Covid Price Caps- The Contrarian View

Late last month, the government of Delhi announced price caps for the treatment of Covid 19 patients in private hospitals. This came around the time, when the disease was rapidly peaking in the city and there was panic all around. The media went to town highlighting the horror stories being played out in public sector hospitals and running stories about rampant profiteering in the private sector. The ordinary patient seemed to be caught in the middle, poor medical services on one hand and unaffordable ones on the other.

The government intervention cited two pressing reasons for imposing the price caps. One, it wanted to make good quality healthcare available to patients at ”affordable” prices and two, it was aiming to come down on alleged ”profiteering” rampant in the private sector.

These are indeed laudable objectives but the medicine prescribed unfortunately does not work and also has wholly undesirable side-effects.

Let us first address the issue of ”profiteering”. The government has been accusing the private sector of profiteering without any evidence whatsoever. Yes, the impression of profiteering comes from high prices being charged by private sector hospitals for Covid treatment. The high prices, however does not necessarily imply,”profiteering”. High prices are a direct consequence of high costs involved in the treatment of Covid 19 patients. The costs emanate from a slew of factors related to the complete unpredictability of the disease and its highly contagious nature. Doctors treating Covid 19 patients agree on one point – that the disease behaves differently in different people and it is impossible to predict its course. Thus, the treatment options cannot be standardized and different patients need varying treatment over a long period of time. Many do not need any treatment at all and many, particularly those with co-morbidities and the elderly need long stay in the hospital, often in intensive care.

Moreover, because of the highly contagious nature of the disease the safety of healthcare workers assumes paramount importance. They are indeed our most precious resource in this battle and if they become sick, we have no way of fighting the scourge. Realizing this private sector hospitals made elaborate arrangements to protect their healthcare workers. The healthcare workers were provided with expensive personal protective equipment; they were housed in hotels near the hospitals, kept in quarantine after their duty periods and treated free if they acquired the infection. All these are additional and significant costs. The private hospitals had no choice but to pass these on to the patients, leading to higher bills reinforcing the impression that hospitals were minting money and profiteering from the crisis.

Now, with the price caps on, private hospitals have no option but to cut back on some of these, making their staff work longer hours at greater risks and resort to salary cuts. This will demotivate healthcare workers and affect patient care and employee productivity. The hospitals will also look at standardizing and straitjacketing clinical care, for a disease, which we know is completely unpredictable. This too will lead to compromised outcomes. These are inevitable steps to make ends meet. Many private hospitals will be forced to either curtail services or simply shutdown. This at a time, when every hospital bed is a precious.

To make matters infinitely worse the price-caps on the private sector have been imposed when thousands of beds in the public hospitals are lying vacant. These beds are free, yet have no takers. While, the price caps have made the service ”affordable”, there is a very high cost attached to this.The government instead of improving medical services at its own hospitals will end up with effectively diluting the high quality of care offered by the private sector hospitals. This would be an inevitable and somewhat unintended consequence of arbitrary price-caps in the private sector.

The reason for this madness is not far to seek. The politicians running the city want to look good to their electorate. One sure way of doing this is to threaten ”big bad private enterprise” into submission. The electorate loves to see the governments of the day championing the underdogs, the poor and the disadvantaged who unfortunately can not afford private healthcare. Thus, bringing in price-caps to tame private healthcare helps them get more votes when the elections come around. The electorate will not remember the sorry state of public hospitals but will certainly remember the ”stern” action of the government of the day.

This is rather unfortunate. Instead of price-caps on private enterprises, what we do need is much higher levels of investments in public healthcare. We need better paid and better trained staff with far more empathy at our public hospitals. This will inspire greater confidence in these hospitals, encourage citizens to choose them over the ”profiteering” private sector hospitals.

We must remember that the responsibility of providing affordable healthcare to the citizens who can not afford private healthcare rests squarely with the government. This is true during a pandemic as much as in any other time. That the governments have chronically under-invested in public healthcare and failed to provide adequate and affordable care, does not mean that private healthcare providers should now be forced to provide these services at prices that do not even cover their costs.

There is no doubt that in times like these, profiteering in any manner must be viewed harshly. The government must ensure that they come down heavily on those who aim to maximize profits through other people’s misery. At the same time, they also have a duty to ensure that they don’t drive private healthcare, the only ones delivering world class Covid care, to an early grave.

The views expressed are personal

Surgeries in Covid Times

With India recording over 14000 fresh cases of Covid 19 yesterday, it is little wonder that we are completely immersed in Covid 19. The social media is agog with covid figures, positivity rates, fatality rates, the increased risks to people with co-morbid conditions and the elderly. The government policy making on Covid can best be described as bizarre, with new and often contradictory guidelines emanating from different mandarins. Essentially, we are drowning in Covid.

