The Patient’s Charter and some Questions

The National Human Rights Commission (NHRC) of India has developed a Patient’s Charter, which has also been released by the Ministry of Health and Family Welfare, Government of India, for comments by various stakeholders. The document enshrines 17 patient rights including the right to information regarding one’s medical condition, emergency care, informed consent, confidentiality, a second opinion, patient safety, and quality care. The charter also tries to establish a multi-layered grievance redressal mechanism involving a grievance redressal officer in the treating hospital, an external Patient Rights Tribunal or the necessary authority to be established under the Clinical Establishment Acts.

The Patient Charter actually puts together various patient rights, which were earlier scattered across multiple documents such as the MCI Guidelines, various court judgments, and extant laws. The charter allows patients to know about their rights in a single document, which in itself is commendable. This document once finalized needs to be vigorously publicised and patients educated about their rights.

While the Patient’s Rights Charter has laudable aims and is couched in lofty language, what is not clear is how will this be implemented. Healthcare in India is largely unorganized, unregulated and mostly in the hands of the private service providers. The majority of patients view their doctors as demi-Gods (yes, even in this age!!!) with miraculous powers to cure. The government institutions suffer from chronic overcrowding, creaking infrastructure, and perennial shortages. I am not sure as to how a harried doctor with hundreds of patients waiting to see him through the day will ever be able to provide complete ‘information’ to a patient about his condition, plan of treatment, likely prognosis etc. To make matters worse, even if the doctor was to attempt this, there would be a great fear in his mind of the patient not fully comprehending the problem or worse misunderstanding leading to completely unintended consequences.

It is nice to have the ‘right to confidentiality, human dignity, and privacy, however, how is one to reconcile this with the reality of many of our hospitals, where patients are often forced to share beds because of lack of adequate infrastructure.

Similarly, it is great to have a ‘right to a second opinion’, it is not clear how will this right be exercised. Should, the primary physician informs the patient to exercise his right to get a second opinion from another expert, should he facilitate this and what happens if the two opinions do not converge. Does the average Indian patient has the ability to fully evaluate the nuances of both the opinions and make up his mind about the treatment options on the table? I have seen even highly educated patients to struggle with this.

I find the ‘right to choose the source for obtaining medicines or tests’ particularly difficult to understand. The patients while in a hospital can choose to bring in medicines from any source of their choice and get tests done from any laboratory. In India, where we have over 30000 drug manufacturing units with many operating from people’s garages and sundry sheds, it is extremely hard to ensure quality clinical outcomes if patients were to get their own medicines. The same applies to unregulated labs thriving on almost every street in the country. While I can understand and appreciate the intent of this direction (to ensure private hospitals do not fleece patients by forcing them to buy expensive medicines and tests), how on earth will we have clinicians and hospitals take ownership of clinical outcomes under these circumstances?

The right to seek discharge from a hospital is indeed welcome. The hospital cannot detain a patient against her wish is simple enough to understand and agree with. However, what happens if a patient insists on leaving the hospital without settling her dues. This happens most often when the clinical outcome is adverse and the patient feels that she has not received adequate care in the hospital. Maybe defining a set of responsibilities for patients along with this Patient’s Charter will be a good idea.

The right to be referred to a higher clinical establishment or to a super-specialist without any commercial consideration is clearly the way it should be. The referring doctor/institution must only be guided by what is good for the patient and not by any other external considerations. This has been on the statute books for long. The million dollar question remains, how will this ever be implemented and monitored.

On the issue of grievance redressal, my view is that hospitals must have an ombudsman or a committee of external experts to be able to address patient grievances. The committee should consist of eminent individuals and experts who can evaluate the patient grievance without bias and address the patient concerns in a timely and just manner. The external appellate mechanism being sought to be established either through the CEA or an empowered quasi-judicial committee works just as well. However, patients must be educated on the nature of grievances that should be raised in these fora. Otherwise, they run the risk of being inundated by sundry patient complaints and fail in their primary duty of addressing genuine grievances.

