Money matters: In life and death

The Delhi government, last month proposed guidelines to regulate the functioning of private hospitals and curb the practice of arbitrarily charging patients. According to the proposed draft policy, private hospitals and nursing homes should restrict their profit margins from medicines and consumables to not more than 50 per cent. The decision, aimed at curbing profiteering by private hospitals, was announced by Delhi Health Minister Satyendar Jain. The draft policy also prohibits private hospitals and nursing homes from refusing to hand over bodies over pending bills.

Delhi, with a population of over 1.9 crore people, offers a range of medical facilities for every strata of the society. While there are 38 government hospitals to cater to the needs of the poor and the middle class, the national capital has some eminent private hospitals too offering world-class facilities.

“One cannot ignore the fact that private hospitals are the lifeline of the Capital. They are equally important,” said a senior doctor from a private hospital.

The proposed guidelines, if implemented, urges doctors to prescribe drugs from the 376 medicines on the National List of Essential Medicines (NLEM), the prices for which are fixed by the Union government. For drugs not on the essential list, hospitals can charge either the Maximum Retail Price (MRP) or a mark-up of 50 per cent on the purchase price, whichever is less, it says.

The same applies to all disposables and consumables such as gloves, syringes and cotton swabs. For surgical implants, the hospitals can charge MRP or a 35 per cent mark-up on purchase price, whichever is less. The policy also says that hospitals must list the cost of various treatment packages and counsel the patients on the expected complications and the added cost, if they happen. An additional surgery or procedure performed on the patient should cost only 50 per cent of original cost. In case of complicated cases, the hospitals may prepare high-risk packages, which can cost 20 per cent more than normal packages.

“We have received many complaints about private hospitals overcharging patients. We are forming a committee to monitor the rates for tests and investigations. No private hospital can force any patient to purchase medicines from their pharmacy,” Delhi Health Minister Satyendar Jain had said then. The guidelines also prohibit private hospitals and nursing homes from refusing to hand over bodies over non-payment of bills.

The suggested guidelines also recommended that the hospitals in the region should also ensure that rates of surgery packages are “transparent, without any hidden charges,” and disclose whether it covers any complications during the procedure. However, the set of rules proposed by the government have some loopholes. Putting a blanket ban on all services will affect the quality of the medical services offered by the private hospitals in the Capital.

“Every private hospital needs a minimum surplus to maintain the standards. If you are not able to generate adequate surplus, then you will fail to maintain the quality of the services. There is large number of employees working in various private hospitals. They all need to be payed well as many of them couldn’t get jobs in government hospitals. Also, a patient coming to a private hospital is well aware of all the charges and chooses for the treatment only if he/she can afford it. None of the private hospitals force a patient to opt for the treatment,” said Dr DS Rana, Chairman, Sir Ganga Ram Hospital.

Family of a 58-year-old Ram Veer, who was taken to a private hospital on Christmas Day last year for treatment of a heart condition, had alleged that he died due to the hospital’s negligence. The family further alleged that the hospital had refused to hand over the body till the bills were cleared. “We were devastated. How can a health provider refuse to hand over the body? They should be the first one to understand the pain one goes through,” said Sushma, his 28-year-old daughter.

The advisory was framed after the AAP government formed a nine-member committee to monitor the functioning of private hospitals in the Capital. The decision to form the committee was made following a series of meetings by the health minister with various professional and regulatory organisations representing doctors at medical institutions across the Union Territory.

The move came after a family alleged medical negligence against Max Hospital in Shalimar Bagh for wrongly declaring a baby dead. Referring to a case, in which a family was billed over Rs 16 lakh for the treatment of a girl who later died due to alleged medical negligence at Fortis Hospital in Gurugram, the committee had pitched for capping profit margins on drugs and consumables sold at private hospitals. According to officials, the health department had received various complaints of private hospitals forcing patients to buy medicines with inflated rates from the hospitals’ owned medical shops.

“But sometimes, you don’t want to stand in a queue for hours. While the state of Delhi government hospitals is improving, we still chose to go a nearby private hospital. The hospitals are well maintained, hygienic and the doctors are immediately available to help. We don’t have to wait for a month to get a surgery done,” said Avneet Kaur, a resident of Lajpat Nagar.

The Arvind Kejriwal-led government came up with the unique concept of mohalla clinics to reduce the burden on the government hospitals. Residents can visit these clinics for a routine check-up that may not require a specialist.

“The aim of setting up these guidelines is to ensure transparency. Nothing will be done to put a pressure on any of the private hospitals. These guidelines will also further reduce the miscommunication between the hospital administration and the patients,” said Dr KK Aggarwal, former president of the Indian Medical Association (IMA) and a member of the panel that proposed the policy aimed at capping profits of private hospitals.

Event those who had worked in the government set-up are slowly moving towards private hospitals. Many feel that with changing times, medical practitioners want to earn more money at an early stage. “In the last 10 years, many new private hospitals came up all over the country. Doctors began to leave government organisations,” says Dr Anoop Mishra, Chairman, Fortis C-Doc.

He left AIIMS in 2007 as a professor in the department of internal medicine. “Private institutions are providing great career options to doctors,” says Mishra, who had spent 30 years with AIIMS where he started his career as an undergraduate.

But, at times, things have gone wrong. Many patients coming to the hospital allege medical negligence and feel cheated with the inflated bills. The bills generated are unclear, which ultimately leads to an altercation between the families and the hospital administration.

“Forming such guidelines is extremely important. We understand the functioning of the private hospitals which is why we have left the policy open for public suggestions. People wanted the government to control the private hospitals. They come to us with complaints where they feel cheated,” said Dr Kirti Bhushan, director general of health services (DGHS), Delhi government.

