( By Dr.S.V.Nadkarni, M.S. )

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Referal System & Charging Pattern

Another important feature of the hospital system which is neglected totally is the way patients approach any hospital any time. There is no step-wise ladder, hierarchy while approaching higher medical centres as per the seriousness of the illness. often the patients attend directly the medical college hospital or major tertiary hospital, but as many as 50% of these patients could have been treated more conveniently at secondary centres or even primary centres like dispensary or primary health centre. Ideally the medical college hospital or any tertiary hospital should get only referred cases from the vast network of primary and secondary centres established by government or private sector. I presume, it is so in developed countries. Thereby, the number of patients to be seen at the hospital is limited and adequate attention can be given to each patient. At present, not only there is an immense overcrowding, but there is no sense of guilt among the attending doctors. The residents, full time doctors and the public administration proudly mention that they treat 100 to 200 patients or even more per day in their outpatients department. None realizes that it is not a matter of pride but is a matter of shame that such a large number is compelled to attend the outpatients department during that short period of 3 to 4 hours just once a week. Neither the care can be good nor can records be properly maintained. The medical college hospital which cannot maintain proper records cannot be called as a centre of education at all. Therefore, there should be a system of referral for the patients to attend such hospitals. For example, in the city of Mumbai, there are number of municipal dispensaries. Many of them have very poor attendance. Then there are upgraded municipal centres and there are secondary care hospitals spread throughout the city. But not even 10% of the patients are referred from these secondary care hospitals or dispensaries nor is it obligatory that the patients must be seen only if referred by general pactitioners or peripheral centres in public sector or from private sector nursing homes. It is high time that such a system is established. It could be fully justifiable to treat a patient with nominal charges (or even free of charge) if he has been referred through the proper channel to the secondary or tertiary hospital. If any patients is not relieved within a few days in any acute condition or within two to three weeks in any chronic condition, the doctor at the primary centre must refer the patient to a consultant at the secondary centre or if the patient is considered serious enough directly to the tertiary centre i.e. medical college hospital or district level hospital. Similarly patients not getting relief at the secondary centre within a stipulated time or patient needing highly specialized, major care must be referred to the tertiary centre by the consultants of the secondary centre. Under the present circumstances, even the patient may be allowed the right to present himself to such a higher centre, if he is not satisfied with the treatment in the stipulated period. It could be further stipulated that patients suffering from specified diseases like cancer, symptomatic heart disease, burns beyond 25% or major accident cases with multiple injuries or internal injuries must necessarily be referred to the tertiary centre, after getting urgent life-saving treatment at whichever hospital he was seen first. Parameters for referral from one centre to the other can be stipulated as best as one can and they will get revised as years pass by, through review of data and experience. Such patients who come through the proper channel must be justifiably treated with nominal charges, as mentioned earlier (or even free, for the time being). However, many patients may not be willing to get treated at the lower canters and, therefore, would insist on coming to the secondary or teritiary hospitals directly. Such patients, even if they attend general OPD, must be charged about 50% of the charges as defined for
the paying patients. Also if the patients are referred from the private sector, they can also be charged upto 50% like the patients coming directly. However, care must be taken that no patient should suffer delayed treatment in this system. Some administrative steps would be needed to fine-tune the system but suffice it to say that the system can be tuned to give adequate relief to the maximum number of people, with a periodical review to improve the system. year by year. Secondly from each clinical unit especially of the major branches like medicine, surgery, gynecology, pediatrics, orthopedic and ophthalmalogy, seniors could attend one such secondary centre once a week and a consultant from secondary centre could visit a single primary centre so that the primary centre is ----- attached to that secondary centre, so-to-say. Lectures from medical college hospitals could similarly attend up-graded primary centers once a week. If this is done, after major part of the treatment at the teritiary centre is over, many of the patients from that particular secondary centre could be referred back and then be followed up at that secondary centre without the need to come to the tertiary hospital. Such a pyramidal system will improve the medical services for the general public, as also will pave way to disburse the crowd of a tertiary centre to various smaller centers. Necessary clinical records at the medical college hospital can now be maintained more easily and, therefore, clinical research will also get boosted. Everybody gains and nobody loses.

So far, all attempt to charge the affording patients in public hospitals have failed basically because the charging pattern was based on the income slab and it was impossible to determine the exact income slab of the patient at the window of registration. It also increased the work of the clerks, those salaries and promotions were unaffected, whether they collected the charges or allowed the patient free treatment. Therefore, even when a patient declared his income above the stipulated limit, it was the very office clerk who dissuaded him and advised him to declare his income in the range of free treatment. The situation would change in the new pattern as suggested above.

(a)the charging pattern has been developed as per the patientís behavior and his desire to get treatment out of turn.

(b)There is a direct incentive for the senior consultants/medical teachers, if they refuse to treat affording patients in the general OPD and insist on their coming to the paying clinic and

(c) The burden of collecting adequate income for the hospital can be put on the Accounts Section, by some steps. Basically, the main step would be that the staff working at the Registration Section, responsible for ensuring proper collection of charges will work directly under the Chief Accountant and the Chief Accountant will have a certain budgetary responsibility to ensure that a fixed percentage of the total budget of the hospital is collected directly from the patients who receive treatment there. This aspect need a more detailed discussion but it is a complicated lesson in management and hence, I am avoiding the detailed discussion on it.
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