Yet, it is important we shift our attention to more mundane but equally pressing matters such as the care we need to provide to other patients who have serious medical conditions and cannot wait for Covid 19 to go away. These patients have been postponing their surgeries and treatment in the hope of going to a hospital, which is Corona free. Unfortunately, with the pandemic still running its course, hospitals are seeing only more and more covid patients. No one knows, when the situation will return to normal. Thus, waiting for covid 19 to subside does not seem to be a good idea anymore.

Patients requiring heart interventions, cancer treatments, tumour surgeries and even transplants should plan their surgeries because for them getting timely medical attention may be far more important than waiting for corona virus to go away. While, the fears of these patients are understandable, they must realize that a far greater danger lies in not seeking appropriate medical care when needed.

With the battle with Corona virus now over three months old, many hospitals have learnt their lessons and have built expertise in tackling Covid 19. They have created stand-alone facilities, developed isolation areas completely segregated from the covid areas and put in place stringent infection control measures to ensure not only the safety of the patients but also of their clinical and other staff. In the initial days of Covid 19, the hospitals were still figuring out ways of managing Covid patients, while ensuring safety of everyone else. Many healthcare workers (HCWs) caught the disease, were quarantined and even hospitalized and the media went to town highlighting such cases and painting hospitals as truly dangerous places. A lot of that was the usual media exaggeration and hype. Now, three months in the covid battle, the HCW infections have significantly come down, patient infections are almost nil and the media has gone quiet.

While, it cannot be disputed that patients in times of a pandemic will always face higher chances of infection, they must evaluate this risk against the risk of postponing a treatment, which can potentially be more harmful. This is clearly not an easy decision, as patients will hardly have sufficient knowledge to evaluate their options and make the right choice. Even if they had, the ability to grasp the nuances of the risk involved, many a times their doctors and the hospitals do not share the full details.

This should not be the case.

It is the responsibility of the clinicians to advise their patients about the urgency of a procedure required and the risks associated with a covid infection or the chances of an adverse outcome in the covid times. This is most crucial as the patient and her caregivers must have a clear understanding of the pros and cons of what they might be getting into. The clinicians must explain in sufficient details all the aspects of either catching a Corona infection or (as the case may be) of a greater probability of an unexpected outcome. They must share data supporting their views and enable the patients and their caregivers to make an informed and intelligent choice. Pushing the patient into a hurried surgery or delaying an urgent medical procedure are both equally dangerous. The patient deserves an honest opinion more than anything else.

The hospitals on their part must ensure that they help the doctors walk the talk. The clinicians can advise a patient only if they themselves are confident that the hospitals will be able to support them. The hospitals must demonstrate to their surgical teams that they are really equipped to handle these procedures with minimal risk to either the patient or the hospital teams including the surgeons. Their is no room for any slippages here and empty talk can prove hugely detrimental to the patients as well as the surgical team. They must realize that a surgeon operating a patient in covid times is doing so only because his patient needs the surgery and does not have the choice to wait out the pandemic. Unlike, other times, the medical team too is risking a potentially serious infection while operating the case. They know they have to be doubly careful for the patient’s sake as well as their own.

These decisions are not easy, either for the patients or for their doctors. They must be taken with great care after evaluating various options and understanding the risks to everyone. The medical teams and the patients are in this together, far more than in normal times.

The views expressed are personal

The Invisible Healthcare Costs Behind Covid 19

The Supreme Court of India, yesterday, asked the government that why should private hospitals not be asked to provide free services to patients suffering from covid 19. In an earlier bizarre judgement (which the court had on reconsideration modified) had ordered free testing for covid 19 at private labs. The court must realise that there is nothing called a free service in the world. The service is free to the user only because someone else is picking up the tab. When government delivers public goods free of cost, essentially it is the government and the taxpayers who pay for the service. In the case of private healthcare providers it would mean the investors in the enterprise who pay for it.

The investors in a private enterprise expect a reasonable return on their investments over a period of time. They also do not have unlimited resources to fund the battle against a pandemic. A global scourge of this proportion has to be primarily fought by the government with help from all other stakeholders. The epidemic has exposed the pitiable state of our public health. Sadly, the public sector healthcare spending in the country stands at a measly 0.9% of the GDP and has been sliding over the years. However, this is not the time to quibble over these numbers.

If the courts impose these kind of arbitrary decisions on the private healthcare providers, we will see hospitals closing down for want of resources to keep the enterprise running. That is hardly a solution, in a crisis, where every available bed counts.