The Patient’s Charter in itself is a great step forward. All the stakeholders, which includes medical establishments, government and patients must ensure that the charter in its final form is implemented both in letter and spirit.

An educated, well-informed and aware patient is after all in everyone’s interest.

The views expressed are personal.

 

 

 

 

Advertisements

The Doctors who Communicate Better, are Better Doctors.

Communication with patients is perhaps the most important component in the overall patient experience at the hospital, yet it is a rare hospital that gets it right. The communication with patients largely involves the clinicians. The nurses, front-office executives, the house-keeping staff and even the security guard manning the elevator too can help deliver a wonderful experience by reaching out with kind words. However, it is really the doctors, whose words make the biggest difference in a patient’s life.

A few years ago, a friend’s husband needed a kidney surgery. The patient was to be wheeled into the surgery at around 10 am in the morning and the surgery was to finish in 4 hours. He was wheeled in for surgery from the hospital room at around 0930 in the morning. When I met the friend’s family a couple of hours later the attendants sat huddled together in the cafeteria, anxious and hopeful in equal measures. The time went by rather lethargically and their anxiety kept mounting. When 6 hours had gone by, the frantic family members approached the doctor’s secretary, who assured them with great panache that the surgery has gone without any hitch and they will soon be able to see the patient. Much relieved, the family members decided to have a celebratory coffee as they waited to see the patient in the recovery.

While they waited to hear from their surgeon, a couple of hours went by. The helpful doctor’s secretary by now had finished work and gone home. The surgeon was no-where to be found and there was just no one who could give them any information about the patient. Again frantic with worry the friend reached out to me to get some information about the patient’s well being and also when can they possibly see him and their surgeon.

Concerned, I made inquiries with the team in the OR and learned that the patient’s surgery had been delayed by a few hours as the previous surgery in the same OT had lasted longer than planned. The surgeon had been busy operating his scheduled cases and did not have the time to step out and explain the delay to the anxious patient’s relatives. The surgeon’s secretary had not heard anything untoward from the OT either and just assumed that everything would have gone as planned.

The patient’s surgery was uneventful and he made a full recovery. However, for the patient’s attendants, this was a harrowing experience. This is a true incident, and we know that something like this happens every day in our hospitals.

I have often pondered over the stark difference in the situation between the surgeon and the patient. Consider this for a minute. For a surgeon, a surgery is something that he does every day (maybe multiple times every day!!!), for a patient it is a frightening and hopefully once a lifetime experience. The surgeon, while operating in his theatre, surrounded by a team that he has perhaps worked with for years is usually confident of his skills and the ability to help the patient. The patient and his family are on the other hand in an alien environment. No one likes to be in a hospital and surgery is scary. The outcome in the patient’s mind is always uncertain. Given a choice, he would be anywhere but the hospital. Such is the power imbalance and asymmetry in the equation between the doctor and the patient, that it is imperative that we use clear communication to keep things on as even a keel as possible.

Patients will always see doctors who communicate well as better clinicians. Patients and their families like their doctors if they step down from their pedestals and treat them as friends. They will readily narrate stories about their interaction with their doctors and tell all their family and friends on how approachable and wonderfully transparent their doctor was. They will readily recommend the doctor to their family and friends and ultimately restore the doctor back on the pedestal!!!

It is very hard for the hospital administrators to mandate processes that define when and how should the clinicians meet their patients. Afterall, this is really a matter between a doctor and his patient and the hospital management isn’t usually welcome as a participant in this relationship.

However, hospitals must encourage their doctors to spend more time with patients and their families and not just fob them off with brusque briefings in the corridors. They must provide infrastructure, where patients and their families can meet their doctors and spend time together.

Doctors who communicate well with their patients can easily transform the hospital experience for a vast majority of patients.  Hospitals will do well to remember that.

The views expressed are personal

 

 

The Need for a new Healthcare Model and some Concerns

The organized private healthcare in India needs to urgently evolve a new business model.

The present model faces challenges as the government goes about changing the healthcare landscape of the country in a ham-handed manner. The price controls that are being put in place essentially mean that private healthcare players will have to develop a new business model, which is ultra low cost and allows them to accept patients at the government mandated low prices.

