ROHIT LUTHRA had heard stories of private hospitals fleecing patients. “They seemed exaggerated,” Rohit, the co-owner of an IT company in Delhi, says. He had recently taken two family members to corporate hospitals for cancer treatment, and was ‘fairly satisfied’ with the handling. Then, in June 2010, Gajanand Singh, 40, an employee in his firm’s purchase department, fell ill. Gajanand came from a poor family in Munger, Bihar, and had been with the company for about seven years. He went home to a wife and three children. A dentist saw something unusual in Gajanand’s swollen jaw and recommended a biopsy. On 26 June, Gajanand found he had non-Hodgkin’s lymphoma, a kind of blood cancer, in advanced stage. Two days later, his first stop was the All India Institute of Medical Sciences (AIIMS). Panicked by the crowds there, he went to the Max Super Speciality Hospital in Saket, South Delhi. His company’s group health insurance covered him up to Rs. 8 lakh. The company also sent its employees to double up as attendants to Gajanand in hospital; he was a well-liked employee due to his quiet diligence and respectful conduct.
Doctors at Max suggested chemotherapy. Gajanand wanted to go to AIIMS but feared the delay, so the Max doctors suggested he start the first course of chemo at Max, and could later move to AIIMS. Gajanand was admitted on 13 July and chemo drugs were administered over three days. On 16 July he developed well known side-effects of chemo: vomiting, dysentery and plunging blood counts. He did not recover. On 27 July, four days after the hospital had moved him to the isolation room of the intensive care unit, Gajanand died.
The cancer he had is typically detected at a late stage, when treatment is ineffective. What did surprise Rohit and his colleagues, though, was how the hospital handled the case. “There was only one doctor taking the decisions, not a panel or a team, even after we asked for it. Senior doctors were not informed,” says Rohit. After Gajanand’s death, oncologists elsewhere told Rohit chemo is not advised to a patient at such a late stage of that cancer.
And then there was the bill for Gajanand’s treatment. Rs. 7.95 lakh, just a shade under the maximum insurance cover. Gajanand’s life had run out remarkably close to his insurance limit of Rs. 8 lakh.
“We think the doctors knew Gajanand wouldn’t survive. But they wanted to maximise the hospital’s revenues from the insurance company,” says Rohit. When Gajanand’s company complained to the hospital about the treatment offered, the response left them ‘very unhappy’. When TEHELKA contacted the Max Hospital authorities, they said, “The patient and his family were briefed about the patient’s condition, the prognosis and the estimated cost.” They say another doctor examined the patient on the request of the family, and that a multi-disciplinary team of the hospital’s tumour board as well as the medical oncology team discussed the line of treatment in detail, which was communicated to the patient and his family, who signed a written consent. On the bill coming so close to the insurance amount, hospital authorities say the thirdparty assessor or the insurer “does not disclose the coverage limit of the patient.”
After all, Gajanand went to Max because AIIMS was too crowded. Most government hospitals have degraded to a point that the experience is dehumanising. In comparison, private hospitals offer immediate care. Patients are pampered even, and attendants feel reassured.
Rohit says his confidence is shaken. He is now considering the only real recourse: the consumer court. His chances are, however, slim.
“Almost all cases of medical negligence under the Consumer Protection Act fail because it is impossible to get a doctor to testify against another doctor. They fear being ostracised,” says Jehangir Gai of Mumbai’s Consumer Welfare Association.
DELHI’S CONSUMER activist Bejon Misra conducted a study in 2004 of the number of medical cases that go into redressal (for the World Bank and the Union government). His finding: 1 percent. Consumer courts, though, deal only with cases of medical negligence. What can people do when they think they’ve been had — overcharged or rushed into tests, procedures or hospital admissions? Nothing.
Most people have either experienced or heard of somebody feeling cheated by private health players — the bigger hospitals get talked about more than others because of their size and presence, but almost all arms of the private sector healthcare are viewed with suspicion. India has created a health system it doesn’t trust.
Says Namita Sharma, a government doctor in Pune, “I had an ache in my knee, quite common at my age. I sought the opinion of a consultant. He spoke to me like I were a novice, and in the blink of an eye suggested a knee replacement surgery.”
