The Big Healthcare Challenges in FY 19

As the present financial year draws to a close, I am left reflecting on the challenges the private healthcare services organizations in the country face in the coming year. The present year has been a pretty tumultuous one. The regulatory environment threw up several challenges. The NPPA orders on price controls of devices such as stents and joints impacted the profitability of most private healthcare companies adversely. The DPCO’s orders on price controls on key drugs too are also likely to dent the bottom line of private hospitals. The media brouhaha triggered by two cases one at Fortis Hospital Gurgaon and one at Max Hospital, Shalimar Bagh, New Delhi created consumer distrust of an unprecedented nature. The private sector hospitals were called names and their doctors were addressed in the vilest of terms leading to all around despondency. Private hospitals are now limping back from this assault. The government of Delhi also announced a half-baked scheme for its citizens, which allows them access to private hospitals if the government-owned hospitals put them on a wait-list of more than a month. Finally, in the budget, the union government announced the path-breaking ”Ayushman Bharat”, which is supposed to provide a cover of INR 500000 to a million families across the country.

All these are expected to lead to some fresh challenges for the private healthcare providers in the next financial year.

Regaining Patient’s Trust 

If there is one thing, which ranks higher than any financial matrix of revenue, costs, and profits it has to be the effort to regain the patient trust. The reasons for the loss of trust are many, some genuine and some purely trumped-up, however, most private hospitals see the urgent need to regain the customer trust. Significant investments will have to be made to improve transparency, patient communication, and organizational culture, which will lead to patients trusting their hospitals. This too is a difficult task and will involve a lot of senior management time and effort.

Profitability

The government and the media have quite successively sold a narrative to ordinary citizens of the country that the private sector hospitals are profiteering and that they are out to cheat patients by over-prescribing, over-billing or worse. Thus, they have ascribed themselves the role of the guardians of the ordinary citizens against the rapacious, profit-hungry hospitals. The truth is far more prosaic and indeed worrying for the private sector hospitals. Most of them have seen a shrinkage in their profits, which to begin with were meager. The biggest challenge that private sector hospitals face in the coming year is clearly of ensuring reasonable returns for their shareholders. In an environment, driven by complete distrust between patients and the hospitals, with power-hungry politicians seemingly baying for their blood in what might be an election year, most private sector hospitals are staring at a bleak year ahead. The EBITDA margins are likely to contract. The hospitals will have to thus figure out a way of reining in costs, without compromising on patient care, safety, and outcomes. This is obviously easier said than done and will probably consume most of the bandwidth of the top management of the hospitals.

Managing the Changing Regulatory Environment

Healthcare is finally getting some attention from the government, which in itself is not a bad thing at all.  However, the controls being put on pricing and the schemes like the Ayushman Bharat and similar programs are not at all well thought through. The private sector, however, has no choice but to adapt to the changing situation. The National Health Protection Scheme (NHPS), will be rolled out this year. One is hopeful that it will be backed by suitable technology, which allows private hospitals to handle patients covered under NHPS. The hospitals will need to usher in change to be able to accommodate the large number of NHPS beneficiaries, which may flow into private hospitals. These changes may include modifying the bed configurations in the existing hospital, tweaking systems and processes and creating special areas to handle NHPS patients and create low-cost models, which allows the private hospitals to manage the NHPS patients in high volumes. Other regulatory changes in drug price controls, devices pricing controls and guidelines on re-usage will all lead to significant tweaks in hospital processes.

Managing Media and Consumer Activism

Consumer and media activism is here to stay. An unexpected outcome, a perfectly explainable error of judgment and sometimes a perceived lack of attention can trigger a media avalanche. Much as the hospitals may crib about being unfairly targeted, they will have to learn to live and cope with it. However, this does not mean that hospitals will not take a stand or push-back particularly when they are in the clear. They will have to learn to work with a partisan media and try their best to put out their side of the story. Speed will be of the essence and the communication teams of the hospitals will have to be beefed-up. Social Media too will throw up new challenges and the hospitals will have to learn to respond quickly and have a ready base of loyal supporters who will help defend them against motivated tirades.