The Ayushman Bharat Scheme and its different versions being developed by the state governments appear to be a precursor to some kind of Universal Healthcare system in India. The government in itself is not in a position to significantly increase its own healthcare spending on badly needed public healthcare infrastructure. Thus, it will willy-nilly rely on private healthcare, which in any case caters to a majority of the citizens of our country. This is likely to see the emergence of a low-cost health care system, which will serve the needs of the masses.

The Contours of the New Model

Going by the prices on offer from the government for various medical procedures, the new model will have to be quite bare bone. Essentially, this would mean less number of people employed in the hospital, very little by way of ”support services”, no private rooms, generic medicines (my fear is of inferior quality as well, as India has over 30000 pharmaceutical companies with poor regulation in place) and very little by way of patient comfort. The model can only work on large volumes of patients and high patient throughput.

The Concerns

While the model can be developed, the biggest concern will have to be the quality of care that will be delivered. The model’s cost-driven approach completely ignores the minimal clinical quality standards that must be delivered. Presently too, this is a nebulous area as the quality of health care services vary widely and there are no comparative acceptable benchmarks. Large private corporate hospitals have their own standards often comparable to global standards and they have systems in place to monitor the quality parameters and clinical outcomes. Small, private nursing homes have fuzzy standards not clearly defined and stated. No one publishes there outcomes.

To make matters worse, in India we do not have a clinical quality watchdog, which keeps an eye on medical processes and outcomes. Thus, hospitals can report their outcomes and clinical data as they wish. This is clearly a recipe for disaster.

While the implementation of National Health Protection Scheme (NHPS) may lead to better access to medical care to a large number of citizens, the large private healthcare players may get deluged with patients far beyond their capacity. When the payor will be the government through insurance companies, everyone would want to access the highest level of care possible. This in itself is fine and laudable if the care available in the country is of a uniformly high quality. However, in India, the quality of care varies tremendously and therefore the private healthcare players with high standards of care may find themselves unable to cope. Sadly, they may end up compromising on these very clinical standards to manage the patient volumes, thus blunting the competitive edge that they had to begin with.

The third big concern is the ability of the government agencies to be able to effectively implement this ambitious scheme. While the mandarins in Niti Aayog are burning the proverbial midnight oil to get the scheme off the ground, the challenge is indeed enormous. The best-planned schemes come to naught if the execution is tardy. That sadly has been the fate of almost all such similar schemes implemented earlier in different states. The government’s track record is hardly inspiring and the stakes this time around are truly high.

The private healthcare players, however, have their task clearly cut out for them. They have to find a new business model, which delivers world-class care to a very large number of people at a cost which is impossibly low. The sooner they get on with finding the right business models for themselves, the better off they will be.

The views expressed are personal

 

 

 

 

 

The Politicians and Private Healthcare in India

Of late politicians of various hues have been paying a lot of attention to the private healthcare sector in the country. Sadly, most of this attention is rather unhealthy, based on their own populist electoral agenda and completely partisan. Let us look at two recent examples. We have had the Prime Minister talking about capping of stent prices and the like, while speaking some time back in London and then more recently we had the health minister of the government of Delhi announcing a slew of measures that the government plans to implement to curb ”profiteering” by the private healthcare players in the National Capital Region.

Even a casual glance at the financial results of private healthcare players in the country will establish the simple fact that far from profiteering, most of them are struggling to make a decent profit on their investments. The EBITDA margins for most of the hospitals are in the range of 7%-15% and the return on capital employed (ROCE) is mostly in single digits even after a decade of hospital operations. The investors who set up these hospitals as ”for profit” businesses, would probably be far better off if they had just chosen to keep their money idle in a bank or may be invested in some other business.

The government and the pricing authority (NPPA) tend to look at hospital profitability through a completely distorted lens. Media stories inform readers that hospitals are making jaw-dropping profit margins on things like syringes, gloves and other sundry drugs and medicines. While these items are always sold on the MRP, the hospitals have also been baselessly accused of colluding with the manufacturers of these items in inflating the prices. Even if for a moment one assumes this is true, the simple fact is that a hospital’s profitability cannot be judged from the profit margins on sundry consumable items.

