Healthcare Reforms

Healthcare reforms are long overdue in our country. Government is making some efforts to streamline the process, especially in controlling the medical education. Many of these like NEET and Vaibhav are good and laudable. There is lot more that needs to be done especially in healthcare delivery.

Most stakeholders (doctors, patients, society, government) in healthcare industry are unhappy. Different stakeholders are trying to outsmart each other and trying to get "more for less", causing the friction, escalating the costs and restlessness. This is applicable to everyone concerned. As a person (patient or doctor) or as a hospital unit or a payer (government/insurance/employees' health schemes) as a whole, the psyche is "get more and give less". Greed is a natural human tendency. When it goes out of control and is added to the vulnerable aspect of human life (health), the results will not be pleasant.

People should try to understand the nature of modern healthcare and try to adopt "less for more". When all the stakeholders understand, participate and put the common good above individual and collective greed, a truly "more for less" system will emerge and everyone will be happy. (My wishful thinking!) Unless people realize and start making changes, things will not improve. System cannot be changed overnight. Takes time. But we should make a start.

Following are some of my views and suggestions which came out my observation after having gone through medical education in India, going to the UK for higher surgical training, working there for a decade, returning to India and practicing in a tertiary care private hospital for 17 years. The ideas and opinions are completely mine.

The idea is to increase the transparency, make healthcare available to everyone at reasonable cost, improving the training standards and making all stakeholders take more responsibility. Healthcare industry should not be a money-making industry, from the vulnerable and gullible people.

Hospital set up: Hospitals must be healthy first two provide good healthcare. They should be categorized into Government, Private non-profit (run by philanthropic trusts or as corporate social responsibility) and Private for-profit. In each category, there should be three categories based on the level of care provided: primary care, secondary care and tertiary care facility. The level of care to be provided, equipment to be available, personnel including doctors, number of beds to be available, training facilities should be clearly defined in each category. This type of framework is already there to some extent but is not being implemented efficiently.

Once the healthcare facility is clearly defined and the services provided are defined clearly, the tariff and source of funds needs to be addressed. Government hospitals will be free anyway. Provision for private paying wards can be made to generate some income and encourage staff. The tariff for these services should be similar to that of the trust hospitals. Second category is the facility run by not for profit by Trusts. Tariff in these facilities should be fixed taking into consideration several factors like staff salaries, equipment cost & maintenance. The staff salaries, especially those of doctors are to be decided depending on the type of facility, seniority and the contribution they make. Ideally, the salaries should be similar in government facilities and the Trust hospitals. Salary should be decent and attractive so that bright young minds get into the profession. Incentive for doctors should be in the form of job satisfaction, rather than purely money. The government and non-profit hospitals should be able to provide major chunk of healthcare and take care of education & training. The for-profit private hospitals can have flexibility in their tariffs over and above the first two categories, depending on the star facilities they create. As the philosophy of care in a for-profit hospital is providing personalized care for payment, there should not be any doctors in training in this category of hospitals.

Funding for hospitals is four types. First is from the government for the government hospitals. Second is from various health schemes either employee welfare schemes or government schemes like Arogya sri or Ayushman Bharat. Third is the insurance companies. Finally, patients paying out of pocket. The tariffs should be fixed depending on the level of care and services provided.

The tariff for surgical procedures and other interventions is skewed by the professional fee. As these procedures are dependent on the skill and expertise of the doctor, they expect more money out of the procedure. Consequently, major variables in healthcare spending are the professional fee and cost of medicines & disposable equipment. The doctor remuneration should be fixed in the first two categories of hospitals. There may be end of year bonuses based on the quality and quantity of work done. The tariff structure for the procedures should be fixed in the first two type of hospitals and the first three types of funding.

The tariff structure should be uniform across all the various schemes and the patients paying out of pocket also. Otherwise, it leads to the private patients cross subsidizing the other group of patients and bitterly complaining about the high costs. Payments from insurance and credit organizations should be prompt. Otherwise, it affects the cash flow of hospitals and they may end up extracting more money from cash paying patients. If a patient belonging to the first three categories of funding wishes to get treatment in a for-profit hospital for whatever reason, they should pay the difference in tariffs themselves, or take a booster insurance policy.

Hospitals should be established based on the above principles and tariffs as dictated by the government. Last few decades, doctors and hospitals had a free run of tariffs. This needs to be streamlined. There is considerable amount of skewing in doctor fees, hospital charges across various specialties and different parts of the country. It is difficult to control the tariffs completely while there is so much greed and self-centeredness around. Government should try and improve the facilities in the first two categories of hospitals. They should be maintained in par with the third category hospitals without the frills. People who have the capacity to pay or higher insurance coverage can go to the third category hospitals for the added luxury.

More number of people, ideally the whole population needs to be brought under the umbrella of one of the first three categories of payment. The existing arrangements of Government funded health schemes are not providing the entire gamut of healthcare. They should be expanded to include all the ailments and treatment. That money may be utilized for improving the government hospitals rather than outsourcing private hospitals. The patients in the first two category of hospitals having some form of insurance should not be made to pay any money out of pocket.

