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.

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A Time for Reflection

The last week of December is usually a time for reflection.

And the private healthcare industry in India has a lot to think about. The last two months have been those of turmoil for the industry. The crisis related to the implementation of a draconian Clinical Establishment’s Act in Karnataka led to angry protests by the medical community in Bangalore, while in Delhi two cases of alleged overcharging and medical negligence at the two leading hospital chains caused an unprecedented furor. Much has been said about these cases, I won’t add more, however, we must reflect upon what lies behind these flair-ups.

These cases must not be considered as an isolated outbreak of public anger with the media and the politicians blowing up the issues. While that did happen, we must look at them as a trigger for a far deeper malaise.

For a long time, private healthcare in India is increasingly being viewed by patients with a great deal of distrust. With the public healthcare in tatters, the consumers continue to flock to the private establishments, where the care and services are of high quality, however, they no longer trust their doctors and hospitals. This is an extremely worrying sign because the only thing that binds patients and clinicians is trust, an implicit faith in the system that the hospitals and the clinicians will always act in the interest of the patient.

We must ponder over what has led to this catastrophic erosion of trust.

Private healthcare systems are being increasingly looked upon as businesses with commercial interests, which far out-weigh patient’s interests. The media has been peddling this narrative for a while, highlighting cases of ‘wrong billing’ without diving into the arcane of what exactly is wrongly billed. Selective charges of profiteering on things like syringes and gloves are bandied about causing more damage. Somehow, the real narrative of hospital profitability measured in terms of financial parameters such as Return on Capital Employed (ROCE) do not find any mention in these stories. The fact that most private healthcare companies are barely profitable just doesn’t seem to register. Private Healthcare systems need to address this urgently. They must get together and build a counter-narrative, which highlights their often precarious finances and the enormous risks they have taken to build a healthcare system, which actually takes care of the needs of the majority of the people of our country.

While this needs to happen on the external front a lot of house cleaning must also happen internally. The hospitals must review their pricing structures and make them more transparent. The patients today are educated and if the components of a hospital bill are explained to them in detail, I am sure many will understand and appreciate.

The other big issue that destroys trust is the difference that the patients find in the estimates given at the time of admission and the final bill that they end up with. Medicine is at best an inexact science and in many cases, it is hard to predict a patient’s course during hospitalization. However, large private chains do have the data and technology to be able to predict estimates with a reasonable level of accuracy in a high number of cases. Thus a system can analyze bills of say, the last 500 patients who underwent a bypass grafting, exclude the outliers and predict the probability of the bill is a certain amount. This can be shared with the patients transparently. Even if hospitals do this for cases of planned and routine surgeries, I am sure the trust levels will increase.

The real trust builder is, of course, ensuring proper engagement and communication with the patients. Large hospitals, with hundreds of patients, often forget to pay enough attention to individuals leading to a sense of isolation and abandonment. The hospitals need to establish protocols for patient communication. The clinicians must sit down with the patients and their caregivers and explain how the patients are doing in the hospital, the challenges that they foresee and the prognosis. My view is that even if the prognosis is grave, it should be shared transparently with the caregivers. This should be done with great sensitivity and empathy and in a language which is shorn of all the jargon.

Finally, the biggest builder of trust is the time that a clinician spends with the patient and their caregivers. In busy hospitals, clinicians often just do not have enough time to spend with their patients. The out-patient consultations are frequently cursory and fleeting, often leaving the patient wondering whether their doctor has even understood their medical condition or not. While admitted to the hospital, sometimes patients don’t even see their surgeons even when they are being wheeled into the OT’s. Why can’t we have a system, where the operating clinician would himself visit the patient either in their rooms or in the pre-op area, reassure them once just before they face the knife. There can be many such processes that can be established, which gives greater comfort to the patients.

The media noise of profiteering resonates with patients and caregivers only because they find their hospital experiences sterile and scary. As the healthcare costs mount, the patients will need better experiences for them to trust their hospitals and care providers.

My belief is that the time has come for private healthcare providers in the country to walk the talk on patient-centric care. No amount of external regulation will help build the lost trust. It is only actions, which build trust in patients and their caregivers, which will help regain the lost ground.

And once we regain our patient’s trust, they will not find us profiteering nor will the media’s false charges stick.

Here is wishing all my readers a Merry Christmas and a very Happy New Year.

The views expressed are personal

 

Marketing a Cancer Service

cancerCan a cancer service be effectively marketed?

Well, to someone who has dealt with cancer either as a patient or a caregiver, the very idea of marketing a cancer service is appalling, even grotesque. Cancer is often looked upon as the ultimate misfortune, a death sentence if ever there was one and juxtaposing a ‘commercial’ term like marketing with it sounds revolting. Yet, we know that in India there are cancer hospitals aplenty, many of them with great expertise and technology at their disposal, but sadly not many effectively engage with their patients beyond the mandatory sessions of chemo or radiation therapy.

