The “Amar Uchala” Way

When I was in college almost 20 years ago, we had a popular Hindi newspaper called Amar Ujala. This was well-circulated in western UP and was a staple amongst students at the ubiquitous ‘dhabas’, which ringed the campus of the Aligarh Muslim University, Aligarh. We all loved to read its over the top reporting, brazen twisting of facts and its economy with the truth. Affectionately the newspaper was called ”Amar Uchala”.

Those were the days of innocent fun and we hardly realized that how insidious and damaging this kind of reporting can be. It struck home to me when I came across this piece of reporting on its pages recently.

Amar Ujala report

Let us look at this report from the Amar Ujala. The headline says that in Gurgaon 11 people die every day in private hospitals. The report cites the response of the Municipal Corporation of Gurgaon (MCG) to an application under the Right to Information Act filed by one Mohit Khatana. The entire story is based on this RTI response and paints an extremely negative image of some of the most well-known hospitals in Gurgaon.

The report without any comparative basis, claims that these hospitals have very high mortality rates and publishes data on the number of death certificates issued by MCG on the request of various hospitals in Gurgaon. It claims that the data shows that the mortality in these hospitals is very high. It also makes wild allegations against private hospitals claiming that the hospitals admit very sick patients knowing fully well that these patients are unlikely to survive and in the process, they make a lot of money.

It also quotes Mohit Khatana claiming that it seems that the larger the hospital, more are the number of deaths.(I don’t know how can it be otherwise!!!) The report also claims some unknown experts saying that mortality is far worse in these hospitals as the numbers cited do not include those who are sent LAMA (Left Against Medical Advice) and die at their homes.The report, of course, does not present any point of view from the affected hospitals.

Now let us examine facts.

Medanta is the largest private sector hospital in Gurgaon with over 1000 operational beds. It is also a referral centre for tertiary and quaternary care and receives patients from all over the country. It is a major hub for medical value travel with sick patients flocking to its doors from all parts of the world. With such a large number of very sick patients coming to Medanta, it is only natural for it to report the maximum number of deaths to the Municipal Corporation of Gurgaon (MCG). How can this be a point of contention is beyond comprehension.

Let us look at some other facts. The MCG records deaths reported by various hospitals. The data includes those who are brought dead to the hospital ER, those who die in the ER before they could be admitted for treatment, stillborn babies and even those who are certified dead at their homes by doctors of these hospitals. All these deaths are reported to MCG by the respective hospitals and a death certificate is issued by the MCG basis this information. These are not mortality figures of the hospitals.

I happen to have the data for Max Hospital in Gurgaon. The hospital reported 73 deaths out of 7609 patients that were admitted to the hospital in the period of Jan 01 2017 to Nov 30th, 2017, which makes the mortality rate under 1%. I am sure other hospitals too will be maintaining their mortality data and with a little bit of effort, the journalist from Amar Ujala should have been able to access this information. In the finest tradition of his newspaper, he never bothered.

To make matters even worse, the mortality data from these hospitals are not even comparable. The mortality in any hospital is a function of the number of patients handled as well as the service mix of the hospital. Thus, a large hospital, attracting a greater number of patients and providing advanced services such as cancer care, high-end cardiac care, and transplants will have a higher mortality than let us say a secondary care hospitals with a lesser number of beds. Thus, one fails to understand how can one compare mortality at Max Hospital, Gurgaon which is an under 100-bed secondary care facility with Medanta Hospital, which is quaternary care hospital with over 1000 beds.

Finally, the conclusions drawn are just as ridiculous and mendacious. Even if one was to assume that this data is comparable and accurate (which it most certainly isn’t), how does it indicate that hospitals are admitting and keeping sick patients who have no chances of survival?

Pray, what else is a hospital supposed to do – turn away the very sick and admit the relatively healthy? If Medanta Hospital is admitting the very sick knocking at its doors and trying its best to save their lives, what is wrong with that?

This kind of perverted reporting, completely one-sided and meant to only cause discord between patients and their clinicians and hospitals is lamentable. The journalist is not only ignorant of facts, sadly he doesn’t seem to be interested in the truth either. He has to find a ”sensational” story to file and this seems juicy enough, the facts be damned.

Amar Uchala, too hasn’t changed much in these 20 years.