The tariff structure should be such that everything is covered, and the tariffs are viable for the hospitals. People should realize that ultimately all the money must come from those using the facilities. In the first two categories of hospitals, money can be spent efficiently, and care provided for a lesser cost. In the third category, cost will be more for the added luxury.

Insurance sector should be encouraged, and more people should have health insurance. There should be more transparency in the tariffs and insurance payments. At present, cost of the same procedure can vary widely in the same hospital depending on the doctor, between hospitals in the same city and in different cities!! This needs to be streamlined. All this needs a considerable effort, understanding, cooperation and will to change for good from all the stakeholders. There should be two types of policies, basic and higher package. Basic policy will be valid in the first two categories of hospitals whereas the higher one in the for-profit hospital. People having a basic package provided by the employer or government may be able to take a booster package to make them eligible for the higher package.

In addition to all this effort, most important thing is the mindset of the people in healthcare industry. As mentioned before, the incentive for doctors should be job satisfaction. The self-centeredness, craving for self-glory and monetary gain should come down. Doctors should stop being money making machines and philosophy of the hospitals should not be the profit margins. Altruism, caring for the needy and enhancing the art of healing should be the priorities in the doctors’ mind. This can only be achieved when the doctor has job security, job satisfaction, retirement plan, and a decent workplace with good infrastructure and facilities. Doctors should not have to run from pillar to post to get something or the other to treat a sick patient. Providing the facilities and maintaining the supply chain is the responsibility of the administration. Healthcare professionals should not be under constant threat by the public and media or the manager breathing down their neck to get more work done. Workplace ethics and discipline should improve.

Majority of the healthcare provision goes smoothly. Despite so many lapses in the system, still most of the time there are no major issues. For planned healthcare, people have time to plan, enquire and go to a place that suits their pocket. Major problems arise in case of emergencies; either road traffic accidents, heart attack, stroke or a patient developing some problem while undergoing treatment in a hospital. These should be ideally managed in the first two category of hospitals. The healthcare facilities should have adequate insurance coverage themselves to take care of any professional indemnity to cover the treatment of any complications arising in their hands. Depending on the size of the hospital, if a greater number of claims are arising, it should be scrutinized. Government should try to bring the entire population under some scheme to provide healthcare, especially the emergency and tertiary care. The highest care should be available in the first two category of hospitals.

Health education should be part of the school curriculum. Children should be educated on the importance of hygiene and to take responsibility for their health. Importance of regular exercise, contemplation, coping skills and healthy habits should be inculcated to children. General public should be educated regarding the nature of modern healthcare and the costs involved. Society has a variety of misconceptions about health and what is involved in the treatment process. It is surprising to see even the intelligent and educated people having these misconceptions. India is one country where people are afraid of hospitals and doctors.

Ethics, communication skills, teamwork, coping skills and other soft skills should form part of the curriculum for medical students. Patient centric approach, importance of seeing the patient as a co human being, alleviating their suffering, and taking a holistic approach should be taught to young doctors. Importance of teamwork for the better delivery of healthcare should be impressed upon the budding doctors.

There are a number of areas where unscrupulous elements are present in healthcare industry and the allied industries. Corruption may be as simple as an ambulance driver using the siren when there is no patient in the ambulance to doctors/hospitals trying to market procedures of unproven value. Theft may be as small as staff pilfering material from hospitals to as big as the doctors/hospitals/patients/insurance companies defrauding or trying to defraud each other. It is never possible to clean the system completely when the society itself is corrupt and degraded in various aspects. What the government should try to do is reduce the number of these unscrupulous elements by encouraging transparency and rewarding the honest practices in healthcare delivery.

Government should look at primordial prevention; In schools with health education as mentioned above, laying & maintaining the roads to good safety standards, increasing the road awareness & imparting traffic discipline to public, personal & social hygiene, reducing substance abuse, improving farming & animal husbandry practices to reduce the use of harmful chemicals, proper sewage disposal, reducing pollution, occupational health and corrections in other areas which impact the health of the people in the society.  

Primary care should be strengthened and should be available to every person in the country. The role of primary care is to treat the minor & self-limiting diseases, to monitor the chronic diseases, reassure the patients and refer to secondary or tertiary care when necessary. We have a variety of indigenous alternative therapies.  Research should be carried out to see the efficacy of these alternate therapies and made part of the primary care. Primary care doctors or Family doctors should be trained in alternate therapies that are effective and made part of the preventive care strategy. Alternate therapies have no role in secondary and tertiary care. They may have a role as complimentary therapy. Either the government or the public should not waste the money on treatments that were discarded by the rest of the world. That money can be utilized for better primary care.

People should be educated regarding primary prevention by having lifestyle clinics in the primary care set up. A good proportion of our society does not fit into the WHO definition of health. Importance of regular exercise, healthy diet and avoiding substance abuse should be constantly reminded. People should be made to take responsibility of their health and plan for the healthcare spending rather than running around after getting an illness. Doctors should lead by example by taking care of their own health, leading a healthy lifestyle and avoiding substance abuse.