Yet, I believe good cancer centres, need to have an effective engagement program with cancer patients and the care-givers. More than anything else, they need to connect with patients and help them understand their disease better, engage with them as partners in the fight that lies ahead and inspire them to beat the great odds  stacked against them. They also need to connect with the care-givers, help lighten their burden of fear and doom at the likely loss of a near and a dear one. Most of all, cancer centres need to give hope and courage to both the patients and care-givers in a world suddenly drained of light and good health.

A good cancer service should aim to constantly engage with its local community. It should help educate about the preventive aspects of the disease. Many oral cancers are completely preventable. Shunning tobacco, eliminates cancer – a simple message if communicated effectively can prevent almost all oral cancers. Extended exposure to known carcinogens such as pesticides, heavy metals or radiation also causes cancers. Avoiding these by taking sensible precautions can help reduce the incidence of cancer.Similarly, the chances of having cervical cancer can be significantly reduced by early vaccination against the disease.

Yet, I have not come across many hospitals running effective mass campaigns against tobacco use or creating awareness about cervical cancer vaccinations. I believe, in the fight against cancer, that is an opportunity wasted.

There are of course, cancers, which have nothing to do with lifestyle factors. They can hit unexpectedly (like the Germ Cell Carcinoma, that ravaged Yuvraj Singh) and there is little one can do to prevent them. However, in our arsenal are now medicines that can effectively combat these deadly cancers, if only we could diagnose and treat them early. Fortunately, we now also have advanced scanners that can detect tumours the size of a few cells, and raise a red flag. Yet, not many cancer services talk about early detection and encourage people to go for regular testing. A good cancer service must connect with the local community and relentlessly drive home the point that a cancer can be beaten by detecting it early.

The cancer service must also understand the fear that the word cancer causes in a person. Many people have an irrational fear of getting themselves screened for cancers. Good cancer services should develop engagement programs, which gently nudge people to shed their fear of the unknown and go for these screenings.

Fighting cancer requires true courage, uncommon grit and determination. The treatment regimen is often debilitating and painful. More than the physical pain, the sheer magnitude of the struggle against a deadly foe, with unknown odds is often difficult to bear. Cancer patients undergoing therapy, need hope and courage to overcome the disease. A good cancer service must realize that even if the disease succeeds in breaking a man, it must not be allowed to break his spirits. A cancer service, which offers hope and a steady hand is the one, which will connect with cancer patients the best.

Cancer Hospitals owe it to themselves as well as their local communities to constantly engage with each other and fight cancer. At Fortis Hospitals in Mumbai, we have for the last couple of months been doing exactly that. The hospitals recently completely a very successful campaign on cervical cancer screenings called ”Teal to Heal” (http://www.fortishealthcare.com/india/Teal_to_Heal.php), are presently running a cancer campaign, which features cancer survivors, sharing their inspiring stories of early struggle and success in beating back cancer. The stories are true and full of hope. The next phase of the campaign, will take up the fight against tobacco.

I do wish, there were more hospitals joining the fight against cancer by engaging their local communities. We can only win, if we fight together.

Hiring Right Makes a Hospital Special

Hiring right, is at the best of times a tricky proposition, more so if one is attempting to hire people to work in a hospitals. This becomes even more difficult if one is hiring people in managerial roles in non-medical areas, folks such as the Front Office Executives, Case Managers, Service Line Managers or Sales Managers.

This is primarily because healthcare services are unlike any other service industry. The customers here are both patients and customers, they are unwell, they don’t want to be there but circumstances have forced them to seek the services of the hospital and the expenses incurred unlike say that of a restaurant or an amusement park are an unforeseen burden. Many a times, they have been compelled to travel far away from home and they are alone amongst strangers, who will have an immense amount of power over them. And to make things a lot worse is the lingering uncertainty about the medical outcomes, indeed about life and death.

People working in hospitals must understand these factors well. Medical folks because of the virtue of their training and  knowledge comprehend these facts instinctively. However service personnel, who have moved to healthcare services from say the hospitality sector are often caught by surprise and are left wondering about the interplay between patients, customers and hospital staff.

Thus, a hospital must be very careful in hiring the right people and then training them in handling customers and patients. Here is a small checklist of what I look for when hiring people in a hospital.

Empathy:

This is the single most important characteristic that I look for in an individual. It is absolutely essential that those who work in hospitals have empathy for patients and their attendants. Many years ago I heard a doctor say that she always tries to remember that it is not a tumour that she is treating, but a human being. Anyone who works in the hospital would do well to remember that. In a hospital I would like to hire people, who can connect with those in distress and interact with a measure of understanding and compassion.They must treat every patient and his problems as the only one that they have to handle that day.

