MANAGEMENT OF THE SICK HEALTHCARE SYSTEM
( By Dr.S.V.Nadkarni, M.S. )

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Health Insurance

It is true that the cost of health care is rising year by year and it is difficult for the common man to meet the expenses; if ever he suffers from any major disease requiring admission and/or operation. It may be difficult even to the upper middle class to suddenly take out Rs.1,00,000/- to Rs.2,00,000/- or sometimes even more when illness strikes. One possible remedy is to think of it and provide for it. Health Insurance – popularly called as ‘Medi claim’ is the right step to provide for the expenses of the health care under the Health Insurance Scheme. A person pays a fixed amount per annum for himself and for his family which ensures the payment of total expenses of say rupees one lakh to rupees five lakhs as per the insurance premium he has paid. Not every one needs hospitalization. If one out of 200 people is likely to fall ill and if the expense for his treatment is Rs. 1,00,000 (One lakh), but everyone pays a premium to share the risk, then the premium for each of these 200 people will be Rs. Five hundred only 1,00,000 ÷ 200 = 500. This is a simplified explanation of how the rate of the premium is calculated. Nevertheless, it proves that the premium to be paid is far less than the actual bill. On paper this appears to be a complete solution for the financial difficulty of the common man about paying the hospital bill. But in practice it is not so. The Health Insurance Scheme, as practiced, suffers from many lacunae. Most important lacuna is that the health insurance policy excludes many diseases with a list of 13 types of diseases like birth-defect, pregnancy and most important pre-existent diseasesunder the terms of medi-claim policy. The insurance companies stretch to a limit this last exclusion namely ‘pre-existing disease’. For example, if a patient has blood pressure and after some years he suffers a heart attack, the insurance company is likely to deny the benefits of the policy by claiming that the heart attack was due to high blood pressure which was a pre-existing disease. Luckily recently the courts have come down heavily on such over-stretched interpretation of the rule of "pre existent disease”. So nowadays major diseases that could arise from the pre existent diabetes, hyper tension etc. are not excluded as pre-existent diseases, if the major illness occurs after 2 years. It is a welcome step. There are companies which allow treatment even for the pre-existent diseases, after certain stipulated period, say 1 year after the pre existent disease was detected but the premium is raised stiff high.

But the most important defect in the present system of health insurance is laxity of the patient himself. He feels secured that he is covered for a big amount of the bill, say rupees five lakhs. The immediate tendency of the hospital and the consultant is to raise their charges by making them double or even more than what the uninsured patient pays; even though most institutions and most consultants will deny this. Even the companies seem to presume that the bills are inflated and, therefore, almost all the health insurance companies object to the anticipated bill and try to reduce it as much as possible. This, in turn, makes the hospital issue an inflated anticipated bill and the vicious cycle continues. The patient himself remains unbothered initially as he feels that he is covered by insurance and does not object to the inflated bill. But he forgets that in case of second illness he may not be left with any balance amount to pay for the second bill and that his next premium is likely to rise. But more importantly, as the patient is insured, the consultant and the hospital tend to investigate the patient more extensively and prescribe costly drugs even if it was not so imperative. The patient is, in fact, happy because he thinks that he is getting a better check up through many investigations done on him. This is the most important reason why the expenses of treatment become high under the Health Insurance Scheme. Very soon, over investigations and prescription of ‘latest’ costly drugs/procedures becomes a habit for the consultants and the hospital is only too pleased with this trend. In order to prevent the practice of inflating the bill or to prevent the shock of unexpected high bill for the patient whether he is insured or not, the Medical Council of India had issued an order that charges like bed charges, operation theatre charge, fees of the doctor, surgery charges, investigation charges should all be displayed in all hospitals. Medical fraternity strongly objected to it and ridiculed this directive which, according to them, was comparing medical practice with a grocery shop. The Medical Council and the government are not insistant anymore. But to me it appears, that this was an extremely important step to curb the practice of raising opportunistic bills either because the patients are not so knowledgeable or because his expenses are reimbursed under company rules or health insurance. It should be noted that the Medical Council did not specify any pattern of charges. Therefore, while one consultant charged Rs.200/- for consultation, another was free to charge Rs.500/- if he so decided. Insistence was on declaring whatever are the charges, so that the patient is forewarned about likely expenses. There was no plausible reason to object to the displaying of charges and in my opinion the government needs to implement this directive very strictly.