The profitability of a hospital has to be established by looking at the revenue that it earns and the entire cost structure that the hospital carries. The huge upfront cost of developing hospital infrastructure, the costs of all the clinicians and the medical staff employed by the hospital, the cost of all the non-medical services (such as housekeeping, the front office and F&B) and the cost of sophisticated equipment and instruments for diagnosis and treatment of the patient forms the bulk of the hospital cost. The hospitals incur these costs right at the start of their operations and continue to make losses for several years before they can hope to break-even.

Even on the revenue side, private hospitals are required to cater to patients such as those covered under the CGHS and the ECHS schemes of the government. These patients enjoy cashless services at the point of delivery, with the government paying a subsidized amount to the private hospitals later on. This is largely because the government’s own hospitals do not have sufficient infrastructure to take care of these patients. Payments from the government are low, sporadic and endlessly delayed. These patients, however, receive the same level of medical care as any non-subsidy enjoying patient and hospitals incur the same costs.

On one hand, we as consumers continue to demand more from our healthcare service providers including better equipment, greater patient safety, higher levels of infection controls, better-trained doctors and ultimately superior patient outcomes, it seems we are willing to pay less and less for all of this. Clearly, this can not work. The hospitals have to recover these costs for them to be financially viable.

Politicians whipping up unnecessary hysteria by claiming that hospitals make huge margins on say a cotton swab and then presenting themselves as knights in shining armor out to protect the general public from the depredations of unscrupulous private sector hospitals is just playing to the galleries. It is actually the politics of the worst kind. A far better approach would be to increase healthcare expenditure and invest in creating better public healthcare infrastructure. Partnering with the private healthcare players in a fair and equitable manner would go a long way in improving healthcare services to the citizens of our country.

Private Hospitals and clinicians provide the bulk of healthcare in the country. Investors who have put their money in these businesses must not be denied a reasonable profit just because politicians have elections to fight. If the government continues with this agenda, they will end up destroying private healthcare in India.

And that truly would be a very high price for all of us to pay.

The views expressed are personal.

When Journalists Pronounce Patients Dead

Quite often these days one comes across screaming media headlines about hospitals keeping dead patients alive on ventilators and other life-support paraphernalia. The headlines almost always accuse hospitals and doctors trying to make more money by keeping the patients in the hospital, even when the chances of their survival are minimal. Strangely, they always mention that the patient is already dead and the hospital is treating them unnecessarily.

This has always left me wondering as to how the journalists filing these reports and the media-houses publishing such drivel know that the patient is alive or dead. Since when have we handed over the responsibility of declaring people dead to journalists? Many of these worthies wouldn’t even know how to record a pulse, leave alone pronounce people dead. Yet, the media-houses carry these stories with aplomb, merrily destroying reputations and widening the gulf between the patients and the hospitals.

The laws in India on this are clear enough. Hospitals cannot withdraw life-support from a patient, howsoever sick he might be just because the patient’s families believe that there is no further chance of the patient’s recovery. The patient’s families often find themselves in a difficult situation wherein the patient remains alive on life-support in an ICU, with very slim chances of survival and the hospital bills keeps mounting. I can understand their dilemma well, to them it may appear that spending large amounts of money, when the patient has a very poor prognosis is futile. The attendants start pressurizing the hospital to hasten the inevitable. This is of course completely illegal and hospitals usually do not comply with these requests. This leads to bad blood between patients and hospitals, media gets called and accusations of making money by keeping the dead alive fly thick and fast.

With the media pressure mounting, the hospitals are forced to waive-off their charges and suddenly, hospitals find themselves in a better place. Patient’s angry relatives are no longer as difficult, they suddenly have a better ”understanding” of the hospital’s compulsions and they now urge the hospital to do whatever they can to ensure that the patient’s suffering is minimized. This drama plays out in our hospital corridors quite often.