Patience and Maturity:

It is imperative that a hospital hires mature people with loads of patience. This will help in managing patients, who are generally impatient-to see the doctor, get the tests done, lay their hands on that elusive report and get the hell out of the hospital. Since most people find it hard to understand matters related to their illnesses and treatment options, it is best that we have people who can explain these things patiently, without losing their cool and without showing the slightest signs of indifference.

Hunger for Knowledge:

It is a myth that in a hospital, medical knowledge should remain restricted to the medical folks and it is only they who need it. I have seen patients asking questions from patient care executives about arcane surgical procedures, about diagnostic tests prescribed by the doctors and even about their prognosis. To my mind, every individual working in a hospital should aim to acquire and benefit from basic medical knowledge. For me, part of the charm of working in a hospital has always been the immense amount of knowledge I gain by interacting with medical colleagues. In conversation with doctor colleagues, if I find myself lost, I never hesitate to ask them to stop and explain things to me in terms that I can understand. It always helps, when I am required to explain a procedure to let us say a foreign patient contemplating travel to our hospitals in Delhi.

Ability to Get Along with Doctors

It takes a special kind of skill to work with busy doctors, who are always short on time and stressed out. One needs to adapt to their work schedules and understand their pressures to put things in the right perspective. Also, one must remember that they are trained as doctors and not as professional managers, thus often their understanding of a manager’s world is not the same as that of another professional manager. In my experience it is best to always try to understand, where they might be coming from rather than articulating management dogma, which they may not understand well or may find obnoxious.

Optimistic and Cheerful Disposition:

Those blessed with an optimistic and cheerful world view do well in a hospital. A hospital needs loads of people with a sunny disposition, who always look at the brighter side of things and who are hard to put down. These are individuals, who are eager to help, who go out of their way, do that bit extra to make someone happy, because that is what makes them happy.

Rigorous training and an organisational culture based on openness and trust helps these people become good to great and transform the hospital into a wonderful place of healing and caring.

Nursing-The Big Differentiator

If someone was to ask me what truly differentiates one hospital from the other, I would unhesitatingly answer that it really has to be the quality of nursing. Yet most hospital managers pay scant time and attention to what is perhaps one of the most critical functions in the hospital. In India, nursing is perhaps one of the most under rated professions and in a hospital senior managers, who are busy driving patient volumes and revenue and focusing on delivering cutting edge medicine often forget that it is Nursing, which truly is the back bone of  hospital operations.

The last few months for me have been nothing less than traumatic. My father lost his battle with cancer and he continued to be in and out of hospitals virtually all of November and pretty much most of December. While, he gradually deteriorated and my worries and frustrations of doing battle with as implacable a foe as cancer, mounted I could clearly see the wonderful role nursing played in delivering round the clock care to him. My admiration for the profession has since multiplied many folds and it also led me to reflect on how we need to acknowledge and appreciate the role Nursing plays in the life of a patient and indeed that of the hospital.

If a hospital is about ”care”, truly speaking it is the Nursing, which is the face of the hospital. While a patient who is admitted in the hospital sees his doctor, usually twice in the day, (when the doctor is on his rounds), he sees nurses all through the day. While, the doctors have the largest role to play in achieving a cure, it is the nurses who deliver care and comfort in a hospital. Their role gets magnified many times, when the doctors know that they do not have a cure or sometimes when hope is in short supply, it is the brisk efficiency and the caring hand of a nurse, which makes a big difference. As my father grew progressively weaker and his condition deteriorated, we became more and more dependent on the nurses. We needed them to give him medicines, control his infusions, give him feeds, rub his back, sponge him, draw samples for tests, help him turn in the bed, decipher his almost incoherent speech and comfort him. Often, they bore the brunt of his ire – many a times he was petulant like an ill-mannered child, difficult to reason and get along with, yet those nurses never flinched, they never once walked out of the room in anger or said anything, which might be hurtful.

I watched all this and more play out in front of my eyes every day for several weeks over the last few months. The more I saw, the more ashamed I felt of how senior hospital managers like me treat nurses in the hospital. The doctors usually take them for granted, order them around, some pull them up for even small infarction, hospital managers just do not have time for them, they are just there, pretty much like hospital furniture.

Is this because the nurses that we have come from a socio-economic milieu, which is very different from our own? Is it because most nurses in our hospitals can not converse in fluent English, which is the undisputed currency of social mobility in our country? Is it because many of these nurses are not as well-educated as the doctors, hospital managers and probably most patients whom they care for slick private hospitals?

Whatever, be the reason we need to introspect about the critical role of nursing in our hospitals. I would surely like to believe that a hospital can easily have a long-lasting and sustainable competitive advantage over its competitors if it gets its nursing right. A bunch of efficient, dedicated and caring nurses are a far more precious asset than fancy equipment, smart doctors and smartly turned out-patient services executives.