Narendra Puri of Gurgaon went to a doctor after an attack of acidity. After an ECG test showed alarming spikes, he was told he had had a heart attack and needed a coronary stent. Before taking a decision, he consulted another doctor, who said there was nothing wrong with his heart and the first doctor had placed the nodes of the ECG all wrong.“We are unfortunate to be born in this country,” says a retired high court judge who did not wish to be named. He developed a urine infection after he needed a catheter for treatment at a prominent corporate hospital. “I had told the doctor I needed preventive antibiotics because of my diabetes and vulnerability to urine infection. He said I did not need it. I did get a urine infection and had to spend an extra 10 days there,” he says, adding he saw no hope in going to consumer courts. “Doctors are minting money. I feel defeated by the corruption in our society,” he says.
The Indian government, regardless of the party in power, encourages private sector in healthcare. A World Health Organisation (WHO) survey ranked India 171 out of 175 countries in percentage of GDP spent in the public sector on health. India ranked 17 on health spending in the private sector. About 80 percent of India’s total healthcare market is in the private sector.
The Centre has practically left healthcare to the private sector, which is booming. “The private healthcare industry in India benefits from low government interference. There are few regulations and, unlike many developed nations, healthcare policies do not work on a reimbursement model,” says Healthcare Services in India: 2012: The Path Ahead, a study by YES Bank and ASSOCHAM.
Private healthcare has the status of infrastructure in India; 100 percent foreign direct investment is allowed under the automatic route, and there are service tax exemptions. The government offers income tax exemptions for five years for setting up private hospitals in smaller cities.
There is no doubting, however, that the private sector has made a positive difference. Private hospitals offer freedom from the crowding typical of government hospitals. Patients have courteous attendants, hygienic surroundings, higher chances of getting good treatment, and are afforded greater dignity and privacy than government hospitals afford. The overall experience is far superior. All this, though, is for those who can pay.
But the worry is that the medical regulation of the private sector is even more friendly than the financial regulation. State health departments and medical councils are supposed to regulate the medical practices of private hospitals.
Rs. 2,11,566 cr INDIA’S TOTAL HEALTHCARE EXPENDITURE
While the departments receive no complaints — the Delhi Health Directorate’s nursing home cell said it had no complaints against private hospitals — state medical councils are infamous for being dysfunctional. The Maharashtra Medical Council, for instance, held its election in April 2009. But the state government has still not constituted it; only one government official handles its work.
THE STATE councils are answerable to the Medical Council of India (MCI), which is charged, among other things, with the job of ensuring “the ethical practice of medicine by all registered medical practitioners”. In May 2010, its president Ketan Desai was arrested on charges of corruption in granting approval to medical colleges, and later dismissed from the Council. The government brought in an ordinance to suspend the Council and appointed a board of governors comprising six eminent doctors to oversee its functioning till it is overhauled and reconstituted in May 2011.
Ranjit Roy Chaudhury, former director and dean of Chandigarh’s Postgraduate Institute of Medical Education & Research, is one of them. “The MCI and the state councils just do not have the investigative wings to catch unethical medical practices,” he says.
So there is little monitoring of healthcare in India. This is a serious impediment to epidemiological research as data from private doctors, nursing homes and hospitals is not reported for most diseases. The effects are felt only when people go through bad experiences.
Narendra Puri of Gurgaon went to a doctor after an acidity attack. He was told he had had a heart attack. A second doctor said the first had placed the ECG nodes wrong
Pradip Saha, a filmmaker and designer in Delhi, saw this up close when his father was detected with an advanced stage of lung cancer nine years ago and taken from Kolkata to Mumbai. Doctors at the Tata Memorial Centre suggested palliative radiotherapy. But a young oncologist in Hinduja Hospital differed. “He said my father was going quickly, and that we should let him go in peace and not interfere; that we should only manage his pain.” He told Pradip palliative radiotherapy would extend the patient’s life, but if he loved his father, he should think about the quality of time he could buy him. He realised what the family faced, and offered to speak to the elder Saha. He counselled the patient and the family, taking them through the paces of what was likely to happen. “It happened exactly how he had predicted,” says Pradip. His father was quiet for two days, then angry for a few days, blaming the family for not doing enough. And then he accepted the truth.