These are all unique and new challenges. I am sure something good and lasting will emerge from these as well.

The views expressed are personal

 

 

 

 

 

 

 

 

 

 

 

 

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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.

The Meaningless Healthcare Awards

The Indian healthcare industry is awash with awards. Not a month passes, when I do not receive proposals from all manner of people to participate in some awards or the other. This is rather embarassing to many of us simply because these awards are just a sham. For some though, this constitutes a compelling business opportunity. Thus, there are companies whose business model is giving sundry awards and to make matters infinitely worse, we now have large media companies rushing in with sackful of awards, to be presented to anyone who is willing to buy media space in their publications.

The Problem

The scheme goes something like this.

A media house announces a bunch of awards to be presented in a “glittering” function at one of the city’s 5 star hotels. The award categories are numerous and almost all aspects of hospitals are covered. This is done deliberately so as to maximise the number of people/hospitals that can be awarded. The media sales people then fan out and start meeting hospital marketing teams, asking for registrations/nominations for the award. These are to be sent with an accompanying cheque, usually the amount ranges from INR 25000-50000 per category. In itself, not a very large amount but the numbers deceive. Usually a hospital applies for multiple awards, let us say 10 out of the 50 or so available. And then there are dozens of hospitals applying in all these categories. The numebrs all add up beautifully.

Well, this isn’t the end of it. The media sales team then come up with media supplements and special pages, which are supposed to cover these awards. This is really the big one. Hospitals, are cajoled to advertise in these supplements and are often promised pictures of they receiving the awards and their quotes being carried in the accompanying write-ups. If the electronic media is involved, the event along with the bytes of the winners get broadcast as well. All this is sold as a package.

To further amplify all this the social media too is available. The pictures are posted, tweets are sent out to gulliable readers announcing the winners of the awards, often accompanied by their smiling visages and small clips of ‘thank you’ speeches do the rounds.

In an intensely competitive industry there is a need to differentiate the awards and hence sometimes consulting companies too are roped in. They are supposed to lend a bit of credibility to the entire exercise, the senior managers are trotted out to present the awards to the winners and it all makes for a nice photo-op.

If the media house is one of the larger ones, they are usually able to get hold of a “neta” or two. If they really get lucky, the health minister might himself turn-up. The lure of the media is usually irresistable to the political class. To add the glamour quotient a socialite is usually brought in, usually to be the MC for the evening. I recall with amusement attending one function, where she couldn’t even pronounce the name of the minister but than it doesn’t matter much.

All of this is of course done with quite a bit of tamasha of going through the motions and following due processes to arrive at the winners. Fortunately, there are enough categories and everyone can comfortably win.

Well, you get the picture.

This is the sad reality of most of the healthcare awards. Bereft of any credibility, done purely on commercial lines, they serve no purpose. In fact, they do a lot of harm.

The readers of these publications/viewers of the TV stations are befooled by the false recognition given to thoroughly undeserving doctors/hospitals, for achievements they never had and things that they never accomplished. This is plain wrong.

The media houses too are diminished by this unalloyed greed. By honouring and recognising those who have done little of value and paid a lot to get the award, the media houses are essentially cheating their readers and viewers.

The hospitals and media houses both must introspect seriously. The quest for publicity on the part of the hospitals and the lure of money on the part of the media houses is the underlying cause for this sorry state of affairs. This is an unholy nexus, crass opportunism at its worst and we must end this, the sooner the better.

The Solution

I would urge hospitals to stop participating in these awards. We need to identify a couple of respectable industry bodies and compete for awards in their fora. FICCI and CII are respectable industry bodies and we can work with them in setting up fool-proof mechanisms of recognising excellence in healthcare through awards. A rigorous process can be set up to scrub entries, reputed audit firms can be engaged to audit and certify the selection criteria and awards given out strictly on merit. A media partner can be engaged to amplify the awards in a legitimate manner, highlighting true merit, excellence and innovation.

