New Delhi: There have been a few occasions in the last decade and a half when one was able to imagine that India’s healthcare choices would no longer be limited to government health system – which robs the patient of dignity and relieves the doctor of accountability – and private healthcare where quality comes at an exorbitant price.
One such occasion was when the Clinical Establishment (Registration and Regulation) Act 2010 came into force. The Supreme Court referred to this Act in its recent strictures to the Union government about the vast disparity in money charged by the private sector.
The Act gave the government powers to register and regulate hospitals to set minimum standards of facilities. The rules framed in 2012 also empowered the government to define a range for hospital charges. None of that actually happened. In some states, the regulatory commission was kept waiting for the government’s nod to fix rates while others did not even make that effort.
In 2011, a High Level Expert Group (HLEG) submitted its report to then planning commission which universal health coverage the lingua franca of healthcare in India for some years. After seven years, the Pradhan Mantri Jan Arogya Yojana (PMJAY) was launched in 2018.
However, the top court’s directions have raised hopes of seeing some movement on this front once again.
Over these years, state governments, despite launching health schemes, have failed to regulate the private sector. One example is that of the Aam Aadmi Party (AAP) government in Delhi. For all his expositions in the Delhi Assembly about the relative excellence of the state government’s scheme against PMJAY, chief minister Arvind Kejriwal has followed his predecessors’ tradition of leaving private hospitals to their own devices, including the ones that got free land from the state government on the condition of reserving beds for patients from EWS categories. On rare occasions when such admission is made, consultants are usually reluctant to visit them as they cannot charge visits on these beds and the level of care that an EWS patient gets can differ significantly from the quality offered for paid beds in the same hospital.
The fine print of hospital charges
According to some reports, the vast disparity in surgery charges in various hospitals is one of the things that irked the apex court. There are many reasons for it. Sometimes surgeons in private hospitals will bill one surgery as two procedures. For example, a gall bladder removal may be charged as cholecystectomy plus adhesiolysis – which means removal of the adhesions that keep the gall bladder in place in the abdomen. The gall bladder cannot be removed without removing these adhesions. However, in the billing process, it is treated as a distinct surgical procedure. This results in a doubling of the surgeon’s fee and operating room charges, despite the fact that only one surgery was performed, and the operating room was utilised for a single procedure.
But surgeries are not the only way hospitals and doctors make money.
Every time a consultant signs on an inpatient’s file, he charges a visit. Sometimes more than one doctor will sign – if a hysterectomy patient is running a temperature and a physician has been referred to, the physician will keep coming till the patient is discharged even if the fever has subsided long back. This is so rampant that some hospitals were forced to issue orders saying that the not more than two fees per day could be charged by doctors from the same specialty.If a hospitalised patient needs their blood sugar monitored, then the hospital actually charges for every prick of the finger. This means that for a few days’ hospitalisation when blood sugar was checked every two hours say, the cost of measuring random blood sugar alone can come to a few lakh rupees. A basic blood sugar measuring device costs anything between Rs 2,000-4,000.
Patients are also charged for medicines at MRP rates even though they are available at a substantial discount right outside the hospital. However, patients are not allowed to buy them while they are occupying a bed. Additionally, various charges, such as those for catheter insertion, then its removal, record keeping, and medical administration, contribute to the overall expenses.
Standard treatment guidelines
Around the time the CEA was enacted, a coordinated effort began to compile standard treatment guidelines for various medical specialties. This initiative was crucial as it established essential parameters and protocols for handling patients presenting with specific symptoms. Without such guidelines, there was a risk that doctors might order tests and prescribe medications based on their individual interpretations or inclinations, potentially imposing unnecessary burdens on patients. Although standard treatment guidelines have been developed for 13 specialties, including critical care, cardiovascular diseases, medicine, orthopaedics, and interventional radiology, they are seldom, if ever, consulted.
Moreover, often when hospitals procure expensive new equipment, prominently showcased on billboards or at the entrance, doctors may feel compelled to recover the cost of the equipment as soon as possible by asking patients to get tests even if there is no need for it. That is why the first question any doctor asks a patient at a private hospital is if they have insurance. Had adherence to STGs been mandatory, this question would have lost its relevance.
Even tests now happen as panels – a fever panel, a diarrhoea panel, a respiratory panel, a meningitis panel. These are PCR based tests that look for a range of pathogens and come at a steep price. But most good clinicians already know the diagnosis. Where a dengue test for a few hundred rupees is needed, the patient can pay upto Rs 25,000 for a panel testing for other pathogens – all of which come negative. The tests are also sold for a huge markup by hospitals.
PMJAY: claims of reduced multidimensional poverty but eligibility on 2011 criteria
In 2018, when the NDA government launched the Ayushman Bharat programme, hopes of universal healthcare were rekindled. PMJAY offers an annual health insurance of Rs 5 lakh to eligible families. Five years later, just about 60% of the targeted population is registered. The scheme’s uptake has remained poor with a CAG report pointing out several irregularities and the National Health Authority dis-empanelling several errant hospitals.
But the big fallacy remains that eligibility for the scheme is based on data from 2011 – the last time India carried out the census. The exclusion criteria is such that the poor in urban areas – who are often even more vulnerable than the poor in rural areas – have little chance of making it. Anyone in the possession of a two wheeler or a refrigerator (not difficult possessions in this era of EMIs) and a member with a monthly salary of Rs 10,000 is excluded.
It must be noted that a government that has, in the last few years, made multiple claims about reduction in multidimensional poverty, continues to base economic criteria with respect to healthcare access based on data from 13 years ago.
Abantika Ghosh is a former journalist and policy professional.