Come to think of it, isn’t it strange that a hospital charges a fee for the doctors, there are charges for the use of the OT, the consumables and the medicines and even the hospital bed. Yet, no hospital that I know of charges a patient for nursing care!!!

PS: My father spent his last days at the Max Hospital in Saket in New Delhi

Pic courtesy http://acceleratednursingprograms101.com/wp-content/uploads/2011/07/Accelerated-Nursing-Programs-08.jpg

Hospitals are all about People’s Skills

skill-setsI have rarely come across an industry, which requires a range of skills, which are wider than what one sees in the people, who work in hospitals. A hospital actually is an amazing aggregation of skills and talent, which one would hardly see in any other human enterprise.

Among the medical folks, there are doctors who are hugely knowledgeable, highly educated and supremely skilled in the art and science of medicine, there are nurses and paramedics, who symbolise compassion and care and there are support folks who provide critical support for running the medical function in the hospital.

Amongst the managerial teams, there are managers who handle the front office and interact with patients and their attendants. They are the face of the hospital, well trained, well groomed very presentable folks, who help put patients at their attendants at ease. They usually have very good communication skills, are people with immense patience and a sunny optimistic disposition.

A hospital also needs a lot of technical support and thus you find high tech bio medical engineers, who ensure that all the equipment in the hospital works flawlessly. Imagine what can happen if an equipment in the OR or in the ICU malfunctions at a critical moment. Much like doctors, their role requires quick thinking, complete mastery of  technical matters and planning for any eventuality.  Most bio medical engineers are rarely seen and heard in the hospital but behind the scenes they control the levers of the hospital.

These days a modern hospital runs on state of the art software, which connects every hospital function. A doctor can not write his notes or ask for medicines till the orders have been punched in the Hospital Information System (HIS). The nurses can not dispense medicines unless requisitioned through the HIS. A patient can not be admitted or treated unless the relevant files and records have been created in the HIS. While most hospitals do have a back-up manual system, it is rarely used largely because an IT team employed by the hospital ensures that the HIS is rarely down. These people are often quintessential techies, with very sound knowledge of hospital systems and processes.

At a 180 degrees of separation from these folks are people who look after functions such as Food & Beverages, Housekeeping and Security. They are all trained individuals as much an expert in their areas as any techie. They interact with patients and their attendants and hence also have superb skills in handling patient grievances. 

While all of those mentioned above contribute towards keeping the hospital humming, another set of people are those who manage the business side of things and have a completely different set of skills. These include the sales and marketing folks, who represent the hospital to an external environment, purchase managers and store keepers, who ensure that the hospital is well stocked with all the essential supplies and the finance guys, who keep an eye on how the money is being spent. People in all these functions have unique strengths. The finance guys are very good with numbers, the sales people drive innovation and have good communication skills and the purchase folks have tremendous negotiation skills and an uncanny smell for a deal.

A good hospital will always have good Human Resources and training personnel. They are the ones who ensure harmonious working relationships amongst a very varied and highly skilled workforce. They make the rules, which govern the conduct of individuals in the hospital, play a critial role in rewards and recognition systems, act as agony aunts and handle conflicts. To my mind the most important skill they bring to the table is an ability to get on with people, understand differing point of views and manage aspirations of a very diverse bunch of people. 

If I was to select two critical skills, which an individual who aspires to work in a hospital must possess it has to be compassion and communication skills. Anyone, who works in a hospital must have loads of compassion towards fellow human beings, an innate ability to see things from the patients perspective and take decisions with empathy and  with an utmost regard for the plight of the patients. The ability to communicate well with language or through a meaningful silence or by just a touch, would be a close second. Be it a doctor, a front office manager or a sales person the ability to communicate the right thing at the right time to the right person is an immensely valuable gift.

Pic courtesy www.flickr.com

Healthcare Loyalty Programs

loyalty-card2 I must confess that without making any serious effort I have become  a member of various loyalty programs and I bet this will be the case  with most of you. I earn reward points whenever I use my credit  cards, shop at my favourite store, fly my preferred airline or buy  books at the corner bookstore chain. I was recently offered    membership of another ‘club’, when I opted to purchase medicines for my mother at the local pharmacy, which seems to have suddenly gone a little high tech and dare I suggest become more customer friendly. Loyalty programs are suddenly everywhere.

I believe time has come for healthcare services to embrace the concept of rewarding loyal ‘customers’.

What is a loyalty program?

A loyalty program involves identifying and rewarding ‘loyal’ customers, who keep coming back. Now I know this sounds a little weird in the context of a hospital, where at one level the objective is to ensure that the patient never comes back again. While no hospital wants to see patients coming back, the fact of life is that everyone needs care at different points in our lives.     Continue reading