“The oncologist told me relatives typically fall at a doctor’s feet and request they do something, anything. And there are so many things to do,” says Pradip. His father spent his last three days in an ICU. As he watched his father’s life ebb, Pradip saw relatives of other patients scrambling around, borrowing money in desperate attempts to save a loved one without any idea of the risks. He is still grateful to the young oncologist for his decisiveness. It allowed his father dignity in his last days.
Not everybody, though, has the option of taking life and death decisions based on what they know. Sachin Kandhari, a neurosurgeon in Delhi, describes his travail. His cousin in Punjab, Anil Mahajan, 28, had discomfort in his chest and was taken to the Fortis Escorts Hospital in Amritsar on 6 November 2009. An ECG and a rapid angiography later, he was told he urgently needed a coronary stent to tackle a blocked artery. “He had no risk factors like obesity, smoking or old age. So I asked the doctor attending him to send me the video CD of the blockage so I could show it to friends here and get a second opinion. They refused and told my cousin’s parents stuff that got them worried,” he says.
A WHO survey ranked India 171 out of 175 countries in percentage of GDP spent in the public sector on health. The country ranks 17 on spending in the private sector
When TEHELKA asked Fortis Escorts about a patient not getting a CD, the hospital denied the charge. “At Fortis the practice of medicine is evidence-based, so the issue of having patients undergo unnecessary tests is out of the question. All test results are given to the patient, including angiography, burnt on a duplicate CD,” say hospital authorities. Jasdeep Singh, director of the Amritsar hospital, says, “There is barely anything that can be doubted with regards to the line of treatment and urgency in the manner it was done, viewing the criticality of the patient.”
Mahajan’s family agreed, and he now walks around with a stent in his heart. “I’m a doctor and I could not prevent one of my relatives from going through this. What chance do other people have?” asks Kandhari. He doesn’t believe Mahajan’s situation was as critical as the hospital claims. A stent, he says, is a foreign body and poses risks, besides requiring lifelong medication; it should not be implanted unless it is absolutely necessary. And yet, he knows, the hospital would have had a logical argument for suggesting the procedure. “But even now, they have not given us the video of the angiography, their tall claims aside,” Kandhari says.
INDIVIDUAL PATIENT complaints are, however, only one part of the story. Patients have become extremely demanding and customer-like; they shop for doctors now. “A 56-year-old man I attended to was unhappy that I recommended tests worth only Rs. 200. He said he was not coming back soon, and wanted a complete check-up done. I had to prescribe unwarranted tests worth Rs. 750 just to keep his trust.”
Rs.1,69,252 cr WHAT PEOPLE SPEND ON OVERALL HEALTHCARE IN INDIA
“What we have is a system that dumbs down a doctor’s instincts, makes them trust diagnostic tests rather than their instincts. It discourages initiative,” says the doctor who witnessed this. It is well known that most doctors — especially general practitioners and those working in smaller nursing homes — get a cut of up to 40 per cent on diagnostic tests they recommend. The most common test doctors suggest to milk patients is the MRI scan, say doctors.
Suraj Rajan, a doctor in a Thiruvanthapuram private hospital, is an outspoken critic of unethical medical practices. “Doctors have a high level of commercial interests. They often suggest unnecessary tests and even surgeries,” he says. “Some doctors play a dirty trick: they put a star mark against certain tests on the lab request form and tell the patient that these tests are important. This is actually a code. The lab guys make it a point to report these particular tests as ‘abnormal’. The doctor then tells the patient that this test has to be either repeated in a few months, or more testing is necessary. The patient now becomes a permanent customer and thus both the doctor and the lab gains. There are ultrasound scan centres where they report appendicitis similarly.”
Renowned heart surgeon Naresh Trehan says there is a term in for it in the medical community: “stretching the indication.” Roy Chaudhury says unscrupulous doctors conduct unnecessary hysterectomies, appendectomies and mastectomies across the world, and that there is no way to stop this. Overtesting, though, has another side: the fear of getting sued under the Consumer Protection Act. “As our society gets more litigious, you will see the need for greater subjective (rather than objective) documentation,” says Arun Bal, a doctor and consumer activist with 35 years experience in Mumbai.