This leads us to addressing the charge of excessive greed and profiteering by private sector players in these extraordinary times, to which the courts are ostensibly responding. It cannot be gainsaid that private healthcare must not charge excessively and profiteer from the misery surrounding us. Most responsible private sector healthcare companies understand this quite well. Yet, the media outlets in the country have gone to town highlighting two contradictory strands. One, private healthcare companies are aiming for excessive profits and two; they have not been adequately supporting the efforts of the public sector hospitals in fighting Covid 19. Now assuming that Covid 19 is an unprecedented opportunity to make huge profits, why the allegedly profiteering private healthcare shying away from stepping up and joining the fight against Covid 19? The fact is that both these allegations are false. Covid 19 is a tough disease to fight. We have seen how it has brought far more advanced healthcare systems to their knees in far more developed markets. The private sector healthcare in India is mostly unorganised ”mom and pop” small hospitals and nursing homes, who have very limited capability to fight the epidemic. Even the more organised corporate healthcare players have struggled to put together a cohesive response to the disease. While, many have become organised and learnt on the go, they have made sizable investments and have seen their running costs go up significantly. This causes price escalation, which leads to false allegations of profiteering.

Let us deconstruct some of these costs. The ones, which are visible, are of course, the Personal Protective Equipment (PPEs), worn by healthcare workers, while working in the isolation wards. Simple arithmetic shows that in a typical 10 bed ICU, the consumption of the PPE’s is at least 8 units per day per patient. Priced at INR 1000 per suit, this adds Rs. 8000 per person per day of stay in the ICU. Not understanding this, we have seen media houses going to town with wild theories of profiteering, accusing private hospitals of selling a Rs 800-Rs 1000 PPE unit for Rs 8000. This is sheer ignorance or worse.

Let us now examine some invisible costs that are peculiar to managing Covid 19 patients. The healthcare workers looking after Covid 19 patients need to stay either on the premises of the hospital or in a quarantine facility (a hotel or a guesthouse) near the hospital. This is to prevent the high risk group of HCWs returning to their own families and communities and putting those at risk. The hospital bears their stay, food, travel and other day to day expenses. These expense easily go up to INR 3500 per person per day.The HCWs after finishing their 14 day duties have to be rested for another 14 days in a secured isolation facility. This too entails a similar cost.

Since the healthcare workers work only 14 days in a month against the usual 25 days, the productivity nearly halves. Additionally, the HCWs serving in covid wards do a 6-hours duty instead of the usual 8-hours as it is impossible and inhuman to have them working longer hours wearing the suffocating PPEs. Thus, a higher number of HCWs are required to manage a Covid 19 ward leading to higher manpower costs.

There is another element of cost often missed out, while looking at the Covid 19 costs. This is of the treatment and care of HCWs who catch the infection, while treating patients. These HCWs are provided free medical care by the hospital and are also supported by way of paid leaves during the period of their illness and quarantine post recovery. This is quite a significant cost as well and often remains invisible.

These are just the operational costs. Hospitals handling Covid 19 patients also need to reconfigure a large part of the hospital into isolation areas, which are completely segregated from the rest of the hospital. They need to source more ventilators and supportive equipment to handle large volumes of patients. Renting or buying these add to the cost.

The need of the hour is for the concerned governments to enrol private sector healthcare providers as partners in the effort against Covid 19. They need to understand and keep in mind their operational as well as financial concerns as they formulate policy. The private sector is not asking for profit and many are even willing to work at no profit no loss basis. They are not an adversary in the fight against Covid 19 but valuable allies. However, they themselves need to survive the Covid 19 onslaught to be effective in the battle against the pandemic.

Views expressed are personal

Healthcare Warriors and All That

A couple of days ago NDTV aired a film shot at the Nanavati Hospital, Mumbai (disclosure – Nanavati Hospital is part of Radiant Lifecare, which is merging with Max Healthcare, my employers) where its ace anchor Srinivasan Jain and reporter Maryam Alvi spent some time in the Covid ward ICU of the hospital. The team donned the full PPE’s and interacted with doctors and other medical staff on duty, saw first hand what it means to be a covid 19 warrior on the frontlines of the battle. They experienced for themselves the stifling and claustrophobic environment in which clinicians and healthcare workers operate. They learnt that once in their PPE’s they can’t have a glass of water or use the washroom for the entire duration of their 6 hours shift. A doctor mentioned that he worries about his elderly parents at home whom he has not seen in two months.

This is a reality well-known to people who are working in hospitals. They look in awe at the sacrifices being made by all the healthcare workers looking after covid 19 patients. The government has made attempts to recognise their efforts. Prime Minister, Narendra Modi had on two occasions asked the citizens to support and motivate the healthcare workers (HCW’s) by stepping out on their balconies, banging pots and pans and by lighting lamps. A dutiful nation, spellbound by the Prime Minister’s theatrical gifts generously obliged. The lamp lighting was followed by fireworks!!!

The Armed Forces did their bit by sending the air force jets on a flypast and we had army choppers showering petals on hospitals with excited healthcare workers waving from the hospital terraces.

Sadly, all this has been symbolic. The reality is very different. Consider these facts.