The views expressed are personal

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A Complete Abdication of Responsibility

The private healthcare sector in India is now increasingly being looked upon as a sector that should focus on doing good rather than being run as a responsible business enterprise. The government wants the private hospitals to be good Samaritans and treat patients at such low prices that the business itself becomes unviable!!!

Essentially, the government wants its duties to be discharged by the private sector.

This is a complete abdication of responsibility on the part of the government and totally unfair to the private sector players and their investors. It is a well-known fact that public healthcare expenditure in India remains abysmally low at under 1.4% of the GDP. This compares poorly even with countries in sub-Saharan Africa. According to the WHO World Health Statistics 2015, the public sector in India spent 1.16% on health as a percentage of the GDP, ranking 187th among 194 countries. A recent report in The Wire says ”global evidence on health spending shows that unless a country spends at least 5-6% of its GDP on health, basic healthcare needs are seldom met”.

Another recent report in The Mint pointed out ”The World Health Organization estimates that India spent about $267 per capita on health care in PPP adjusted terms in 2014—China spent three times that amount, Brazil five times, European nations 10 times and the US 20 times” 

To make matters far worse is the fact that much of the funds allocated to the sector remain unutilized. This is nothing less than criminal negligence. Sample these facts reported in The Hindustan Times in August 2017.

”More recently, in a performance audit of the Reproductive and Child Health scheme under the National Rural Health Mission (NRHM) tabled in the Parliament last month, CAG said the cumulative unspent amount in 27 states increased from Rs. 7,375 crore in 2011-12 to Rs. 9,509 crore in 2015-16.”

Since the government allocates a minuscule amount for public health and even spends less, the out-of-pocket (OOP) expenditure in India remains high. In the year 2014-15, 62.42% of health spending was borne by the citizens themselves. Unexpected medical expenditure remains the single largest cause of individual families being pushed below the poverty line. The National Health Policy Draft of 2015 estimated that ”nearly 6.3 crore people are faced with poverty every year because they do not have financial protection for their healthcare needs“.With the OOP remaining high, there is a sense of anger and frustration amongst the consumers and the politicians have been cleverly channeling this palpable anger towards private healthcare providers by painting them as uncaring, profiteering and worse.

Now compare this with what is happening in the private healthcare space in India. A recent report (August 2017) in The Scroll cites a PwC study saying that private health spending in India was more than double the government’s expenditure, at 3.3% of the GDP in 2014. The private sector consisting of individual doctors, clinics, nursing homes, diagnostic chains, trust hospitals and corporate hospitals provide care to more than 80% of our people. A report by the India Brand Equity Foundation (IBEF)  published last month points out that healthcare sector in India is the largest employer in the country. The sector is expected to record a CAGR of 16.5% between 2008-2020 and the industry size is expected to grow to USD 280 bn.

The same report quotes Department of Industrial Policy and Promotion (DIPP) ”The hospital and diagnostic centers attracted Foreign Direct Investment (FDI) worth US$ 4.34 billion between April 2000 and March 2017.”

A mere glance at this data indicates that while the government has wantonly abandoned its duty of providing good quality healthcare to the citizens of the country, the private healthcare sector continues to make significant investments. Private investments are by definition ”for profit” investments and are made in the rightful expectation of a reasonable return on the capital employed.

Instead of spending scarce public funds on building new infrastructure, decongest government hospitals, ensuring efficient and smooth management of these hospitals and providing greater access to the citizens to public healthcare, the government is busy pandering to the masses through populist measures and what may even be called as bullying.

Populist policy announcements, which are not even clearly thought through are being made every day. It has been announced yesterday that any citizen in the city of Delhi who fails to get timely medical attention in a Delhi government hospital can approach a private healthcare institution and avail of cash-less services, which will be reimbursed to the hospital by the government later at rates, which are very low. The private hospital has no choice but to accept the patient and treat him at government-mandated pricing.

This kind of policy-making, akin to shooting from the hip must stop.

The government should define its own role in the healthcare sector in the country.

It must be said, even though it may sound harsh that the responsibility of providing good quality healthcare to those who cannot afford private healthcare squarely lies with the government.This is a responsibility, which it must not attempt to shirk or palm off to the private sector.

The views expressed are personal

 

 

The Winds of Change

With the trust levels between clinicians in private practice and their patients plummeting to what many would call an all-time low, many clinicians have been wondering what they need to do to regain the lost trust.