This also explains at least a part of the reason so many negligence cases fail. “We have dealt with more than 400 complaints of medical negligence. Not more than 4 percent did we find justiciable,” says Bal. “Many complaints have to do with patients feeling mistreated or due to poor communication from doctors. That does not comprise negligence,” he says.
FOR DOCTORS, the choice is between working either in the public sector, which is resource-poor and crowded with patients, or for the private sector, where the best of doctors in the best of hospitals have to make some adjustments with their conscience. It is not an easy choice. “This is the only vocation in which by the time one is ready for an independent professional life, one is typically above 31-32 years of age. And we watch our friends in other professions settle down into a career around the age of 25,” says a doctor into his third year of practice. An MBBS takes about six years, post-graduation for a specialisation takes another three, and they then have to work as senior residents for another three years. Super specialists often end up studying/training/interning for 14 years before they begin to work as independent professionals.
Besides, young doctors come through a system in which they do the work and their seniors get the money and the credit. In private hospitals, the seniors are like the portals that bring in the business. “The world of medicine is highly feudal, hierarchical,” says Rama Baru, professor at Delhi’s Jawaharlal Nehru University’s Centre of Social Medicine and Community Health. “A lot of close mentoring goes into making a doctor, which is why they stick to a code like the IAS officers do.” What aggravates this is that junior doctors are paid a pittance, and have to work through the system to get to a stage where they are comfortable. The large capitation fees candidates have pay in private medical colleges only worsens this.
“It is never easy to tell if a surgery or a diagnostic test is unindicated. India has no clinical guidelines or national protocols on diseases and therapies, only textbooks,” says Arun Bal. He as well as Naresh Trehan say it is important that the patients ask questions of doctors. That can happen only when the patients are well informed. Or there is an insurance company that asks questions about expenditure. But health insurance penetration in India is not even 5 per cent, Trehan points out.
Another concern is the nature of contracts by which private hospitals hire doctors. Contracts are confidential, and their terms vary from hospital to hospital. There are three broad tiers of doctors. The younger doctors get a fixed salary. There are associates and junior consultants who get a fixed salary and incentives based on the business they bring. And there are senior consultants who are paid on the basis of the business they bring.
Younger doctors get a fixed salary. Associates and junior consultants get a fixed salary and incentives. Senior consultants are paid as per the business they bring
The revenues senior consultants generate in OPD go mostly to them, with a hospital typically deducting 15-30 percent for use of its premises. But when a doctor’s patient is admitted to a hospital for a procedure like a surgery, the senior consultant’s payment is often tied to the total bill. Each private hospital has its own way of putting the onus of generating business on senior consultants. “This is why I dread working in a private hospital,” says an associate professor at AIIMS. “I cannot stand the thought of having a manager asking me why the number of patients I’m bringing in is sagging. Next time I see a borderline case, I’ll tend to admit the patient.”
And it’s not just the business model; the medical model in private hospitals is also flawed. “It makes doctors compete rather than function as a cohesive unit,” says Rama Baru. She has had government doctors who now work in private hospitals as consultants tell her that since remuneration is tied to the number of patients, it promotes competition and individualism, rather than collaboration.
RITU PRIYA, doctor and professor of community medicine at JNU, says in the current medical model, senior doctors are consultants on call, specialists are brought in on request, and staff doctors are mostly junior. Several senior doctors, including Trehan and Roy Chaudhury, say this is a common model of hiring doctors, and it is worrying.
A doctor recalls a case that illustrates Ritu Priya’s concern. A young man came to his hospital for a bariatric surgery — medical term for surgically removing fat — on his abdomen; he said he felt social phobia because of his obesity. The senior consultant told him he did not need it, and that he should try other means of losing weight. Another surgeon in the hospital took his case and performed the procedure. “Imagine what the first doctor would have felt for taking a tough decision. Next time he gets a similar case, he will think twice before turning the patient away.”
In this regard, the Sitaram Bhatia Institute in Delhi has a good reputation; its doctors are organised in teams. Which is why it has several doctors from AIIMS. “Unlike other hospitals, it does not pay us by the amount of money we earn for it,” says a junior consultant. Even senior doctors are not paid by the number of patients they attend to or based on the total billing of the patient; their salaries are fixed and medical audits check the performance of doctors as a team. This allows research and collective learning, as shown in its programme that has lowered the rate of caesarean sections.