The Resident Welfare’s Association of the tony GK1 Enclave in South Delhi stopped HCW’s going off duty to check-in into a OYO guest house rented by Max Healthcare in Delhi. These healthcare workers had completed their 14 days Covid duty and were to rest for the next 14 days before they resumed their duties. The healthcare workers were sent back to the hospital as the vigilante association demanded certificates that the HCW’s were covid 19 negative. The hotel too was warned of stringent action if it allowed HCW’s to stay on its premises. All these HCW’s were asymptomatic, had no unprotected exposure to any patient and were well with in their legal rights to stay at the hotel. To make matters even worse, Wg Cdr. Virender Sharma, the Secretary of the RWA proudly and shamelessly sent out a whatsapp message narrating the incident titled ”Successful Disaster Management in GK Enclave -1”. The ex-air force officer, didn’t see the irony of the air-force showering petals on the same HCW’s, who were persona non-grata at a hotel in the locality.

This is not an isolated incident. At Max Healthcare, we have recorded incidents where residents of Vaishali, Ghaziabad have objected to nurses staying in a hostel in their locality and the RWA in Rohini in North West Delhi have threatened to disallow nurses to stay in another hostel. The other day, newspapers carried stories of a doctor returning home in the South Delhi locality of Vasant Kunj after recovering from Covid 19 was beaten up by her neighbour. I am sure other hospitals treating covid 19 patients have faced similar situations where their healthcare workers have faced unwarranted stigma, ostracism and assault.

In the light of all this, we must ask ourselves, what kind of a society and nation have we become? We take great pride in symbolic gestures but when it comes to showing some spine, we buckle. We show great respect and pride in the work being done by the HCW’s but when it comes to taking care of them even at a minimal risk to ourselves, we blanche. We are happy admiring hard working dedicated professionals but from a safe distance. We are happy abandoning those whom we would likely depend upon when the need arises. What would happen if the same healthcare workers choose not to treat patients from let us say GK 1 Enclave? Will that be justified? Of course, this would never happen, professional HCWs will never turn away patients because they have been mistreated by the very people who might now be knocking at their doors.

Speaking for all the HCWs, I can confidently say that they are not seeking great honour or appreciation from anyone. They are not hungry for idle adulation from fellow citizens. They are not asking to be hoisted on eager shoulders or be paraded amongst fawning crowds. Most of them are doing their duty and fulfilling the oath they took many years ago when they chose medicine as their profession. They are making personal sacrifices not because it is glorious to do so but because of their total commitment to their calling. They are taking great risks because that goes with the terrain and not because they don’t have families to go back to.

And, all they expect in return is some kindness to them and their families, some respect and courtesy in the ordinary course of life and a little support in these difficult times.

We must ask ourselves, is that too difficult for us to offer?

The views expressed are personal

Idle Thoughts in Corona Days

The government of India remains chary of testing for Covid 19. The most obvious reason is that the more you test, the more covid 19 positive patients will be found causing panic and alarm across the country. Thus, being an ostrich helps in these difficult times. Strangely, this bizarre strategy seems to be working as well. For some reason that no one is sure of, we are not seeing too many sick patients at the hospitals either. While, the lockdown has certainly helped stymie the wildfire spread of the disease, it does seem that the virus is passing India by or for some unknown reason is not as virulent as in many other parts of the world.

Many pundits have been holding forth on this strange phenomenon. Some believe that the virus in India has mutated and become less virulent, some others believe that India’s universal BCG vaccination program running for decades is helping protect the population and some think it is the Indian summer, which has made the virus somnolent. There is no evidence or science behind any of this so far. Whatever, the reason, we must be thankful for this.

While the fear of the virus keeps most people indoors, what is very worrisome is the stigma that infected people seem to be carrying in our country. We have had incidents where Max Healthcare ambulances have not been allowed in residential areas when they have gone to pick-up suspect covid 19 patients. Family members of doctors who have unfortunately tested positive have been ostracised by their communities and nurses had to face the brunt of their neighbours ire as they have continued to do their duties in hospitals. This should make all of us hang our heads in shame. As someone who works in a healthcare organisation and who is obliged to go to work everyday to help keep our hospitals running, I shudder to think the burden I and my family would have to carry if I was to test positive for the virus. This is something unique to our country. No where in the world are healthcare workers held responsible for catching the virus, while serving others.

The other thing, which is deeply disturbing is the way hospitals and healthcare facilities are being portrayed as infection hotspots. Media reports everyday highlight hospitals being shut down because a few patients or HCW’s tested covid positive. Hospitals by definition are places where the sick need to go to. Some HCW’s working there in-spite of all possible precautions are likely to catch the virus from their patients. Alternately, they may also end up bringing the virus into the hospital from the communities they live in. (Max Healthcare has decided to test all patients and healthcare workers employed in their hospitals for Covid 19 as a precautionary measure) This is something to be expected, however shutting down entire hospitals because a few doctors or nurses test positive is not only short-sighted but positively detrimental to patient care. If we were to keep shutting down hospitals, who will be left to treat the patients? The ideal situation would be to contact trace individuals who might have come in contact with the infected personnel, isolate, test and treat them. The hospitals need to activate their deep cleaning and decontamination protocols and get back to work as usual. Screaming media headlines highlighting such incidents and baying for blood do great disservice to themselves as well as the cause. They also end up demoralising the healthcare workers, the most valuable resource during a pandemic.