In a recent interaction with some senior clinicians, I found that many are reflecting deeply on things that they perhaps need to do differently and maybe unlearn some of what they learned early on in their careers. The new skills they felt they needed to acquire lie not in the domain of medicine but in the areas of patient communication, documentation and even bed-side manners.

The clinicians are increasingly realizing that treating patients and saving lives is much more than just wielding the knife or taking life and death decisions based on their clinical acumen and skills. The clinicians feel that they need to engage with their patients in multiple ways to earn the patient’s trust once again.

The good news is that they are more than willing to do so.

The new age clinicians are learning lessons in patient communication (pun intended) as they deal with Google strengthened patients, who have dozens of questions on their differential diagnosis, tests needed, treatment plans and even backup plans if things go wrong.  The patients are asking questions on drug reactions, likely side-effects and how would one cope with them if God forbid, they occur. They want to know why a particular implant is being recommended, what are the chances of an allergic reaction from the metal used in the implant and what can be done about it!!! From the clinician’s point of view, this is many worlds’ away from the time when they were treated like demigods and their pronouncements considered to be almost divine.

The clinicians are getting used to the new reality and many are keen to be trained in being able to address these questions adequately and in a manner that the patients understand. The clinicians are trying hard to learn the language of their patients. Many do not shy away from passing on patient literature developed by hospitals, especially for this purpose. Many are equipped with videos of past patients, which they happily handout to their new patients. Some, direct the patients to check out authoritative resources on the web and satisfy their thirst for knowledge. Clinicians are writing blogs and creating web content for patients to read and understand their conditions better before they decide on surgery.

In India, very few clinicians are as digital media savvy as say their colleagues in management. I reckon this is primarily because many senior clinicians are still from a generation when they never had social media when they were growing up or training in medical schools. They became professionally busy well before the advent of the smartphone and the 24×7 assault of the Facebooks, the Linked-Ins, and Twitters of the world. Thus, they hardly had time to get used to the tremendous power these digital tools wield in engaging with consumers today.  This too is now changing. Many clinicians are now harnessing the power of these social media platforms to engage with their patients. That the mediums allow for a continuous engagement, which is way beyond the episodic nature of a surgery or hospitalization is an added advantage. Many clinicians in a sincere effort to shed the old world aura of being  Gods are also sharing snippets of their personal lives, hobbies, family pictures and vacations to connect better with their patients.

The doctors are also trying to be nicer to their patients and are even considering sartorial changes to make them look smarter and more approachable. It is now quite usual to see smartly attired,  doctors welcoming patients in their OPD chambers. Some are even spending time in the gym, making them look fitter and healthier. They are certainly willing to spend more time with the patients and their attendants. The clinicians are also realizing that patients admitted to the hospital under their care look forward to seeing and hearing from them at least once a day. Many now hold conversations with their patients on their medical rounds, which are far more reassuring than in the past. Some clinicians are also sharing their phone numbers so that patients can WhatsApp if they need to reach out for anything.

These are all welcome developments.

However, the biggest change, which appears to be happening is in the area of documentation. Unfortunately, medical education and training in India, which is still largely in government-run institutions does not equip doctors with the meticulous documentation needed, while working in large corporate hospitals. The clinicians need to learn to work on HIS systems of various degrees of complexity, put in orders in the system, prescription have to be recorded in electronic formats and the smallest of thing needs to be properly documented. The days of the clinician’s iconic scrawl are well and truly over. Verbal orders barked to nurses no longer suffice. The culture of documentation and the use of technology allows for significant reduction in medication and other errors. It leads to far greater patient safety and protects everyone from doctors to nurses to hospitals from disputes and legal action.

These are welcome changes. That the clinicians are thinking about ushering in these changes to help reach out to their patients better is indeed reassuring. I am sure these will go a long way in bridging the gulf that now divides patients and their doctors.

The Myth of Overcharging in Private Corporate Hospitals in India

Why is it so easy for us to believe that corporate hospitals ‘overcharge’?

If one was to poll educated, middle-class Indians, mostly professionals and smart and rational people, most would unhesitatingly aver that private corporate hospitals in India inflate their bills and take patients for a ride. If one was to ask them the same question with respect to a five star hotel, a dinner at a fancy restaurant or even an airline, where fares vary on a daily (and sometimes on an hourly basis), the answer would usually be that, yes they are expensive, but than they do offer certain comforts. I am yet to hear someone moan about a luxury hotel, overcharging.