The Indian Medical Association (IMA), however, said that the advisory was a populist move that might affect patient safety and healthcare quality.

IMA President, Ravi Wankhedkar, said, “This advisory is harsh and lacks proper research and understanding. Instead of strengthening and improving the public health system in Delhi, the government is trying to gag private healthcare by issuing such an advisory without bothering about sustainability.”

“Decisions will be vague and incorrect conclusions will be derived in case only specific aspects of healthcare costing are picked up without considering the total cost of healthcare delivery.”

Former IMA president Vinay Aggarwal said, “We also have strong reservation against capping of prices of investigations. It will affect the quality of service, depending upon the choice of equipment, investigation, material and the expertise of the clinicians, pathologists, and radiologists who are interpreting the findings and preparing the results. We also feel that this kind of notification is infringing upon doctor-patient relationship and bringing in more mistrust.”

The Association has proposed that a standard operative system be developed by the government in consultation with all stakeholders in case of medical negligence.

Campaign for Dignified and Affordable Healthcare, a forum of patients and families, civil society groups and health experts, said that advocate strengthening regulation in the private healthcare sector and reforms to ensure ethical, respectful treatment of patients gave a mixed response to the proposals.

“We welcome the proposed measures to lower the costs of treatment and bring more transparency and accountability to private healthcare services in Delhi. Indeed, they are progressive in intent and signal a paradigmatic shift in governmental thinking. But we are afraid, the measures need further careful consideration and legal vetting to ensure they do not get stuck in courts. The proposals have some merit but we do not see prospects of them succeeding,” the forum said.

PAST CASES

The state commission has received 68 complaints against hospitals between January 1, 2015 and November 22, 2017. These are mostly medical negligence related cases from private hospitals and nursing homes. When a commercial angle is involved, there tends to be dishonesty and careless attitude, which leads to loss of life.

A KILLING WAIT OF 40 HOURS

Sudhir Verma, a resident of Delhi, alleged that his wife Kiran was being treated for obesity and diabetes when she suffered severe pain in her abdomen on April 22, 2006. Her husband took her to Safdarjung Hospital with all her reports but she allegedly could not get proper treatment till 40 hours of her admission. Verma, while seeking a Rs 45 lakh compensation, alleged that after his wife was put on drip, she started feeling restless and vomited. He said that her health kept deteriorating. He further claimed that his wife was not attended by any doctor nor any tests were conducted till the next day. She died four days later due to medical negligence

COMPLICATING SIMPLE CASES

Rajbir Kaur, 28, a nursing officer with AIIMS’ medicine department, was declared dead on January 21, 2017, after being on ventilator support for three weeks. She was admitted to the hospital’s obstetrics and gynaecology unit for delivery on January 16. Her family members and colleagues claim that hours before delivery, doctors found out that the he art beat of the fetus was slow, indicating a threat to the life of the unborn child. An emergency caesarean section planned to deliver the baby was delayed, the family claimed, as the anaesthetist arrived late. The job was performed by a junior resident, who did not have the required experience.

‘JHOLACHAP’ TERROR

The DMC said that it was the duty of a hospital to verify the credentials of their doctors. The council was responding to a case where a quack was practicing at a Delhi hospital. The quack, RK Yadav, was caught after a female doctor, also the sister of a patient, filed a complaint of medical negligence following the death of her brother. The incident took place on November 16, 2017, after Utpal Saikia was admitted to SHL Hospital in Munirka. According to Mochumi Saikia, patient’s sister, Yadav prescribed some medicines which left her brother  unconscious. He was immediately referred to Safdarjung Hospital where he was declared dead on arrival.

RECOMMENDATIONS MADE BY THE GOVT COMMITTEE

• A sub-committee has been formed for capping the prices to be charged by private hospitals for investigations
   
• The packages fixed by the private hospitals should be transparent without hidden charges
   
• The package should disclose whether it covers complications or not. If a particular package does not cover complications, proper counselling should be done about all possible complications and their financial problems
   
• Mechanism to be developed by hospitals/nursing homes for mandatory recording or counselling
   
• Package covering complications i.e. high risk package shall cost not more than 20% higher than the actual cost. High risk package must be clearly defined so that there is no ambiguity
   
• If the patient dies in the emergency room or the casualty department of the hospital within six hours of his/her arrival, therein the hospital shall waive off 50% of the total bill. If any death occurs between six to 24 hours of the arrival of the patient, the hospital should waive off 20% from the total bill
   
• A patient should have the right to decide whether any consultation or counselling is required by the referring doctors during his course of indoor admission in the hospital
   
• Any charges paid to doctors/individuals/organisations without the knowledge of the patient and not reflecting in the patient’s bill should be considered a malpractice
   
• Cost of treatment of all medico-legal road accident victims, where the incident has occurred in Delhi, shall be reimbursed by the government as per the Delhi Government Employment Health Scheme’s (DGEHS) approved rates
   
• No body can be detained in the hospital because of non-payment of dues
   
• Showing disrespect and inflicting indignity to the body, even in the form of detainment for want of payment of dues, is to be considered an offence
   
• Private hospitals can sell medicines on their MRP according to the National List of Essential Medicines, 2015, which has capped the prices

WHY WAS THE COMMITTEE FORMED?

The decision was made following a series of meetings by the health minister with regulatory organisations . The move came after a family alleged medical negligence against Max Hospital in Shalimar Bagh for wrongly declaring a baby dead. Referring to a case, in which a family was billed over Rs 16 lakh for the treatment of a girl who later died due to alleged medical negligence, the committee had pitched for capping profit margins on drugs sold at private hospitals