Need To Work Towards Transparency

Keep recent incidence of alleged medical negligence while treating the patients in mind, today it is important to know that Why is the Society Angry with Medical Professionals? To understand this question, we must revisit the time when doctors were revered and literally placed next to God!. From that time till now there have been many changes in the understanding of illnesses, medical practices, technology and thereby expectations of the medical profession……

Impact on lifespan: As life expectancy rose from 30 years plus in 1947 to approx 70 years in 2017, our expectation too rose that ‘all’ will live long lives. This belief was further fuelled by the rapid advances in medical science and technology – death from illness slowly became more and more unacceptable!

These changes were reflected across the lifespan – thus, introduction and acceptance of immunization programs resulted in many children living after age five; and mothers lived after childbirth as institutional deliveries became common. Alongside, while all this was happening, there were huge advance in anesthesia and surgical techniques, and gradually more and more patients began seeking medical services in their own cities.

1990, most people who could afford it, travelled to the US for medical procedures. With rapid adoption of advanced technology by doctors in India and number of premier institutions like AIIMS becoming Centres for Excellence and Learning turned the tide, and people began to rely on the services provided by hospitals in India and by doctors who were Indian. Unfortunately, the state-run hospitals alone could not keep up with this increasing demand from the society and the private health care sector, sensing an opportunity, began investing in physical infrastructure and handsome remuneration to doctors and other health care human resources.

Result: Our society, once mortally afraid of undergoing even a simple surgery, reacted to the favorable outcome and increased quality and quantity of life, by undergoing complex surgeries when required. Medical practice assumed heroic proportions and even complex life threatening cases were being treated in hospitals in the country.
Expectations from medical treatment had reached a scale, where death is considered to be the result of a mistake. While this may be true some of the time, in most cases it is not. Medical treatment and its impact of health and life, is a complex interaction of many factors, which cannot be attributable to one factor alone.

Thus, death while undergoing treatment of complex diseases is a possibility that family, relatives and friends may not be willing to accept, which becomes a major cause of anger when it happens.

Cost of treatment: This changing scenario of private sector providing tertiary care was associated with high cost of medical and surgical treatment. There was a very high setting up expense involved (approx Rs 1 crore per bed) as well as huge operating expense. There was no preparation of the community for such an expense especially when the medical treatment in Government hospitals was provided ‘free’ for the patient by gathering tax payers’ money. On the other hand, the prompt, personalized, better service and treatment options in the private sector were appreciated by all, yet the high price was deeply resented and criticized especially when they were paying out of pocket and when comparisons were made with the ‘free’ government facilities.

Hospitalization expenditure is still hardly ever budgeted for in families and medical insurance has a low penetration. In spite of such a scenario, there has been a rapid expansion of private healthcare to meet the demand of the community. In fact, private hospitals in India are now attracting patients from overseas as the standards of service in these hospitals have increased and pricing was much lower in comparison. Interestingly, the pricing (even when they were paying 25 to 50% more) was considered very reasonable by International patients while domestic patients continued to complain!

One of the problems regarding pricing/billing has been lack of logic based billing in place of market driven pricing. In the current system (market driven), a hospital makes money on some products and loses money on many others. Fault finding by the community focused on areas where hospitals appeared to make high and unreasonable profits with no discussion on its overall economic situation.

There needs to be a wider debate and discussion about the economics of providing good healthcare to people. A misgiving about the cost of medical services is at the root of major discontentment. In spite of the fact that private hospitals are being blamed for looting and fleecing, most hospitals are financially stressed and most medical professionals are not earning as much as professionals in other fields.

To address this, there is a need to work towards transparency in pricing and a change in the billing system based on actual costing. This may not bring down the prices but will help both hospitals and community to understand the rationale of pricing.This is applicable for both private and the government runs hospitals.

If transparent pricing is required for the private sector, then the same is also true for the government run hospitals, but this is often not asked for since the service provided by the latter is perceived to be ‘free’. Thus, in comparison private sector charges appear to be high and unreasonable. Even after repeated requests, the government does not reveal its financial data to show how much are they spending for various procedures in their hospitals. Availability of this data will help everyone understand the relative cost and benefit of both.

A recent study done in Karnataka showed that Government is paying only about 50% as reimbursement for the cost of procedures, and hospitals are eventually loading their costs to regular paying patients.

This lack of transparency in billing and pricing by Government run hospitals results in anger in the community as they are unable to understand why the private sector charges are so high.

Medical Errors: The expectation from the treatment has reached a proportion where every unfavorable outcome is dissected till a mistake is found! There has been no exposure of the public that despite spending huge amounts and best intentions of doctors, medical errors will happen.

The fact that medical errors have become the 3rd leading cause of death in a developed country like USA is a pointer to the possible scenarios around the world especially in developing countries including India. One of the milestones to highlight that medical errors were not anecdotal but a regular feature even in the best of the hospitals was the famous article “To Err is Human” published by Institute of Medicine (IoM) in the year 2000.

The study estimated that as many as 98,000 people were dying every year from medical errors that occur in hospitals in the US – more than the death rate from motor vehicle accidents, breast cancer, or AIDS – three causes that receive far more publicattention. A 2006 follow-up of the IoM study found that medication errors were among the most common medical mistakes, harming at least 1.5 million people every year. The World Health Organization has recognized patient safety as an endemic issue of concern and has declared that healthcare errors impact 1 in every 10 patients around the world.

Nonetheless, these statistics are not a licence to kill for the medical profession; and the need to recognize that to increase the number of lives that continue to be saved is a call for administrators to do something more. The only way such errors can be minimized is to analyse the root cause. Most errors are due to systemic failures and hence punishing individuals is counterproductive.

To make systemic improvement, the Quality Council of India introduced NABH and NABL accreditation. Even after 12 years of the inception of this initiative, less than 1% hospitals and labs are accredited. Them why some reasons are lack of skilled manpower and supporting infrastructure.

The need of the hour is raising the level of awareness in all sections of the population, the media with its reach and penetration would help by focusing on affirmative action that would encourage systemic improvements rather than wasting time on individual incidents and fuelling the now-common mistrust between the medical profession and public.

In addition the community needs to be educated that medical errors cannot be equated to criminal acts like murder and they need to be addressed through available redressal mechanisms like the Medical Council of India, consumer and/or other appropriate judicial forums

  • Author :

    Dr Vijay Aggarwal

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