three, wedesigned an integrated mother and child programme. It had antenatal workshops, one-on-one sessions with pregnant women, trainedchild birth educators and physiotherapists. We use birthing balls to reduce pain perception, birthing beds to avoid shifting patients twice.We created a protocol so all the doctors follow the same treatment. And there is monthly auditing to see the C-section rate.

How do the patients respond?The patients who have a normal delivery were grateful because they feel most hospitals nowadays do a C-section. But women whohave a C-section despite trying for a normal delivery feel disappointed. One who had an elective C-section earlier with a good-sizedbaby (3.3 kg) had a normal delivery next time. This time the babys weight was 3.5 kg. She was happy with her faster recovery. Butsome turn away thinking our hospital forces you to have a normal delivery.

[email protected]


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