Published in Mint on 14th December,2017. Written by Kapil Mehta
Once again, the public and the government are at loggerheads with hospitals. Several high-profile cases have been reported in the media with blame being generously meted out. Unfortunately, if the posturing does not address systemic issues, it would be a crisis gone waste. The situation in hospitals is solvable. What’s more; it is one of those problems that can be sorted out by several stakeholders, if they have the will.
I have a diverse exposure to these issues. As an insurance industry person, hospitals are our adversaries, out to overcharge and reduce the health insurer’s profitability. As someone with immediate family and close friends in the medical profession, I can see the doctors’ frustration in being stereotyped and unfairly maligned. As a large distributor of medical malpractice insurance, there are several liability claims I review that bring out the increasing breakdown of the doctor-patient relationship.
What are the issues? Let’s begin with the price of treatment. When you walk into a hospital you do not know how much you will pay when you walk out. There may be a series of OPD examinations and medical tests and you discover the prices when the payment has to be made. If hospitalisation or a day-care procedure is needed, you are presented with a cost estimate. At this point most people have built a relationship with the doctor and would like to just go ahead and get treated. Patients also get daunted by the thought of changing hospitals and repeating the entire process.
The way prices are set is wrong. Currently, prices depend upon the room you select, a surrogate for how rich you are and whether you have insurance. If you opt for a single room, you will pay more for doctor visits and consumables than in a shared room. This is illogical because the cost of the doctor’s time and consumables is fixed irrespective of room type. Doctors are and should be the final authority on treatment protocol but there is a tendency for insured patients to get unnecessary tests or be discharged later than patients without insurance.
Then there is the problem of deciding which hospital or doctor to visit. Neighbourly references have a role but the anecdotal recommendations are sometimes wrong. Such recommendations tend to give a higher weightage to bedside manners than medical outcomes and patients are not in a position to determine a doctor’s medical track record quantitatively.
There is also an issue in the way doctors are compensated. Their fixed salaries are low and most of their income is variable, linked to treatments they give. The fixed salary of a doctor with 15 years’ experience is often less than that of a freshly minted MBA from an average business school. This means that the doctor has to treat, test and operate to earn an income. This is not a problem unique to doctors. Teachers face the same dilemma, which is why most are not the primary earners in the family or need to resort to extra tuitions to earn a reasonable income. The other critical aspect that most people do not appreciate is that doctors earn a fraction of the hospital bill and usually have no say in the hospital’s charges.
There is little doubt that the corporatisation of health care has led to increased commercialisation. Over a decade ago, the meetings in hospitals between doctors and administrators used to focus on medical issues. Now, these tend to be about costs and revenue generation.
The first targets of official ire in a crisis are private doctors and hospitals. But what of the government’s own medical centres? I recently tried to have a staff member treated at the local government hospital and had to give up after waiting three days to see the specialist. In another situation, we had to pay a medical compounder to get seen. I’m quite certain that many critical patients do not get timely care. Patients are often expected to buy their own medicines, supplies and consumables. The government, both Centre and state, should scrutinise medical standards in government medical facilities with the same intensity that they apply to the private hospitals.
To solve these issues, hospitals must introduce package costs for treatment, publish these and other treatment prices, share medical success rates by doctor, pay doctors on medical outcomes rather than business generated and create far stronger independent ethics committees to review treatments. Creating package costs removes the incentive to keep patients hospitalised for a long time or to perform unnecessary procedures. Publishing these rates allows patients to know what they are in for when they select a particular hospital. Sharing medical success rates and linking pay to that lets doctors focus on what they do best. A vibrant, peer-led, ethics committee should be able to identify major medical malpractice issues and take action systematically.
These steps are not difficult to implement. Hospitals could initiate this; medical councils could recommend these or state and central governments could mandate this. If supported by disclosure requirements, insurers can take the lead and publicise their information on treatment costs and recovery rates. How many medical crises must take place before thoughtful action is taken?