Media’s role in this is quite suspect. They deliberately publish inflammatory and baseless reports of the dead continuing to receive treatment. They rarely carry statements from the treating doctor, even if they do, these are tucked away or played out in a manner that does little justice to the treating clinicians. The only objective is to put pressure on the hospitals and get the concessions for the patient and paint the hospital as the devil incarnate.

Hospitals can avoid this by taking a view that when patients are so sick that they have no chance of survival, they would on their own waive off their charges till the inevitable happens. This, of course, hurts their revenues and it isn’t really fair to them to continue providing a service free, but there is hardly a choice here. The inevitable media hoopla, which is far more unfair and even damaging can perhaps be avoided in this manner. They also have an opportunity of earning goodwill from the relatives of the patients, who one assumes would be grateful for this help in difficult times.

The other alternative is really a change in the laws of the country, which in a manner of speaking is underway. Do Not Resuscitate (DNR) guidelines have been given legal form through a judicial pronouncement. These though still remain nebulous and much more needs to be done to publicise the new laws, at least a good beginning has been made. Laws regarding the end of life care need to be framed with complete clarity and any loopholes regarding potential misuse must be plugged.

Till such time, this happens, doctors and hospitals will continue to be at the receiving end of a biased media in search of lurid stories and patient attendants, who see little point in continuing to pay for a relative who is unlikely to make it.

The views expressed are personal

 

 

 

 

 

 

 

 

 

 

Managing Hospital Marketing Costs in Difficult Times

The last financial year has been a difficult one for most private healthcare services providers in India. The regulatory headwinds related to the capping of prices of stents and knee implants, the extremely negative media campaigns and unruly patient activism have pegged back revenues and dented profits. The Prime Minister has been running a most undignified campaign of his own caricaturing Indian doctors as blood-thirsty parasites out to mistreat patients and highlighting the fact that he has been able to stop the rot through legislative action. In Delhi, the Chief Minister is busy rolling out his pet half-baked schemes and many states have come up with draconian provisions under the so-called Clinical Establishment Acts.

However, all this has left private healthcare providers in a hard place. They are left with no option but to ruthlessly cut costs and scale back some long-term investments. Many are re-working their growth and investment strategy. Marketing budgets are being slashed, head-counts being ” rationalized” and various kinds of harsh cost control measures are being implemented.

Marketing costs and costs related to patient amenities in the hospital are perhaps the easiest to cut. They do not involve the pain let us say of reducing head-counts by handing out pink-slips. They also do not significantly impact patient outcomes.  A few lesser ads in the newspaper and maybe a water-bottle less in the patient room is unlikely to cause too much of pain.

This is also the commonest mistake hospitals make.

Marketing activities and great patient experiences help spread the word around. Brand communication works quietly in pushing a particular hospital in the consideration set of new patients. It helps build perceptions about the quality of care provided by the hospital. It also helps position the hospital as a possible choice whenever the need arises. The messaging has to be continuously reinforced in an unobtrusive manner, gently working on the consumer’s mind, building the desired imagery of the hospital.

In times of turmoil, when an unforgiving media is hellbent on creating issues where none may exist and when politicians are vying with each other in demonizing a reasonably well-working system the marketing communications put out by the hospital assumes greater significance. Patient stories in the form of nicely crafted testimonial ads can go a long way in reassuring new patients. Announcement ads related to the induction of new technology and equipment can inform patients about new choices available to them. A digital marketing campaign can help patients access the hospital services with greater convenience. A well-executed community outreach program can allow the hospital to enroll patients in long-term relationship programs, binding them together with the hospital.

Great patient experiences also work in a similar manner. Satisfied and happy patients are the finest brand ambassadors. Their credibility based on their own experiences counts for a lot more than any advertising would ever do. It is also foolish to assume that patients will not notice small things, which quietly disappear when stiff cost programs are executed. That nice friendly GDA who takes the wheel-chair, the missing dessert in the meals, the fraying blanket or the worn upholstery on the attendant’s sofa in the patient’s room will always be noticed. Discerning patients will be able to see through these ”small” compromises and will definitely talk about them. This kind of talk is extremely detrimental to the brand equity of the hospital and is almost always impossible to fix later on.