As explained earlier, the tendency to over investigate or over treat will not be resisted by the patient, even if the charges are displayed. Not only the patient does not object but he is somewhat happy that he is getting very ‘thoroughly’ investigated and is being treated with costlier (meaning best of the) drugs as long as the bill does not exceed the amount for which he is insured. Ideally it is necessary that the patient should critically evaluate both the needs of the investigation and the treatment as also compare the cost incurred, with costs in other hospitals.

This is impossible under the present system. However, the patient will critically evaluate the need for the various investigations and the need for costly drugs, at least to some extent, if he has to pay some part of the bill. The best insurance policy, therefore in my opinion, would be the one which will cover upto 80% of the bill and the patient will have to pay 20% of the bill from his own pocket.Coupled with the insistence that all charges must be displayed in the hospital, this step of making the patient pay directly, from his own pocket, atleast 20% of the total bill will help in curbing the tendency mentioned above. That in turn will also help to reduce unnecessary investigations in other patients to some extent. Health care will become a little cheaper than at present or the annual insurance premium will come down.

Health Insurance for the poor and Elderly

Worst effected are the elderly and the poor. The health insurance does not help all the people. Health Insurance companies refuse to insure any person above the age of 50 years/ 55 years at the most. The health insurance is not available to any elderly person above age of 55 years unless he has been insured for his health from the earlier age of his life. One lesson to learn is to insure one's health almost on the day one starts earning. The insurance premium at that time is pretty low and worth paying even if one is sure that he will not need any hospitalization. Similarly the poor are greatly handicapped. Even though schemes are announced for the poor wherein the poor people can pay about Rs.300/- per year or Rs.25/- p.m. to get covered for the expenses upto Rs.50,000/- these schemes are not put into practice by the companies. (such an insurance policy was announced during Mr. Vajpayee’s regime), In fact, a circular was issued to the Insurance agents not to accept any policy for less than one lakh rupees even while the circular mentioned above was announcing the scheme for the poor. So, even if the poor man wishes to insure for his health it is impossible for him to do so. Only those who can pay a premium of more than Rs.2000/- and going up to Rs.8000/- to Rs.10,000/- for getting insurance cover of one lakh, can take advantage of health insurance scheme. For 60% of the population in our country the Health Insurance Scheme is not available at all. This needs to be corrected.

Though I have repeatedly suggested the measures to bring the expenses of health care down, I must say that making the health care cheaper is not going to be a very easy task. Measures I have suggested might help only partly to bring the expenses within the reach of common man. It is therefore, imperative that the government itself works out a scheme akin to the health insurance, collects relevant health cess from every one above poverty line, as also from elders above 60 years of age and arranges to pay for all these people through its own health care scheme. Families below the povery line will have to be registered separately and given insurence cover. As emphasized again and again, free treatment is not a solution but payment done through health care scheme would be a much better way of ensuring health care to the needy. The service charges suggested earlier will have to be paid to the hospital by each patient but now these will be made through government insurance scheme, if not from private companies.

Consumer Protection Act v/s Cost Reduction

However this also would become difficult if the health care continues to remain as costly as it is today and further efforts are necessary to see that the cost should be reduced. I believe that
there are enough number of doctors in the society who have a sense of social responsibility and wood conscience and all these doctors would be eager to see that the cost of health care is reduced. They would be willing to avoid unnecessary investigations-especially the costly ones and try simpler
medicines and/or perform operations without using the high-tech equipment, so that the cost of treatment can be reduced substantially. As mentioned in the chapter of medical curriculum, if social awareness is created amongst students during their internship programme and throughout their post-graduate studies, the number of such doctors would definitely increase – provided that doctors', own emoluments are not reduced drastically in the name of economy. One cannot get a good professional for low cost but a good professional can definitely reduce many other costs because of his deeper knowledge of the subject and sympathy for the patients.