People want the “best doctor”! There will be only one best doctor and he/she cannot treat the whole population. The emphasis should be on improving the training standards and standard of care. Every doctor and hospital should be safe, efficient and trustworthy. Both doctors and society should come out of the person-based healthcare delivery and move towards establishing/improving systems and protocol-based healthcare delivery which is evidence based.

There is no quick and fair grievance redressal system. People are resorting to violence which leaves an awfully bad taste in the mouth for all doctors when seen in the media. Patients who have genuine grievance also are having to go through a prolonged legal battle. The following is a suggestion which can be amended. The IMA should take a lead in this area and work with the help of Government. Doctors in general and IMA also has failed to safeguard the interests of the patients in the event of a mishap. It is a common practice to support the doctor or hospital and deny any negligence or iatrogenic complications. This contributed to increase the suspicion about healthcare providers by the society and losing the faith in doctors. All practicing doctors should be members of IMA and should have indemnity insurance. The IMA branch should have a grievance redressal cell consisting of local IMA President, district collector/RDO/MRO (depending on the jurisdiction), or his/her representative, representative of local police, local MLA or his/her representative. This cell should be able to convene periodically or as necessary when a grievance happens and sort it out quickly. Their mission should be fact finding and see if the mishap is avoidable or due to negligence. Post-mortem examination should be sought to establish the cause of death if necessary. There should be openness, transparency and fairness. In case of avoidable mishaps, appropriate compensation should be offered to the patient, which should ideally come from the doctor’s indemnity insurance company. Rules should be amended to allow this local arbitration and payment. If a decision cannot be reached or not agreeable to the concerned doctor or the patient party, it can always be escalated to a court of justice. Any aggression or violent behavior against the healthcare workers or damage to property should be firmly dealt with and appropriate legal proceedings started. This IMA cell or a similar one should take care of the vigilance on doctors too, to make sure their members are not resorting to any unscrupulous practices.

There should be good data recording and reporting systems. Ideally all the patients treated, nature of treatment given, and the outcomes should be recorded in a national registry. This will help in research, audit and planning for better systems. The health education should be streamlined and planned as per the need in the country. Unless the training and working conditions are improved in the country, healthcare industry may not be attractive to the youngsters and may lead to further imbalance in the system.

The credentialing system and titles should be streamlined. Any therapist can use the title “Dr” these days. This should be addressed, and measures taken to clearly identify the allopathic doctors from the rest of the people belonging to various other categories using the title of Dr. The specialists using various titles should also be streamlined.

This is just a basic framework. Government should establish a “Think tank” with representatives from all the stakeholders, take stock of the emerging situation and take remedial action in healthcare provision. Specialty associations should be involved in this process. Changing the system and steering the course is a colossal task. Any healthcare reforms should have long term view and should be done in consultation with all the political parties and stakeholders. There is no point in bringing in a system which will last till the next election and is discarded.

Pharmaceutical industry and other industries allied with healthcare should also be looked at. The same medicine manufactured by the same company is being marketed with different wrappings by different companies at different prices. This leads to unhealthy practices. Sale of medicines should be controlled with clear demarcation between over the counter drugs and prescription medicines. These are just a couple of examples. There are many other aspects that need looking into. There should be more transparency in the allied industries. Healthcare industry and allied industries should have the ethos of service and healthy growth. Not simply expanding their business and increasing the profit margins year on year. Healthcare industry alone cannot be purified without controlling the allied industries.

There should be some advertising standards control so that hospitals do not advertise excessively and improperly. It is usually “for-profit” hospitals that resort to marketing and advertisements. They need to promote their new equipment, facilities and create work for themselves. This will lead to unfair advantage for them against the first two category of hospitals. All the money spent on marketing and advertisement will be borne by the patients only!! Media should try to reduce the fear and anxiety in the society by not sensationalizing the events, good or bad.

All these things need constant vigilance and checks & balances. Regulations may mean, breeding more corruption in our country. The regulations should be self-governed by the doctors and healthcare industry as much as possible by drawing guidelines themselves and by willful participation. Society, doctors and hospitals should own their responsibility. There is no point in blaming each other.

Society in general, especially politicians and bureaucrats, also should introspect and take remedial actions themselves. When there is so much greed, self-gratification, self-glory, insecurity and cutting corners to achieve success or money in the society, it is bound to affect the healthcare and allied industries too. As health is associated with added fear, people become gullible in the hands of unscrupulous healthcare professionals or the hospitals. Unless the government machinery takes a hard look at itself and brings in healthy reforms with transparency and fairness to all concerned, we will continue to be in this chaos. People in power should remember the oath they have taken at the time of taking up the post and try to implement it.

These are purely my views and may be biased in some areas. Anyone can use any of these ideas for the betterment of healthcare. It is not my intention to blame anyone. My intention is to see affordable and transparent healthcare delivery to every person in the country. Anyone should be able to walk into any hospital with confidence and without the worry of being looted or given wrong treatment.

Jai Hind.

Prasad Mallipudi

Hyderabad, 2 October 2020                                                                                            V 1.3