Many years ago I had learned that there is usually a cost associated with cutting cost. Sadly, sometimes this cost is not visible at least in the short run. One has to be very careful while taking drastic cost decisions particularly when they look easy or simple. They often are not. The costs thus cut, have a way of coming back and hitting hard in the future. Marketing and patient experience costs usually return with a much greater vengeance and that too in the not so distant future.

So, what should hospitals do in difficult times such as these?

While they knuckle down to protect their meager profits, they should avoid knee-jerk cost action at least in these two areas. If anything, they should further reinforce their communication and patient experiences to ride out the storms.

The views expressed are personal

 

 

 

A Case of Abuse of Social Media

The last week saw a chastened-looking Mark Zuckerberg, testifying in the US Congress about data leaks from Facebook and explaining how he himself has been a victim of the same leaks. That may be cold comfort for most people and data leaks from social media behemoths are perhaps far bigger a problem than what ordinary folks face on social media on a daily basis.

Social media has been prone to abuse in multiple ways. While this piece cites a specific example that I came across last month, the wanton abuse of social media in spreading canards, abusing people in the vilest of terms, destroying reputations by twisting facts and sharing half-truths is quite worrying. Even more worrying is the lack of recourse that the aggrieved parties have in getting redress. While they can always present their side of the story, the abusers tend to ratchet up the diatribe and the language used is not something that perfectly decent folks can match. Thus, they give up.

Here is what happened last month.

A relative of a patient who died of liver failure at Max Hospital, New Delhi put up an extremely derogatory post abusing one of the doctors on the Liver Transplant team. The posts used the filthiest of language and dragged her extended family, including her long-deceased grandfather in a matter that was purely in the domain of the clinician’s work. The doctor, a lady with an impeccable track record of academics at the finest medical institutions in India and abroad was called horrible names, her competence questioned and her family’s name dragged through the mud.

The facts of the case as gleaned from the hospital records are quite straightforward. The patient had first been seen at Max Hospital, New Delhi in the last week of November 2017 when he had presented with symptoms quite clearly suggestive of liver cirrhosis. The patient was admitted to the hospital, investigations were conducted to confirm the provisional diagnosis and he was managed on medicines. He improved symptomatically and was discharged from the hospital 3 days later.

The patient again showed up at the hospital in early February 2018 and was advised admission. The patient’s family chose to disregard this advice and took the patient home. The patient was subsequently brought to the hospital in an emergency situation by the end of the month. He was admitted to the hospital ICU and was managed with medications. The patient’s family, however, decided to leave the hospital against the medical advice (LAMA).

The patient returned to the hospital the very next day. He was admitted and advised a Liver Transplant Surgery. The patient was managed and was provided all supportive therapy and the hospital waited for the patient’s family to take the decision on the liver transplant and arrange a suitable family member who can be the donor. The family once again discharged the patient LAMA and moved him to another hospital.

Incredibly, three days later the patient once again arrived in an emergency situation. The patient had deteriorated significantly. He was admitted to the hospital, needing an urgent liver transplant. The family now consented to the transplant. His wife agreed to be the donor and she was worked up for the surgery. Unfortunately, she was not found fit to donate and the patient in the meanwhile kept deteriorating. Sadly, the patient passed away without receiving the transplant. These are facts recorded in the EMR’s of the hospital.

While going through the hospital records, it was quite evident that the patient hardly followed the medical advice provided to them, they remained undecided about the transplant, till it was too late.

To blame a particular doctor in the transplant team for their travails is clearly unfair. The doctor advised them well, did her duty even when the family kept vacillating. To abuse her in the vilest of terms on a social media platform and to declare a ”war” against her and the hospital, vilify her family, which had nothing to do with any of this was most unfortunate.

The clinician chose not to respond to this calumny and decided to sue them for defamation. Taking on such elements on social media itself would clearly have been futile.

In an environment, where there exists a huge trust deficit between doctors and patients is there anything else that she could have done???

The views expressed are personal