But the greatest impediment to all such doctors in their attempt to reduce the health–care cost is the Consumer Protection Act made applicable to the medical profession. However genuine the efforts of the doctors, avoiding modern investigations or avoiding costlier drugs or high tech equipments can definitely result in a failure in a few cases. In many of these cases, where treatment fails, the failure may not be attributable to the avoidance of these costlier methods. It may be purely incidental and stastically the results of such conscientious doctors may even be better than the results of those doctors who freely use high tech investigations, high tech operative equipment and costliest of the drugs. For example, while I was In-charge of Trauma ward as professor of surgery, I treated several cases of head injuries without the use of any high tech equipments. I merely used some logically simple methods of treatment of unconscious patients. My results compared well. In fact, they were a little better than the results in the world literature for the same severity of the head injury. C.T.Scan of the brain was avoided in more than 50% of the cases. Yet C.T.Scan not done on any of the patients would now be considered as a serious lapse in the management in a case of head injury. Actually, C.T.Scan is merely an investigation and the transport for C.T. Scan itself can cause dangerous complications but in the eyes of the people and even judiciary, it has become part of the treatment because of the powerful marketing of high technology and the views of elite experts. Therefore, not doing a C.T. Scan for the case of head injury could become a sufficient proof of negligence. Even today C.T. Scans in cases of head injury are avoidable in more than 50% of the cases of head injury but who will dare to refuse to do the C.T. Scan test, only to be held up for negligence in the consumers court under the consumer protection Act ? The consumer protection act was enacted to protect the consumer’s right of compensation if the promised qualities were not provided in actual use after he purchased any useful article for a price. Deficiency in service was compensated under the consumers protection Act. Unfortunately the treatment given by the doctors to the patients was also considered "service” and the patients became entitled to sue the doctors for the deficiency in service and claim compensation. Doctors started insuring against the medical negligence claims. These insurance policies are called ‘Professional Indemnity Insurance’. Even though such a policy does relieve the doctor from the burden of paying the compensation, it does not relieve him of the severe stress in his day-to–day clinical practice as also from possible disreputation he gains in the society, as and when such complaints of negligence are publicized in the press. Thus, doctors go into a defensive shell by advising more investigations, calling more specialists or super specialists, giving more drugs or costlier drugs or using high tech equipments which are presumed to be safer than the old styled equipments and procedures. Everything adds to the cost of health care. There is a further addition of the premium of professional Indemnity Insurance to be recovered from the very same patients. In U.S.A. I met a team of 3 orthopaedic surgeons, who together paid a professional indemnity of 2,50,000 dollars per year i.e. 80,000 dollars per head merely to protect themselves and that was more than 20 years back. Naturally the consulting and operation charges got revised upwards proportionately for the patients who were treated by the team. The ill effects of such heavy health–care costs have now become evident in U.S.A and most low income population is virtually denied any heath care service there. In fact, president Barack Obama has won his election with one of his main promises that he will give affordable health care to the common man. Yet we are going in the same direction. The application of consumer protection act to medical practice has become counter productive. A team of workers in social sciences studied health–care in U.P. and Bihar and found that 40% of those who were admitted to major hospitals for major illness went below the proverty line, at the end of hospitalization. Luckily the Supreme Court in a very recent judgement has come down heavily on the complaints of negliegence against the doctors and declared that…. "Doctors will not be able to treat patients freely and conscentiously, if they are burdened with such litigations. Doctors cannot assure that patient will be cured and adverse outcome or error in the judgement, cannot be considered as negligence.” At the same time it must be considered that some patients have genuine reasons to complain. They are inadequately attended and inadequately treated but such negligence can more easily be defined. Not attending the patient when the patient was serious and/or when juniors in the hospital had reported that the patient is serious, or not taking simpliest of the precautions or using entirely wrong method of treatment are all obvious causes of negligence and the patient has a right to complain and seek justice. This is criminal negligence and the patient can sue the doctor under criminal law, since a long time.

