Demand for reform in private health care grows louder

Fortis Hospital
Corporate hospitals have been feted for their entrepreneurship and excellence but recent incidents in the national capital region leave a lot to be desired.


These gaps came to the fore after probes following patient deaths in Fortis and Max hospitals found negligence, non-adherence to protocols, astronomical margins in sale of drugs, and violations in rules related to concessional treatment of poor.


In the face of media outrage, hospitals and medical associations are calling for self-regulation and restraint in government action while activists are clamouring for a change. The fault lines are clear as demands for reform and regulations in private health care become louder.


Weak regulation, poor oversight


About 80 per cent of all outpatient treatment and 60 per cent of in-patient (admissions) treatment in the country is carried out in the private sector (hospitals and clinics). Most of the spending on health care is out-of- pocket and insurance coverage is limited. Yet regulations on pricing and patient rights in private health care institutions are nonexistent or weak. “To the best of my knowledge, not one hospital has fulfilled any of the conditions imposed by the government in lieu of concessions in land lease or duties,” said former Union health secretary K Sujatha Rao.


Then there are issues of review and reprimand in the private health segment. “Every medical error ought to be inquired into by a medical audit system within the hospital and rectified. In other countries such errors are discussed in the whole department and even nurses are present and such peer review has a salutary effect. There is no such system in India barring perhaps in a handful of hospitals,” Rao said.


The Medical Council of India (MCI) has an ethics committee and it can fine and punish hospitals for wrongdoings. Rao said the MCI had been negligent in enforcing ethical practice. “I have not heard of any doctor being permanently delicensed,” she added.


But a public outcry has forced the government to act. The Delhi and Haryana governments have launched inquiries into two incidents — the death of seven-year-old Adya Singh to dengue-related complications in Fortis Hospital in Gurugram and a case of a baby being wrongly declared dead in Max Hospital, Shalimar Bagh. The licence of Max hospital was cancelled temporarily while Fortis hospital faces police action.


A Max Healthcare spokesperson said all its hospitals followed protocols laid down by the National Accreditation Board for Hospitals and Healthcare Providers. "We also have well-defined clinical pathways for several medical conditions and these are strictly monitored for compliance.”


Is self-regulation the way out?


Yet doctors feel self-regulation is the best solution. “Why should doctors need any regulation? Their ethical practices and self-regulation should be sufficient to look after this aspect,” said Dr K K Aggarwal, national president of the Indian Medical Association (IMA). On its part, the IMA has proposed self-regulation. It says all IMA members shall practice with compassion and follow the ALERT policy (Acknowledge, Listen, Explain, Review and Thank). The association has also proposed creation of medical redressal commissions in each state to conduct quality audits and look into grievances.


To be fair, several doctors have opined that the premature baby that was wrongly declared dead by Max Hospital was, in fact, a foetus. The IMA and other medical associations have now issued guidelines on handling premature deliveries. Before the incident at Max Hospital, a similar case was reported in the government-run Safdarjung Hospital in June.


Bhavdeep Singh, chief executive officer of Fortis Healthcare, said the industry needed to establish self-regulation or an oversight mechanism. “We need to have some thresholds and limits. Nobody talks about the free or discounted treatment Fortis has provided. Even in baby Adya’s case, the team in the hospital decided to prescribe less expensive medicines when they realised her stay would be long. We are still being accused of administering expensive drugs. We need to do a better job in communicating,” he said.


Shobana Kamineni, executive vice-chairperson, Apollo Hospitals, echoes Singh’s view on self-regulation and pricing transparency. “Apollo Hospitals fully supports this. I am worried that the private health care sector will slow down. India has a high disease burden, plus we have inadequate public health. This is the time for true public-private partnerships.”


Unreasonable margins?


The National Pharmaceutical Pricing Authority has found that Fortis Hospital charged up to 1,700 per cent margin on drugs and consumables while treating Adya. Similarly, a Competition Commission of India inquiry released earlier in the month said the Max hospital in Patparganj made 275-525 per cent profit on sale of disposable syringes. Fortis’ Singh  said government pharmacies were operating at margins of 500 per cent on similar items and nobody talked about it. “The input costs for hospitals have been increasing rapidly and hospital chains make very small net profits. The contention of profiteering by the hospital is a fallacy,” the Max Healthcare spokesperson added.


Then there are other questionable practices, too. In Bengaluru, income tax raids on diagnostic labs and IVF clinics in December found doctors were being paid 20-30 per cent commission for referring patients. Ravi Duggal, health sector expert and member of the Jan Swasthya Abhiyan, blames doctors for unnecessarily referring patients for diagnostic tests. “It is a case of supply-induced demand where service providers are creating the demand,” he said.  


In 2015, investigation by public health activists in Gulbarga in Karnataka had laid bare hundreds of cases of unwarranted hysterectomies. “Women were told to undergo emergency surgeries by doctors to avoid complications but later medical investigations found that many of the surgeries were unwarranted,” said Akhila Vasan, convener, Karnataka Janarogya Chaluvali.


Yet despite all the controversies, the government’s attempts at regulating private health care are at best patchy. The Clinical Establishments Act, 2010, has been adopted only by a handful of states. “The central government had set up a committee to frame the methodology to fix rates for procedures in hospitals, but it was dissolved as the Centre decided to leave rate regulation to states,” said Dr Arun Gadre, member of the Pune-based NGO SATHI.