We will all win if we do it this way.

The views expressed are personal

Great Experiences and Brand Promises – Lessons from Indigo Airlines

Indigo”It is time you packed-up and left for the airport. You are on Indigo and they always leave on time”, said my colleagues at work. I was in Bangalore and had a busy day at work. I was trying to cram in as much as I possibly could in the day and I guess, I was getting late for my flight to Delhi. In any case, with the way the Bangalore traffic these days is, reaching the airport is akin to a lottery.

The Gods were kind that day, Mr David managed to get me to the airport well in time and, sure enough, Indigo boarded right on the dot. However, much to our chagrin we learnt that there would be some delay before we took off. Soon after being air-borne we had the captain on the PA system, proudly telling us that though we had departed Bangalore 10 minutes behind schedule (and it was all because of the congestion at the airport), he was quite hopeful of getting us into Delhi on time. He explained the benefits of a friendly tail-wind assisting us in the journey and also how he would try his best to get us on ground in Delhi on schedule.

It was soon evident that we had a chatty captain, who would tell us that we could see the lights of Hyderabad towards our right and that we were over Jaipur and were cruising over 33000 ft. The captain kept us engaged. He was never intrusive, but I did observe that in almost all announcements that he made, he did refer to the fact that we were likely to reach our destination on time. The crew also kept reminding us that an ón-time’ performance was their paramount goal. They urged us not to leave any waste around, so that they can turn around the aircraft faster for the next flight. It seemed that the crew was really focused and keen to get us to Delhi on time.

As soon as we touched down in Delhi, the crew announced that we have indeed arrived a little before schedule. They seemed to be genuinely pleased with their performance and wore big smiles. As I headed out of the aircraft, I noticed the captain standing just outside the door of the flight deck, wishing passengers the time of the day and amicably chatting with his crew. The captain and the crew looked like a wonderful team to me, who had enjoyed flying us to Delhi that evening and were genuinely happy that they managed to get us to our destination well in time.

This episode left me wondering how difficult it really is to conjure up this kind of experience every time Indigo takes flight, day in and day out. This would mean hundreds of flights everyday, flying thousands of passengers and ensuring a steady and consistent experience delivered through thousands of employees. No wonder, Indigo is one of the most successful airline in the country and their brand promise is synonymous with timely flights.

And since, I work for in healthcare, where a great experience is perhaps so much more important, it left me wondering, why most hospitals in India fail to deliver a consistent experience that can become their calling card. Unfortunately, we still do not have hospitals, which can deliver some if not all experiences in a pre-defined and consistent manner. Is there any hospital in India, which can claim that the OPD’s in its hospitals always begin on time, or where patients with prior appointments don’t have to wait or where physicians see off patients at their doors? Or, where patients are uniformly greeted by the staff at the front office, always treated with courtesy and where compassion counts for more than anything else?

I am aware that this is no easy task. Unlike passengers in an aircraft, patients are sick people, some are in life threatening situations, many are in the hospital for the first time in their lives and are truly unsure of what to expect. I also understand that unlike the airline, patients in a hospital will be staying for several days, they will be interacting with a multitude of people (doctors, nurses, paramedics,housekeeping, F&B services, general maintenance, billing etc.) and it is so much more difficult to synchronize all of these interactions into one great experience, which can be crystallized into a succinct and powerful brand promise.

However, hospitals, which hope to build a brand for themselves must start looking at ways and means of doing this. They must meld their varied customer interactions into one great experience that a customer can expect even before she enters the hospital. The true power of a hospital brand will only be unleashed, when it will learn to deliver that one experience again and again, every time that a patient walks through its door.