However, if he decides to avoid costlier methods of management, the doctor must explain to the patient the reasons why he thinks them avoidable and record the same in the case notes. Therefore, he should be fully protected, if he reasonably proves that the patient was explained the pros and cons. Secondly the doctor must be fully protected if he keeps adequate record and proves that under the course of management he adopts, his results for similar disease with similar severity are comparable statically with the results of the other specialists, or results in the literature. In short, statistical proof of the successrate by his method of management should protect him fully against any complaint of negligence. As yet there is no evidence that courts have accepted such statistical proof, nor has any one offered such a defence in any case within my knowledge. But this idea needs to be propagated and adopted. The conscientious professional doctors will thus be encouraged to try cheaper methods of treatment and bring down the cost of heath care. Alternatively it would be much better if the law was made applicable optionally i.e. the patient may be allowed to opt out voluntarily from the application of the consumer protection act and promise the doctor that he will not enter into any litigation over the decision and methodology adopted by the doctor in the treatment of the patient. He will still be entitled to complain against gross negligence as mentioned earlier. Such voluntary rejection of the consumer protection act by the patient will go a long way in freeing the doctor of the hidden fear of litigation by the patient which in turn will help in reducing the cost to a remarkable extent. It must be realized that most doctors are equally or even more worried about failure of their treatment or of any complications. There is no need to add panic to his tension. Personally I am convinced that, in most illnesses, the patient can be treated with nearly ½ the cost (or may be even less) without materially affecting the result. Most of the time, there is sufficient time to switch over to the modern methods, in the few cases where this simplier line of treatment fails; so that not much harm is done even if the first line of approach fails. At times unexpected complications do develop without anybody’s fault and the patient dies or becomes handicapped or his expenses mount sky-high. Immediately the blame-game starts but leads to nowhere. The out-burst of the relatives is understandable, as apart from a huge financial loss, they suffer a big emotional shock, especially if the patient was an earning member in the family. Dr. R.D.Lele had suggested that in such cases instead of litigation, there should be "a no-fault compensation” that may be paid to the family through certain funds created by the hospital or government. These incidents are indeed very rare. Therefore, if only 5% excess bill was collected from each patient and all that money was deposited for this ‘nofault compensation’ scheme, the families who unexpectedly face such disaster would atleast be financially compensated. I think the scheme of this sort is worth being considered seriously.

In short, Consumer Protection Act has become a greatest obstacle in reducing the cost of health care. The fear of litigation has compelled the medical professionals to go for more investigation, more reference and costlier methods of managements, than what he would have done normally. If this obstable was removed, atleast socially conscentious doctors would try to avoid unnecessary expenses and give affordable treatment to the common man.

At the same time sufficient protection can be given to the patients (a) for unexpected adverse result and (b) against gross negligence by unscrupulous or incompetent doctors. The risk of patients falling in the hand of incompetent doctors can be further reduced by some more administrative methods such as...

(1) defining role of various ‘grades’ of doctors like general practitioners, specialists and super specialists
(2) accreditation of the medical centres i.e. dispensary, diagnostic center nursing home and hospital etc.

Research on Cast Effective Clinical Practice

Medical science is progressing very fast. Now, there is no part of the body which can not be mapped and/or seen. C.T. scan and M.R.I. can show the structure of only organ and any distortious therein. Endorcofric instruments can visualise not only the gastrointestinal and genito-uninary tracts but can now enter bloodvessels and perform carrective procedures. Knowledge of stemcells is helping to create healthy tissues to replace diseased ones. Minutest quantities of enzymes and other bio-chemical ingredients of the body can he detected to diaguose various diseases, like Dancers of their very onset, and Lazers and rediation can destroy the unwanted cells. High-grade technology is enabling handicapped persons to move their antificial limbs or even their own paralysed lumbs. Babies can be formed in the laboratory and transported across the world to the placed in some-body's womb. The news-papers and television media are widely showing these miracles of modern science, all over the world and thus are creating a fond hope in every mind that their 'incurable' disease may be cured now. What is forgother is that all these modern inventions cast lakhs or even millions of rupees, to treat a single patient. But the 'Market of these high technologies is very aggressive. The specialist doctors, and the upcoming generation is too enamoured by these inventious and even the political leaders are led to believe that the society will benefit by adopting all these new technologies. 'We will fuid the money' 'money is no problem' are common pronouncements heard from them, when the purchase of these 'State-of-art' technologies is being discussed.