Such results depend on teamwork. Then again, at this hospital, a caesarean section costs nearly as much as a normal delivery; it has no incentive to push women towards caesarean sections, unlike lots of other nursing homes and hospitals. Several larger hospitals, meanwhile, have no incentive to train and groom doctors. They have the money to buy talent from where it gets groomed. And AIIMS has long been a good hunting ground. Sir Ganga Ram Hospital, run by a private charitable trust, is another. One reason is: doctors decide on running the hospital. It is managed by a 22-member committee, of which 19 are senior doctors working in the hospital.
MEDANTA, RUN by Naresh Trehan, is trying to become a similar hospital that creates teams of doctors and conducts research. But the jury is out. “Corporate hospitals don’t allow this much. A doctor’s reputation cannot become bigger than theirs. The brand that matters to them is that of the hospital,” says a surgeon who has worked at a government hospital and now works for a private one.
‘Several hospitals noted that profit rates are around 13 percent, lower than that in other high growth sectors such as IT, finance or retail,’ says an IIM study
A doctor who worked in a corporate hospital summarises what several doctors say: “We live in a capitalist society that is changing rapidly. When there is commercialisation all around, it is outright hypocrisy to expect doctors to follow a superior moral code.”
60% HOSPITALS 75% DISPENSARIES 80% DOCTORS
To be fair to private hospitals, there are more profitable avenues. “The single most important constraint is the high cost involved in setting up hospitals, the long gestation period of such investment, and the relatively low returns on investment,” says a study on FDI in hospitals by Rupa Chanda, professor of Economics and Social Sciences at the Indian Institute of Management Bengaluru.
“Several senior persons at leading corporate hospitals stated that they are in an expensive business involving huge upfront capital-intensive investments and high running costs. According to many, it takes 4-5 years to break even and 7-8 years to make reasonable profits,” her study says, adding, “Several hospitals noted that profit rates are around 13 percent, lower than that in other high growth sectors such as IT, finance, or retail.”
Rohit Luthra, whose IT business is a result of India’s economic liberalisation, is horrified by the comparison: “We need to discuss again the fundamentals of certain institutions. How can hospitals use corporate jargon like KPIs (key performance indicators) for doctors, which includes the average billing that a doctor creates for a hospital? The income of senior consultants is 70 percent variable on the revenue they generate for a hospital. Health and education have to be beyond commerce, they cannot run on the profit motive alone,” he says, wiser after Gajanand’s death.
‘I have had physicians ask for commissions for sending patients to me. That’s how shameless people have become’
Heart surgeon Naresh Trehan, chairman and managing director of Medanta: The Medicity, also heads the health committee of the Confederation of Indian Industry. Excerpts from an interview:
How does the private sector get to command 80 percent of India’s health market?
That’s how it has always been. In villages, the local doctor or quack was the one providing the services. In smaller towns, a doctor would open a small nursing home with his wife or somebody else from the family. Metros had bigger nursing homes, built by doctors of a bigger stature. In the 1970s, Mumbai saw some large trust hospitals supported by business houses. In the 1980s came the first corporate hospital, Dr Prathap Reddy’s Apollo Hospital. Max then took a trust hospital and gave it the flavour of a corporate hospital. In 2000, the Confederation of Indian Industry formed a health committee, with a powerful secretariat. It tried to bring the stakeholders together and build a healthcare sector in India, rather than everybody being on their own. That’s when we realised we had no idea what was going on. We commissioned McKinsey to figure out the health sector. We found India and 134 countries had signed the Alma Ata Declaration in 1978. It said we shall commit to provide a minimum standard of health prescribed by the WHO. McKinsey’s data showed India was 40 percent of where we wanted to be and that we need to double the sector. That $25 billion incremental investment was required. And at the current rate, we would be spending only about $10-15 billion. The corporate sector saw the opportunity and got excited. That’s when a lot of activity started like buying up of trust hospitals. That is why this mad race of how many beds you own and what not.
How do you view the government’s regulation of private healthcare?
The government is not regulating. And the private sector, too, is at fault. Some of us took land in the old days with the promise of offering free services, which most of the hospitals are not providing. The problem is also the definition of free. The government realises it must advance healthcare, and that the private sector will play a larger role in it. But the expectation of the government is also that the private players will have a sense of social responsibility.