In India no one wants to be quarantined even if this means they continue to spread the disease. We have very low levels of civic responsibility and the quarantine facilities available are nightmarish. Many people who are asymptomatic and need to be tested as they live in a hotspot or might have inadvertently contacted a Covid 19 positive patient believe that they are being targeted for some strange reason and are willing to go to any length to escape being quarantined. All this has led to a most unusual and rather depressing situation, where we see mobs attacking medical teams who are trying to enforce testing or simply escorting suspects to quarantine facilities. Beating up or stoning medical parties is inhuman, afterall they are just doing their duty and actually trying to help those who might be sick. We must condemn this completely irresponsible behaviour in the harshest of terms and ensure these people are suitably punished. This is madness of a very different kind altogether.

Finally, we need to start looking ahead. Covid 19 is not going away in a hurry. We need to learn to live with the virus. The hospitals will have to adjust to a new normal, which involves a far greater degree of surveillance and testing of potential covid 19 patients. Patient treatment protocols will have to be redefined, patients will have to get used to healthcare workers in heavy protective equipments looking after them and hospitals will insist on having minimum attendants and visitors. Similarly, our work places too will have to undergo significant changes and all of us will have to learn to work remotely and while in office maintain appropriate physical distance from each other. We will see a lot of masks (I understand designer masks are already available) and hand sanitizers in our offices.

This is just the way it is going to be till we find a vaccine or a cure for nCoronaVirus. Let us get on with it.

The views expressed are personal

Lessons from the Corona Virus

The Corona Virus pandemic has been ravaging the world like no other in living memory. The disease, really something as innocuous as a viral flu has disrupted life like never before. Millions of people the world over are locked into their homes, not daring to step out lest they catch the virus and end up in a hospital or even in an early grave. The developed world with showcase medical facilities is the worst hit. Italy, Spain, France and the UK are struggling to get their act together against the marauding virus. Prince Charles and even the British Prime Minister are reported to be nursing mild Corona Virus infections. The US is likely to overtake everyone in this ghastly tragedy. The US President, an unstable and tempestuous man at the best of times, believes that if they end up with deaths in the range of 150000 to 200000 people, he would consider that as success in his efforts at controlling the virus.

The economists are already talking about a global recession. Most businesses are shuttered, the Olympics have been postponed to the next year and no one knows when will all this end. The international and even domestic travel is at a standstill, airlines are expected to go bust in a matter of months, the hospitality industry is in the doldrums and there isn’t a single economic activity anywhere in the world, which is not impacted.

The medical systems, the very best that mankind has been able to put together are teetering at the edge. Hospitals in the most developed parts of the world have run out of ideas. They just do not know how to cope anymore, as thousands of people are dying everyday. The doctors and the nurses and all the gadgetry, which is an inevitable part of hospitals today have no answers to the unending blood-lust of the virus.

Imagine, all this mayhem is caused by just a virus, which isn’t even considered a living organism. Mankind, in-spite of all its knowledge, skills and computing prowess remains so fragile as to be threatened by nothing more than a few cells of DNA or RNA. The virus is a timely reminder of our inherent fragility, it should make humankind a lot more humble and respectful for other forms of life on the planet.

The virus has also exposed all our differences and fault lines as completely false. The virus does not respect nobility, royalty or cares for Prime Ministers or Presidents or their spouses. It does not care for geographic or national boundaries. It needs no passports or visas to cross these. It has scant respect for the religions of the world, or their mighty leaders preaching lofty sermons to their fawning followers. It cares little about people’s stations in life, their affluence can’t save them from its ravages, their knowledge and education is no consideration in the inexorable march of the virus. It attacks all humans and spares all life, which isn’t human. As we cower behind the four walls of our homes, all the life on earth must be laughing at us silly.

The virus has also laid bare our limitations as mankind, as a species that considers itself above all others in the world. It has punctured our pride as the ”masters of the Universe”. While we are capable of destroying the planet and all the life on it many times over, we still do not know how to save ourselves from something as low a life as a virus. While we have traveled to the edge of the known Universe, we have no idea how to deal with what a virus does to our own bodies. As we scramble to save ourselves from the virus, we realize that we have nowhere to go except our own homes.

One day, the virus will surely fade away, some brilliant scientist laboring in a far-off lab will soon enough master it and render mankind immune to its depredations. Or it will just mutate into something friendlier. Mankind will perhaps regain its swagger and disdain for all the other life on the planet. Yet, deep in its heart, it would remember what it was to be a prisoner of a virus for a few months.

Hopefully, it will also serve as a lesson in humility too for we are after-all not as indestructible as we have always thought us to be.

