About two years ago, Stanford University’s Dr John P AIoannidis, who currently is considered the most-cited physician, wrote in the prestigious Journal of Clinical Epidemiology: “Under market pressure, clinical medicine has been transformed to finance-based medicine…In many places, medicine and healthcare are wasting societal resources and becoming a threat to human well-being. Science denialism and quacks are also flourishing and leading more people astray in their life choices, including health…We have supported the growth of principal investigators who excel primarily as managers absorbing more money.”
“Every time I read this, I feel depressed,” said Dr G Chandra Sekhar, the Vice Chairman of the L V Prasad Eye Institute, Hyderabad, the Institute noted for its models of providing top quality eye care to all, irrespective of the ability to pay. Sitting last week with a host of doctors, healthcare leaders and management experts in a classroom at IIM Udaipur, Dr G C (as he is called) read out words that capture all that has gone wrong with healthcare in many parts of the developed world: “Under market pressure, clinical medicine has been transformed to finance-based medicine. In many places, medicine and healthcare are wasting societal resources and becoming a threat to human well-being.”
This is depressing indeed, but even more depressing is the way some of these ideas (and practices, if not research) have spread to a country like India, with weak health infrastructure, limited capacity of patients to pay and a large number of self-appointed healers and quacks. As a result, there is a crisis brewing in the area of healthcare with a confluence of factors that bring together possibly the worst of all models: rising costs, declining trust, poor understanding of patient rights, exploitation and the rising burden of disease. Thus, the nation struggles with the rising burden of drug-resistant tuberculosis on the one hand and nutrition and sanitation issues on the other while at the same time a string of super-specialty hospitals continue to thrive. Every hospital in the metros want to super-size, glamourise and premiumise. As Dr G C would say, there is nothing like a super specialty – all that a doctor can claim is sub-specialty, which is what it is – specialty in a narrower domain.
In some of these “super specialty” places in Mumbai, patients can be told on a Friday that they need a procedure or a test on a Saturday or a Sunday, only to be then billed at double the rate and more on the plea that this was a weekend! It is now an accepted position that doctors can work with targets given to them by hospitals, that pathologists and test centres who give cuts get more referrals and the amount of fees being charged are randomly levied, obscenely high and poorly correlated to the complexity of the case at hand. In short, there is enough material available to understand why patients or their relatives might prefer soothsayers to doctors.
In the game is the growing size of the health insurance business, the skew in the claims ratio (which is the percentage of the total premium collected that is paid out as claims by an insurer), the rising agent commission as companies compete for business and the poor quality of service that can be seen from the high complaints rate. One study by NIPFP has estimated India’s complaints rate against medical insurers to be the highest when compared with other common law jurisdictions like Canada, Australia, the UK and California. The claims ratio of private sector health insurers is falling, from 67 per cent in 2013-14 to 58 per cent in 2015-16, and inching up to 62 per cent in 2017-18, indicating that premia are high or claims are not been attended fairly. But public sector companies have over 100 per cent claims ratio (a high of 122 per cent in 2016-17) indicating that they are unsustainable because they are paying out more as claims than they are collecting as premia. And while the business size overall is growing, premia are also rising fast and the quality of service is actually falling.
“We find that the quality of health insurance products, when measured in terms of complaints generated, is substantially inferior to other jurisdictions with similar legal systems. It may be the case that with such poor levels of consumer protection, households which purchase basic financial products, like health insurance, are worse off than households which do not,” wrote Shefali Malhotra, Ila Patnaik, Shubho Roy and Ajay Shah in the NIPFP Working Paper last year. This is a damning indictment and begs some fundamental rethink of the direction the health sector is moving, with patients caught between marauding doctors and fleecing insurance companies. In fact, the joke these days is that having an insurance carries the additional burden of unwanted tests and procedures, as hospitals work to maximise the billing. At the root is rising medical costs – small ailments, minor surgeries and procedures can relieve a person of tens of thousands today, if not more. The bottom line is that those who were meant to be healers are beginning to be hated. The anger is almost palpable. Stories of feeling cheated abound. And the system is responding with initiatives of the kind that took the stage at IIM-Udaipur. This one is called the Equitable Healthcare Access Consortium, which brings together management experts, doctors and institutions, who want to reclaim the medical profession from the moneymakers. The leaders among them took the stage to speak to young doctors from hospitals in Udaipur with the simple message that it is possible to do good and do well.
There are many stories of how this can be done. Many of them are innovative models but ideas are not particularly discussed at medical school. It is interesting that ethics is not a subject in any medical school syllabus. A blind learning of the anatomy and an understanding of disease tend to leave students unanchored in the way their knowledge can work in the real world. What they then pick is models that are exploitative on the misunderstanding that this is how you recoup the long years spent studying medicine. Worse, most hospital setups (barring a few) do not have training for an ethical code of conduct, they do not write whistleblower policies and are not known for fighting for the rights of patients though some efforts have begun in this direction.
All in all, the signals from the medical ecosystem work to push the ordinary young doctor into a path that has failed us in healthcare. This is a rootless, anchorless expert, armed with the power to save a life but eventually so heartless that he or she ends up taking lives. And this is unlikely to change till more voices come out from within the profession and health becomes a hot political debate to raise some difficult questions on quality, costs, ethical conduct and respectful care.