The Sales Vs. Marketing Conundrum in Healthcare

The Sales and Marketing functions in many hospitals in India still work independently of each other. There are invisible boundaries that separate the two and often it is considered heretical to get the twain to meet. The Marketing folks are the smart and savvy guys, who sit in their cloistered offices working on the holy grail that is called ‘strategy’, while the sales guys are the lowly folks, who need to sweat it out in the ‘field’. They are the ones who chase ”numbers” and perpetually suffer from their tyranny, while the Marketing folks grapple with the subtle nuances and the neat turns of phrase of advertising communication and the like. The sales folks are street smart, the Marketing guys worldly wise, the sales folks are rough at the edges, the Marketing guys are all suave and well rounded, the sales folks are the ones with their sleeves rolled-up and with their hair in the eyes, while the Marketing guys are impeccably turned out with neatly gelled hair, all in the right place…you get the drift.

Well, while one can go on in this vein, citing their differences, the fact remains that unless the Sales and Marketing folks work together, neither can really achieve great success. Yet, in many hospitals they hardly interact, leave alone work together.

The blame for this sorry state of affairs lies at both the ends of the spectrum. The sales people are programmed to chase, they are given no respite from the continuous and if I may add mind numbing quest for revenues. They do not have the time and even the inclination to sit back and think. A sales person, sitting idle, would soon enough invite the wrath of his supervisor. He would be labeled as a lazy day-dreamer who lacks ‘drive’ and ‘initiative’. On the other hand a Marketing person will have all the time in the world to think through each and every piece of communication that passes through his hands. He will weigh the pros and cons of the ‘copy’ and the way it is laid out in the ad. He will hold forth on the relevance of the ‘image’ that adorns the ad and of course the smallest detail like a misplaced comma or the uneven size of the font will not escape his attention. After all, he has been taught that God lies in the details.

In all this he will forget that the purpose of the advertising is perhaps to help the sales person drive in a few more customers through the hospital doors!

On the other hand this is what happens when sales guys try their hands at Marketing. Some time back I had the occasion to attend a sales review meeting at a hospital. The sales guy was holding forth on launching a few specialized clinics and the idea was to create communication informing the local community about the introduction and the benefits of these clinics. I recall one of the clinics to be launched was the ‘Heart Failure Clinic’, which offered specialized advise and support to patients in Heart Failure. The sales head briefed the Marketing team about the clinic and requested an ad. The Marketing team, sent out an ad, which talked about Heart Failure and exhorted patients suffering from heart failure to come to the clinic. The communication failed to inform the readers how to identify their condition as ‘Heart Failure’ and when exactly to approach the clinic. Strangely, it was also not very clear as to how a ‘Heart Failure Clinic’ was different from a routine consult with a cardiologist! ”If I am having a Heart Failure, wouldn’t I call the Emergency and rush to the hospital rather than wait for an appointment at the Heart Failure Clinic” asked a baffled HR person sitting in the review.

It was a mindless piece of communication done at the behest of the sales person, who was in a hurry to launch the clinic and a lazy Marketing guy, who wasn’t too bothered with the outcome of such inane advertising.

Now if only the Sales and Marketing teams had sat down together and looked at the issue at hand, which was how to drive cardiac patient volumes in the hospitals and come up with a plan, things could have been very different. Maybe a ”Heart Failure Clinic” might still have come up and the Marketing guy would have pointed out that it was best to market a Heart Failure Clinic to referring doctors rather than consumers in general. After all, isn’t Heart Failure a condition that will be identified by a local community doctor and would subsequently be referred to a ”Heart Failure Clinic” in a larger hospital.

If only the Sales and Marketing teams in hospitals forgot their differences and worked together, they could achieve so much more…together.

Where are the Healthcare Innovators?

When did you visit a hospital last and found a process, which made you sit up and take serious notice?

Hospitals in India are crying for serious innovations, yet we see so little of them. While, one keeps hearing about mind-boggling advances in medicine and technology, yet very little of that is reaching our hospitals. The largest and the most modern hospitals in India at best pay lip service to serious innovation. They do not even have innovation teams, which can identify and adopt innovative practices, which help cure faster, keep people healthy and provide a better customer experience at the hospital.