The views expressed are personal

A case for an Indian Bumrungrad

Bumrungrad International Hospital in the Thai capital, Bangkok is easily the world’s leading hospital for international patients. It has been a beacon for patients across the world for over two decades now. The hospital treated over 1.1 mn patients in 2018 with over half of them being foreigners from 190 countries. The hospital has a reputation for great medical care along with excellent international patient services customized to the needs of their global patients.

Indian hospitals too receive hundreds of thousands of international patients from different parts of the world every year. Max Healthcare, in New Delhi, where I happen to work received over 70000 patients from over 100 countries last year. Yet, we do not have a hospital in the country that can really be called a super-magnet for International patients. For most Indian hospitals, International patients are just a tiny sliver of the patients that they take care of. Unlike, a Bumrungrad Hospital, Indian hospitals are designed to cater to local patients and the international patients that they receive, while important, are rarely an area of great focus.

International patients travelling to India often have needs, which are very different from local patients. For many, visiting a hospital in a far-off country is a big leap of faith and they often rely on the services of healthcare facilitators (HCFs), which are intermediaries representing hospitals in different countries. The HCFs often interact with these patients before they board the flight for their medical destination. The HCFs connect them with local doctors and the hospitals, help them get a medical opinion for their afflictions, advise them and help them make appropriate choices regarding their treatment. They also help arrange tickets, often pick-up patients from the airports and make their arrangements for their stay. While the HCFs need to professionalize and become more organized, the hospitals too need to build a full suite of concierge services for international patients. Since most Indian hospitals consider International patients as just an ”add-on”, the international patient services do not get as much attention as they should.

It is time, we looked at setting up hospitals, which consider mainstreaming international patient services. This would essentially mean that the hospital should fundamentally be designed to cater to the requirements of International patients. The infrastructure would typically include plush International patient lounges, exclusive international patient registration and admission desks staffed with executives with appropriate language skills and a full services concierge desk to assist the patients for any need. that they may have. The hospital will also need signage in multiple languages, medically trained interpreters available 24×7 to assist clinicians when they wish to communicate with their patients and a maybe global choice of cuisine.

The international patient experience as distinct from the medical services being offered by the hospital has to be truly world-class. The foreign patients should be made to feel comfortable and at home right from the moment they step out of the airport. India will be able to draw a significantly larger chunk of International patients if we are able to elevate the international patient experience to the highest possible level. A business case for such a hospital can easily be made. However, apart from capital and investments, this will also require a change in the mindset of the hospital promoters and their key executives. That is perhaps the bigger challenge.

Serving International patients allows the country to earn precious foreign exchange and is considered as export of services. With relatively low costs and world-class medical outcomes, Indian hospitals have tremendous competitive advantage. They must not squander it away with what might today be called as a half-hearted effort.

It is time we built a Bumrungrad Hospital of our own!!!!

The views expressed are personal

A Letter to the Finance Minister

Dear Madam Finance Minister,

I must start by acknowledging the very difficult task that you have in front of you. Preparing the Union Budget this year, in times of such economic turmoil, is far from easy. Ordinary people of the country have huge expectations from the budget and I know, it is almost impossible to meet everyone’s aspirations. I am also sure economists and self-styled pundits of all hues must be offering you gratuitous advise on how to aim for greater growth, generate employment, rein in the burgeoning deficit and balance the budget. I am no expert in these matters and hence will refrain from adding to the chorus. My sole purpose in writing to you is to draw your attention to the healthcare sector and the urgent support it needs from the government.

As you might be aware, the National Health Policy of the Government of India itself has committed government spending on healthcare at 2.5% of our GDP. Currently, the government spends a measly 1% of the GDP on healthcare. This isn’t getting us anywhere at all. The health of the citizens of the country and their access to good quality healthcare you would accept is of paramount importance. Even a small increase in the allocation for healthcare can go a long way in improving public healthcare infrastructure particularly in the far flung regions of our country and in the area of primary healthcare.

The government had announced the world’s largest healthcare insurance scheme called Ayushman Bharat a couple of years ago. The scheme was envisaged to provide an insurance cover of INR 500000 to over 500 mn poor people. The scheme is indeed ambitious in its scope but does suffer from lack of funding. The insurance companies (mostly government owned) have been arm-twisted to accept extremely low premiums and private hospitals are being asked to support the scheme even though it is almost impossible for them to provide good quality healthcare at the government mandated price-points. Ayushman Bharat, which is designed to provide access to healthcare to the poorest of our poor needs proper funding and government support. I trust, this will be right on the top of your agenda, while looking at competing demands for funds from other government welfare schemes.

The private sector provides the bulk of healthcare to the citizens of our country. In the last couple of years the private healthcare players have had a tough time with respect to the regulatory environment mandating price capping for medical devices like stents, joints and life-saving cancer drugs. While, this has helped the common man in making healthcare more affordable, the hospitals have seen their slim margins shrink further. It would greatly help if the government was to include healthcare sector in the ambit of infrastructure sector. This will allow private sector hospitals to raise funds at low costs, which will go a long way in shoring up their sagging profits, which in turn will kick-off fresh investments in new capacity, technology and new jobs.