One of the reasons for this perhaps is because expenditure on healthcare is almost always a forced expenditure. No one goes to a hospital to enjoy a few days of surgery, rest and recuperation. We spend in a hospital only because we do not have a choice. This expenditure is also usually unplanned, which means that it is an unwelcome drain on one’s savings. Thus, we hate to spend in a hospital, anyways.

To make matters far worse, the expenses in a hospital are also uncertain. They also do not guarantee the desired outcome. Thus, it is possible that in a hospital we may end up paying far more than what was initially indicated and we may also end up not fully regaining good health. Sometimes, we may end up paying an obscene amount and also lose a loved one. In these situations, it is almost certain that we will blame the hospital for ‘overcharging’ and not providing proper care.

Then there is the old inherited belief that healthcare is a noble profession and the providers of healthcare services should aim to serve the society rather than try and make some profits for their shareholders. This belief is so ingrained in our psyche, right from our childhood, that it is impossible to reconcile to the present day reality of private healthcare is as much a business as any other. An entrepreneur invests a very large sum of money upfront in creating infrastructure, buying state of the art equipment, hiring highly skilled and experienced clinicians and sustaining cash losses for many long years before he makes a profit. Yet we grudge him this and believe that since he has chosen to invest in healthcare, he must continue to serve humanity without expecting a reasonable return on his investment.

This sadly is the perceptual reality of private healthcare even amongst the well-educated, well to do people in our contemporary society.

Juxtapose this with the reality of high-end quality tertiary care in India being the cheapest in the world. Thousands of people travel from all across the world to avail of India’s high standards of healthcare at prices, which by global standards are almost unbelievable. Yet, in India, private healthcare institutions are reviled as expensive, profiteering and seen as overcharging. I remember meeting a CEO of a private insurance company in the US. The meeting happened at a global conference on medical value travel.

‘So, where are you folk, from’?

‘We are from New Delhi, India’.

‘Aha, India, so tell me something about your hospital’

The usual spiel about the hospital followed. I talked about some great work we were doing in Cardiac Surgery.

‘So do you guys do ‘bypass surgery’

‘Yes, we do. In fact a lot of it’

‘In a month, how many cases, would you be doing in your hospital?’

To keep things simple, I told him that in just one hospital we do about 10 surgeries a day. The gentleman clearly thought I had no idea of what I was talking about.

‘That seems a lot, how much does a bypass surgery cost?’

I thought, I should not tell him the real cost of USD 4500, lest he thinks that I was completely unaware of the cost of a bypass surgery.

‘Sir, we charge USD 10000 for the surgery’.

‘Well, that is impossible, it is humanly not possible to perform successful bypass surgeries for USD 10000 anywhere in the world’.

‘So what is your success rate?’

‘Well, it is close to 99%’.

‘That is simply impossible, we don’t have these kinds of numbers even in the US’.

I hesitatingly asked him, what in his opinion, would be a reasonable estimate for a bypass surgery in the US.

‘Well, I would say anything below USD 100000, would be difficult’.

‘But, you just can’t do this for USD 10000, there must be a catch somewhere’

By now, I was becoming a little hot under the collar. I told the gentleman, that we would be delighted to host him at our hospital in India and show him how the impossible is done. He would still not believe me.

Finally, I told him that just as he doesn’t understand, how the surgery can be done for USD 10000, I fail to understand, how does it cost upwards of USD 100000 in the US.

The gentleman never did accept my invitation to travel to Delhi to see how we worked. This is a true incident, and I narrate it only to underscore the point that while the world wonders at how private healthcare in India is able to deliver high-quality medical care at such low prices, patients in India, believe that the same healthcare services at even lower price points are obscenely expensive.

Private healthcare costs, though rising, still remain one of the lowest in the world. Large corporate hospitals have well-defined billing policies and most of the bills are generated through a sophisticated HIS system. After having worked for over 15 years in large private corporate hospitals in India, I am yet to come across a stated (or even unstated) policy, which says that let us overcharge for our services from our patients. The pricing is usually based on a cost-plus model and the ceiling is determined by the competitive situation in a particular market. Finally, the consumers always have a choice. If they find a particular hospital expensive, they can choose to go to the one that they believe is rightly priced.

Private corporate hospitals in India usually provide world-class care, medical outcomes comparable with the best in the world, highest possible service levels and at prices lower than anywhere else in the world.

By clamoring for more, let us not destroy that we should all be rightfully proud of.