The reason for this are not far to seek.

Healthcare services in India are still in their infancy. While, large hospital chains like Fortis, Apollo and Max Healthcare have the latest equipment and the most sought after doctors, they are still not customer focussed. Innovations happen, when the customer is the focus of the organisation. Our healthcare services organisations are still mired in pandering to the egos of their senior doctors, guarding them like mother hen, lest they fly the coop. Since, there are only so many ‘star doctors’ and they are mostly responsible for pulling in the patients, one can not really fault the hospitals for focusing on their crown jewels rather than on patients. To make matters worse, most of these star doctors are older, quite often set in their ways, it is virtually impossible to make them innovate. They are wildly successful individuals, who have been at the top of their game for many years and see no reason to do things differently. Thus, in a Max Hospital in Delhi, you will have the younger doctors, using the Hospital Information System, the older and more senior ones, would still prefer a pen and paper, mindless of the fact that this means that every-time the patient comes to visit them, he would be carrying the past prescriptions and records in a file. And, this when Max has spent a fortune in putting in place a state of the art HIS!!!

The other driver of innovation is competition, which in the Indian context is sadly lacking. While, there are millions of mom and pop nursing homes and down the street clinics, good hospitals are few. With India growing close to 9%, many Indians can now afford good quality healthcare services. With health insurance also contributing its might, we have a situation, where there are too many patients chasing too few hospital beds. As the economy grows further and we see the benefits of our growth percolate down deeper, people would continue to move up from small and dodgy nursing homes to swanky, well organised hospitals. Thus, at the top end of the Indian healthcare market, serious competition is a long way off. This does not augur too well for healthcare innovations.

Health Insurance companies can drive serious healthcare innovations. They are always on the lookout of shaving costs and innovations often do that. However, in India, health insurance is still largely controlled by the state-owned general insurance behemoths, whose health insurance portfolio is a tiny fraction of the general insurance business that they handle. They themselves are riddled with inefficiency and corruption and can hardly be expected to drive healthcare innovations. The standalone health insurance companies in the private sector are still wobbly and are trying to find their feet. They too are quite clearly a long way off from driving innovations at our hospitals.

The only way we can possibly drive innovation in healthcare services in India is by becoming more demanding as patients. Impatient patients can bring about change in the delivery off at least the non medical services at our favourite hospitals. Thus, if a doctor is running late with his OPD appointments, patients can ask the hospitals to send sms’s in advance to patients, who are scheduled later in the day. If the hospital queuing system is inefficient, a patient can always suggest another system, which works better. (Check-out the new system at Max Medcentre in New Delhi, it is simple and efficient).

As far as bigger innovations are concerned, the hospitals and their various stakeholders have to drive those. Change inevitably brings pain in the shorter run, however those organisations, who have their eyes set on the horizon, cannot but embrace change. Even though, in India, the external circumstances may not be very conducive to innovations, we must remember, all great innovations are internally driven, largely rooted in a desire to be more efficient, more customer friendly, more differentiated and more profitable.

Indian hospitals must innovate to compete with themselves and to be better than what they were yesterday. That is the only way to long-term success.

The Perils of Standardized Health Care

Can healthcare delivery be standardised? This is the question, which has been bothering me this week.

The thought itself was triggered by a report in ‘Mint’ earlier this week titled ‘Government plans common healthcare standards’. (http://www.livemint.com/2010/08/24233218/Govt-plans-common-healthcare-s.html)

While the report portrays the benefits of standardization of care with millions of patients receiving standard care prescribed by the government thus saving them from being shortchanged by unscrupulous doctors and mercenary hospitals, there is also a flip (and a more real) side of the argument that we must understand.