To attract private sector healthcare investments in smaller cities and towns in India, you must consider offering incentives and subsidies to private healthcare players. They will be able to partner with the government in setting up ”low cost” hospitals, readily accessible to most of our citizens at attractive price points. This will lead to investments and job creation, locally something that the government will be delighted with.

Healthcare insurance penetration in India is abysmally low. Most people are either uninsured or under-insured. This makes quality healthcare completely inaccessible to a very large number of our citizens. It would be very useful if the government was to consider making healthcare insurance mandatory for all private sector employees with the responsibility of providing a suitable cover with the employer. This should be mandated for all Small and Medium sector organisations as well thus dramatically increasing the number of people covered under healthcare insurance. While, we are at this, may I also point out that the Central Government Health Scheme (CGHS), which covers millions of serving and retired government employees is in dire financial straits and owes millions of dollars to private healthcare providers, who are now increasingly constrained to refuse services to CGHS beneficiaries by opting out from the CGHS panel. You must consider funding CGHS and other similar government schemes adequately so that their beneficiaries continue to receive adequate healthcare.

The export of healthcare services from India popularly called Medical Value Travel (MVT) has the potential to earn billions of dollars of foreign exchange for the country. Indian healthcare service providers have tremendous advantages. They deliver quality healthcare at very low costs. We have the potential of attracting people from all across the world to India for medical care. Last year, at Max Healthcare, where I work, saw patients from over 110 countries. The opportunity is immense. However, we do need some help from the government in marketing India as world-class destination for inexpensive healthcare. The previous government had set up a board to promote wellness and medical value travel to India. For the last few years, it is lying defunct. It would be very useful to revive this board with adequate funding, infrastructure and a clarity of vision to help promote India and its healthcare prowess across the globe. Tax breaks and incentives to private healthcare players investing in MVT will also go a long way in attracting foreign patients.

Finally, I must draw your attention to technology, which is changing the landscape of healthcare delivery across geographies. India has an excellent penetration of mobile telephony and we can deliver and address a lot of healthcare concerns of our citizens using technology. A mobile phone can be used to capture healthcare data remotely, images can be sent and analysed, AI applications can be used to report and diagnose smartly. The world is increasingly moving in this direction. My request to you would be to set aside a small sum of money and create a mechanism, which encourages entrepreneurs to invest in these technologies helping deliver healthcare to our people living in far-flung areas of the country with limited access to healthcare.

Madam, the health of its citizens has to be a major priority for any forward looking government. I am sure, you will be addressing some of these concerns in you budget proposals. We are eagerly waiting to hear from you.

The views expressed are personal

What Makes a Hospital Great

We are finally on the last day of the year and the decade too. This is usually a time for reflection and I too have been thinking about my good fortune in never having been admitted to a hospital so far. God has indeed been kind and merciful. However, while I have been able to avoid a visit to the hospital so far, I have spent most of my working life and almost all of the last 10 years roaming the corridors of hospitals all over the world. This has been a great privilege for someone who isn’t even a clinician. I have been a part of teams trying to create wonderful hospitals that patients would love to come to. This quest continues with the realization that patients do not love to go to any hospital, whatsoever. They go there under the force of circumstances and are keen to return home as soon as possible.

So, what would constitute a hospital that one wouldn’t mind going to if the situation so demanded? Here are some thoughts.

The first and foremost is the obvious. The hospital must have great clinical expertise. This essentially means that the hospital should have a great set of clinicians well trained and experienced in their areas of medicine. It should also be equipped with some of the best medical gadgetry to allow the medical wizards to treat patients safely and to the best of their ability. This is relatively easy to achieve. The really difficult part is to get the great clinicians and the nurses and everybody else who delivers care to work together in the best and abiding interest of each patient. It takes years for a team to tango together. Large, successful hospitals are busy places, filled with thousands of patients demanding attention and care round the clock. For most patients a hospital visit or a surgery is perhaps a once in a lifetime experience. For busy clinical teams, scores of patients everyday is the norm. In all this a great hospital would be one where care and attention is lavished on each patient as she is the only one under their care that day.

Apart from providing great medical care, I would truly treasure a hospital that talks to me as a partner and treats me as an equal stakeholder in my own care. Very often this is a neglected area in most of our hospitals. Rarely, clinicians take the trouble to explain to the patients the medical conditions they have been diagnosed with, the treatment plan, the prognosis and the complications that may arise. There are many reasons for this – doctors are extremely busy juggling multiple balls all the time, do not consider this conversation as very important one, believe that patients do not have adequate medical knowledge to benefit much from this discussion and some, dare I say, are just not trained to address all the queries the patient may have. In a great hospital, medical teams must spend time with each patient, explaining and answering their questions as best as they can and with candor, empathy and respect.