But money is short. The state spends only 1.1% of the G.D.P. of health-even if it is prosurmed to be spending 5% as was reported recently, the amount will fall dismally short to cater to the primary and secondary health-care needs of the average citizens. Yet high-tech-equipments are purchased both in public sector and private sector. The aggressive marketing of these, and the general attraction of the average health-conscious population results in massive usage of these equipments, with heavy expenditure for the patients, but not necessarily with better results. Most often there is a grass abuse and the ultimate results are same or even worse than before. The patient may or may not have benefited but the family was definitely ruined. This grass abuse of modern equipments and modern drugs ought to be embed. But it is not going to be easy. It is a fight against the stream. There is an urgent need to initiate research as to when and where the use of these 'modernities' is not at all indicated, when and where the picture is hazy and its use is, at best, doubtfully beneficial and, therefore, the limited field when and where the modernities are definitely useful. The research of this kind will establish the 'Limitations' or 'uselessness' in the use of every modern investigative and treatment modality, especially when they are very costly. The research will thus offer complete protection to those specialists who limit these uses, and save costs to the patients a type of protection that will stand, in the count of law, of complaint of deficiency in service was lodged. I have prefered to call this 'Research for Cast-effective Clinical Practice.' To site an example, repeated C.T. scans in a case of head-injury is quite unnecessary. In fact, if a patient rapidly improves in his level of uneousciousness or if he was not unconscious at all, C.T. scan may be hardly needed. The patient, however, needs close clinical observation. Similarly, there are enough case-records in the world literature, to prove that some of the cheaper combinations of chemo-therapentic drugs are as effective as the newer costlier drugs. In every clinical field, cheaper alternatives are often available but convencing data has to be re-established by proper research methods to convence the practising doctors to boldly go against the stream and adopt the cheaper modalities of treatment.

Who will fund such research activities?

Obviously, the 'market' would be least interested in promoting such a self-destructive activity. The 'Elite' consultants and superspecialists are most likely to denounce such research, as 'playing with the lives of the poor people'. The central government has established Indian Council of Medical Research' I.C.M.R. to promote research but the chunk is taken away for research on 'modernities' or for 'fundamental research.' Thus, only the State government with a political will or a socially conscious large trust can initiate such a research activity. It is time that the state government should provide a large fund under state council of Medical Research and promote such an activity. A Journal of cost-effective clinical practice will be a natural out-come and will propagate ideas to effectively control the costs of medical treatment for the poor. Publications in this journal will compare the results of different protocols of treatment including investigations, in the same disease with similar sevenrity, with comparision of the costs incurred. It will help practsing consultants to choose cheaper methods of treatment–at least for their non-affording patients.

Similarly, costs can be reduced by better administration, and fuller utilisation of the facilities provided in the hospital. This aspect is allowed to elsewhere again. Publications about successes in reducing costs by management techniques will also help the un-initiated hospital managers to try the 'new' management methods. The maximum retail price (M.R.P.) of the same drug manufactured by different companies varies as much as 3 times or even more. This discrepancy has been reported in the media–but very rerely. The Journal of cost-effective clinical practice can keep on high-lighting these discripancies–and even the response of the coampanies. That will create a healthy delete.

All these methods of cost-reduction-without materially affecting the final results-can be initiated and widely published– only if a -cost-conscious' state governments allots a substantial fund, under the state council of Medical Research and pays the chief research officer adequately. I hope it will be done soon.
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