While the government pushes through the Healthcare Standardization agenda, one wonders how can the delivery of healthcare be standardized across all medical facilities in the country? Every individual is different, reacts differently to treatments, the doctors are required to take decisions based on their experience and training and not on the basis of a set of guidelines decided upon by the government. If I was to fall sick, I would want my doctor to treat me based on his knowledge and experience and do what he feels is the best for me rather than stick to a standard set of guidelines mandated by the government. All doctors and medical establishment should have one guiding principle – the interest of the patient must be supreme and if there is a situation of uncertainty, I would want my doctor/hospital to always err on the side of caution.

Also, the healthcare delivery model in the country is hugely diversified. In its current form with poor regulation and monitoring it just does not lend itself to any standardization of care.The government-run tertiary care hospitals in large cities are filthy and over-crowded with patients and over-worked and under-paid doctors. The government run district hospitals as well as Primary Health Centres are even worse off with out dated equipment, poorly trained doctors, who often do not even show up for work. The private healthcare is dominated by secondary care establishments (usually called nursing homes), which have 10-50 beds and are usually owned by a doctor or a group of doctors. These are mostly mom and pop establishments, where owner doctors reign supreme and are answerable to none. Quality of care in these establishment is of dubious standard and these are neither properly regulated nor monitored vis-a-vis outcomes or treatment protocols. Christian missionaries and other charitable institution also run a large number of hospitals and now we have a nascent category of corporate style hospitals coming up in large cities offering cutting edge care. My point-all these hospitals are differently equipped, have differing goals  (for profit, non-profit, govt. owned etc.), have vastly different resources at their disposal, have different cultures and widely varying medical expertise available to each of them. How on earth can they all provide standardised, similar quality care to their patients?

Last December my father underwent a prostate surgery in a hospital in Delhi. Elderly men usually require this surgery at some point in time in their lives. Now, while I researched the treatment options for him and took surgeon’s opinions I discovered that we had several options. Our surgeon felt that the best and the safest alternative for him would be a laser surgery involving a cutting edge holmium laser. Now, this option is not available at most of the hospitals even in a city like Delhi, thus it can safely be ruled out from the ‘standardised treatment guidelines’ that are being framed by the government. In a situation like this, will it mean that patients like my father will be denied this option and he will have to endure the conventional surgery with its attendant risks of infection, excessive bleeding and a much longer hospital stay?

Let us now also look at the genesis of all this.

The health insurance companies (mostly state-owned)  want treatment protocols for some common diseases to be standardised so that they can fix a rate for these procedures, irrespective of the hospital and the doctor one chooses to go to. For the insurance companies this will lead to a state of nirvana, as they would be required to pay a fixed lump sum to the hospitals irrespective of the bill a patient runs up. They can then squeeze the hospitals further and make greater profits. Now, I am not against profits, however the problems that I see in this arrangement is that the patient will suffer, the quality of care will go down as hospitals will try to manage the delivery of care with in the financial limits set by the insurance companies (after-all they also need to be profitable). This is clearly hazardous.

One buys a health insurance cover  to ensure that in the time of need, financial constraints do not come in the way of accessing the optimum quality healthcare. The operative words here are ‘optimum quality’ and not ‘standard quality’ as mandated by the government. To equate these two will be a great folly. If the insurance companies believe certain hospitals are taking advantage of the situation by excessive billing (which I submit happens), they must put in place strict monitoring mechanisms including peer group reviews of treatment provided by the hospital. A healthcare regulator needs to be set up by the government to arbitrate between insurance companies and the hospitals. The regulator can possibly frame broad treatment  guidelines, which can serve as references in case a dispute arises between a patient, the hospital and the insurer.

Standardizing treatment protocols in a healthcare environment as complicated and as unregulated as ours is a dangerous and mostly an impractical idea. We need to first standardize our healthcare delivery systems before even thinking about standardizing treatment protocols. Paying hospitals based on these standardized treatment protocols because it makes health insurance companies profitable is inviting hospitals to cut corners. Once this happens, it will lead to serious erosion in the quality of care and even more  importantly a big trust deficit between patients and hospitals will emerge.

That would really be the ultimate irony, for if a patient does not trust his doctor or hospital, he really would have nowhere to go.