There is something else that as a patient I rarely get to see or know but is absolutely critical for my well-being. This is the effort and investment a hospital makes in ensuring patient safety. Hospitals are inherently dangerous places teeming with germs and instruments, which are used for jabbing, invading and cutting open patients. Of course, all this is done in a controlled and highly sanitized environment, yet chances of someone slipping somewhere, making a grave and maybe an inadvertent error is always round the corner. The trick is in trying to eliminate these errors as far as possible through technology and stringent process controls. Ultimately, patient safety is an organization wide effort to establish a culture, which looks at learning from mistakes all the time. Great hospitals are obsessive about patient safety and treat even the smallest transgressions with utmost seriousness. To them nothing is more important than ensuring that the patient comes to no harm in the hospital.

Everything else to me in a hospital is a given. I would expect the hospital to be clean, the food to be of decent quality and served on time, the air-conditioning to be working well, the nurses to be responsive and the staff pleasant. I would greatly value efficiency in a hospital and wouldn’t like to wait endlessly for things to get done. I do expect the hospital to transparently charge me for its services and make a reasonable profit for its share-holders. A great hospital is also one, which does all of this effortlessly and as a matter of course.

As the new decade begins, I would certainly hope not to land up in a hospital in the next 10 years too. Yet, if it becomes unavoidable, I would certainly want to be in a hospital, which does all of the above rather well.

Here is wishing all of you a wonderful new year, filled with good health, happiness and much joy.

The views expressed are personal

On Medical Errors and Negligence

Medical professionals like everybody else are prone to errors. These errors are pretty much an essential part of being human. No one is infallible and therefore to expect our clinicians to be free from mistakes is foolishness. In the case of medical professionals, however the consequences of a medical error can be horrendous. A small error can leave a patient in a wheel-chair for life or can lead to life threatening complications and even death. A recently published report by John Hopkins University School of Medicine estimated medical errors to be the third largest cause of death in the US accounting for a little over 250000 deaths in a year. In India, these numbers are difficult to estimate. Business Standard quoted a Harvard study in Oct 2018, estimating that a staggering 5 mn lives are lost to medical errors annually in India.

Medical negligence on the other hand implies that an adverse medical outcome occurred because a clinician or a care-giver failed to adhere to well-established standards of care. This happens because the care givers were too casual in their approach, did not take their onerous responsibilities seriously, failed to adhere to well established medical processes and procedures or were simply careless. Often, clinicians in busy hospitals are over-burdened, are constantly multi-tasking and perennially dealing with highly stressful situations. This leads to short-cuts, a deviation from the norms and established procedures causing a catastrophic outcome. Sometimes, medical negligence can be traced to over-confidence where a clinician has supreme belief in his own abilities and becomes a little cavalier in treating patients leading to a stupid unforgivable mistake.

As patients and consumers of healthcare services it is imperative for us to understand and recognize the difference between a genuine medical error and medical negligence. Patients often tend to blame doctors for an unexpected adverse outcome, not realizing that the practice of medicine is inherently fraught with risk and an adverse outcome is always in the realms of possibility. A doctor can only try and minimize this risk by his knowledge, skills and work-ethics, he cannot eliminate it or wish it away. Medical errors can also be significantly reduced by establishing a hospital-wide culture of patient safety. The use of cutting edge technology, which warns clinicians, nurses and care-givers whenever a deviation from an established process is detected, allows clinicians to review their decisions and stop just before an error was about to happen. Many private hospitals in India now use these smart systems to prevent medical errors thus improving their medical outcomes. (At Max Healthcare, we run a program called ”Chasing Zero”, which through multiple initiatives helps weed out clinical errors. While, this program is almost invisible to patients and consumers, it is one of the most important initiatives, running silently in the background ensuring greater patient safety and better outcomes.)

Medical Negligence, of course is completely unacceptable. That a clinician or a care-giver failed to adhere to a well-established standard of care is an egregious failure and must not be countermanded or swept under the carpet. Even a single case of medical negligence is a blot and the hospitals should not shy away from accepting the mistake and taking remedial action. Sadly, many don’t, fearing a media backlash and legal liabilities.

From a patient’s perspective, being a victim of either a medical error or medical negligence is terrible. Patient’s go to the hospitals in search of a cure and an enhanced quality of life. To emerge from a bout of hospitalization in a worse condition is a tragedy. It is hardly a consolation to know that the medical error was either ”unforeseen” or ”unavoidable” and a result of human fallibility. These patients have to learn to live in altered circumstances and daily face up to the new reality of their diminished lives.

It is thus imperative for hospitals to continue to invest in technologies, which help avoid medical errors. The hospital leadership teams should continuously work towards creating a culture which respects and honors professionals who are always vigilant, all the time looking over their shoulders and going out of their way to help ensure minimal medical errors. There can’t be anything more important in a hospital than patient safety.

If we have to err, let us always err on the side of caution.

The views expressed are personal