How responsive have you been?
We have almost finalised PPP (public private partnership) model and we are saying we can build good quality secondary care hospitals in B and C cities. The government will help with up to 40 percent of the capital costs. In return, the private partners will offer the first 30 percent of the beds to people below the poverty line, and another 30 percent to the lower middle class. Another idea is that private players adopt a district each and develop the health infrastructure there. The pilot project will be Jhajjar in Haryana.
Why do private hospitals push patients to expensive options?
The cost is high from a patient’s point of view. But a hospital cannot do it cheaper. Hospitals operate on small profit margins; it is difficult to keep a hospital afloat financially. Don’t go by the stock market frenzy, I don’t know what they do but nobody is breaking the bank here. A hospital is the hardest way to do business. And we are offering healthcare options like surgeries of the same standard as in the US for a tenth of the price. But if hospitals resort to practices that inflate the bills, that is wrong. Like any other profession, there are hospitals and greedy people who are doing bad things.
Corporate hospitals make doctors compete with each other. Does that worry you?
Yes it does, and that is why at Medanta we are doing the opposite. That is the difference between a housewife and a whore. We are saying institute of bone and joint, it is not an orthopaedic surgery unit. A doctor heads a team of doctors who work on different things. We have full teams with different parts working in coordination. We do emphasise growth of a doctor’s knowledge, year by year, as well as research.
Is a doctor’s income linked to the number of procedures/total billing that they bring in?
Yes, that does happen; most of them are veering to a model like that. It is worrisome; a doctor’s pay should not be linked to the numbers. It is to avoid it that we do not have consultants in Medanta. Almost all our doctors are full-time staff. Their pay depends on the quality of healthcare delivered to the patients, determined by measurable indicators. The results are audited.
‘We brought down caesarean deliveries from 70 to 46 percent’
Dr Sonia Naik of the obstetrics unit of Delhi’s Sitaram Bhartia Institute talks about a programme that reduces caesarean deliveries. Excerpts from an interview:
Why are caesarean deliveries so common in private hospitals?
They are more common in private hospitals than in public hospitals. One reason is richer patients with sedentary lifestyles. Another is better food availability, which, combined with a sedentary lifestyle, is leading to higher baby weight. Yet another is that women are having babies later, after the age of 30, which is more risky.
Do hospitals have a role in this?
Most private set-ups have individual doctors and not a group of doctors or units working together. The entire responsibility is on that one doctor, who typically does not want to take risks regarding the mother or the baby. She goes for a Csection if there are signs of distress to the baby. A C-section in a later stage of labour increases distress to the mother (more blood loss, injury to the bladder). Individual responsibility also means the doctor is not available 24×7. Caesarean gives the option of conducting deliveries at her convenience and availability.
Who decided to reduce the C-sections?
It came about when we started the integrated mother and child programme. The hospital director was keen on it. From more than 70 percent, it came down to 46 percent.
But don’t hospitals earn more from C-sections?
C-sections involve an anaesthetist and operation theatre, and more drugs. I really don’t think it is more profitable for the hospital overall. In the long term, more patients come to a hospital that will not do unnecessary interventions. The surgeon’s fee for a normal delivery and C-section does not differ that much in our hospital. And a surgeon needs to give far more time to a normal delivery; she may have to wait for hours, whereas C-section is over in an hour.
How can a hospital reduce the C-section rate?
One, doctors need to be sensitised. Two, they need to work in a team; visiting consultants will not make such an effort. Three, we designed an integrated mother and child programme. It had antenatal workshops, one-on-one sessions with pregnant women, trained child birth educators and physiotherapists. We use birthing balls to reduce pain perception, birthing beds to avoid shifting patients twice. We created a protocol so all the doctors follow the same treatment. And there is monthly auditing to see the C-section rate.
How do the patients respond?
The patients who have a normal delivery were grateful because they feel most hospitals nowadays do a C-section. But women who have a C-section despite trying for a normal delivery feel disappointed. One who had an elective C-section earlier with a good-sized baby (3.3 kg) had a normal delivery next time. This time the baby’s weight was 3.5 kg. She was happy with her faster recovery. But some turn away thinking our hospital forces you to have a normal delivery.