Curing the poor : Dedicated to sustainable healthcare transformation

We have to accept the fact that there is a segment in our society, and we are talking about 260 million Indians, who are surviving with the burden of disease, estimated of around $ 30 billion constituting 5% of GDP.

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By Dr. Shuchin Bajaj
Founder Director, Cygnus Hospitals

Today as the world stresses on economic growth, globalisation and privatisation; a silent section of the society seems to slip through all safety nets. In India, one is talking about at least 26% of the population who fit into this category. The percentage varies from state to state. In most of the northern states poverty seems to be increasing and if you further disaggregate from urban to rural, you will find that 40% of the rural population in 10 states in India are below the poverty line. If one further disaggregates the figures into schedule caste, schedule tribes, the marginalised etc., the percentages just keep on rising. So we have to accept the fact that there is a segment in our society, and we are talking about 260 million Indians, who are surviving with the burden of disease, estimated of around $ 30 billion constituting 5% of GDP.

Potential Health care industry is the world’s largest industry with total revenues of approx US$ 2.8 Trillion. In India as well, health care has emerged as one of the largest sector with maximum expenditure incurred. An astounding 60% of this is out of pocket expense. India has one of the highest proportions of private health spending, comparable only to a only few countries in the world with a recent history of major internal unrest, such as Cambodia and Myanmar. Such is the lack of trust in the public health system that not only do 80% of the wealthy seek treatment in the private sector, but a similar percentage of the poor also
goes to private practitioners, even though the treatment may be of low quality and provided by untrained practitioners.

To address this gap and in view of the crumbling public health infrastructure and unskilled/untrained medical manpower, the Government is now planning major initiatives. We have acknowledgement of the various “A”s of Healthcare
1. Accessibility
2. Affordability
3. Appropriateness
4. Accreditation
5. Accountability

The problems of Accessibility and Appropriateness have been on the path of resolution in North Indian towns with the rapid mushrooming of multi speciality hospitals in district headquarter towns associated with overall urbanization and associated developments like malls and schools, thus offering young qualified doctors incentives to settle in these towns, away from the pollution and competition of megapolises like Delhi. The solution of providing high quality tertiary healthcare at the most affordable costs, though, is still in the works. The need to take care of tertiary healthcare needs of the poorest of the poor and
target the untouched and unorganised segment bringing the revolution of super-speciality tertiary health care in slums, peripheral areas and small towns is now overbearing and immediate. Even after 70 years of independence, as a country, we are unfortunate that we have been unable to provide quality tertiary healthcare services, especially emergency tertiary care like services for heart attack, or patient suffering from trauma or neurosurgical problems at affordable costs for our disenfranchised communities. Our residents have to travel for hours and stand in long queues, or shell out their life’s savings for treatment of trauma or heart attacks.

We have to realize the huge need of emergency medical facilities especially during the ‘golden hour’ which is the time period that the patient’s chances of survival are greatest if they receive care within short period of time after a severe injury. To compliment this effort further, we need to institutionalise centers for excellence in intensive care, neurology, cardiology and trauma, to unlock the golden door of quality and speedy medical service. The passion to bring accessible and finest quality healthcare, at zero cost at the point of delivery, should be our goal. We also need to remain on the forefront of innovation and evolution to meet the dynamic needs of our communities, benchmarked to international quality and efficiency standards. In view of the ever expanding needs for manpower and shortage of skill, the government needs to partner with the private sector to bring on board a bigger team of qualified doctors and healthcare providers to better achieve the dream of providing world class healthcare to the most deprived of communities, at the most affordable price points.

Our contribution to inclusive healthcare development agenda and commitment to ‘universal healthcare for all’ mission, have to be an integral part of our service delivery within the entire healthcare ecosystem , by ensuring free medicines in the pharmacy, free
consultancies and free surgeries to the economically weaker population of the society, and delivery at zero out of pocket expense at point of delivery to the rest. We will also have to mobilize the larger community on various facets of health awareness through rural and slum outreach on issues such as diabetes, joint replacements, emergency medical first-aids, maternity, cardiology, preventive care etc. leading to socio-economic justice and poverty alleviation. Adding to this, we will also need to conduct CMEs (continuous medical education programmes) as an effort to create sustainable healthcare solutions; which should be interactive academic sessions provided by expert doctors of relevant specialities to other medical practitioners in the community; sharing recent and latest updates on modern healthcare development and diagnostics. We will have to reach out to community medical practitioners across the small towns and villages, to empower and enable them to deal with common health problems in an evidence based manner. These sessions can be rendered as live events, written publications, audio or video etc. In delivering this, we will have to forge alliances/partnerships with numerous like-minded organizations/associations collectively contributing to our efforts and multiplying our impact. We should also tie up with global organisations to deliver educational modules to the health practitioners and paramedics at subsidized rates.

We can also launch many initiatives at Community education and Empowerment which aim to make the community leaders empowered with knowledge and finance in the expectation that they will pass on this knowledge and financial capabilities to the lesser fortunate in the community. We can also have a pre approved health loan card to take care of healthcare problems that overshoot the insurance limits. We have seen that most households save for weddings and celebrations but have no provisions to deal with a healthcare emergency. This leads to them selling land and household items to take care of the healthcare expenses. This
leads to permanent impoverishment. The Loan Card will give the money to deal with the healthcare issues which they can repay in easy instalments over years. We should also start telemedicine Clinics at locations which are away from hospitals and health centres so that patients are saved from spending money on regular commutes to the hospital for small issues or regular consults, thus saving money on a regular basis.

To summarise, our mission should be to:

● Ensure that no one is denied quality healthcare due to lack of financial resources

● Build capacities and run centers for specialized surgeries in the areas which lack speciality care

● Deliver world-class healthcare, with a focus on service, by creating institutions committed to highest standards of medical excellence, patient care, scientific knowledge and medical education for the masses at the most affordable prices.

● Provide world-class integrated healthcare facilities to all sections of the society.

● Create unparalleled standards of medical and service outcomes.

● Ensure dignity of all stakeholders

● Provide ethical care to all patients

● Invigorate our vision, reignite our passion and connect to inspired leaders and institutions changing lives.

● Catalyse solutions healthcare.

● Gain a 360 degree view of complex landscape of change.

● Learn about engagement with our community in ways that matter most.

● Share platforms with global network of leaders dedicated to building sustainable solutions for poverty.

● Convene with thought leaders in social change from around the world.

● Share best practices and technologies to meet challenges.

● Connect with like-minded people and organizations who can contribute to our efforts.

● Learn new and better processes and better healthcare delivery models.

● Forge alliances and partnerships to multiply our impact.

● Share strategies with peers, meet top entrepreneurs and explore cutting-edge opportunities.

Current challenges:

● Arranging investment opportunities to benefit more geographical locations.

● Attracting, retaining, and ensuring regular presence of highly trained medical professionals.

● Poor healthcare infrastructure and limitations especially in context of advanced machinery, Doctors and paramedical staff and adequate insurance cover to all patients.

Current Opportunities and Potential Pitfalls of the Ayushman Bharat Scheme

 It is a scheme that promises to transform the healthcare delivery scenario of the country, skewing it inexorably towards the private sector. While in the short term it may have an incremental effect towards better healthcare access to communities, in
the long term it has the potential to lead to the decaying of public health institutions and an endless upward spiral of costs, replicating the flawed insurance based US Healthcare model. On the other end, if we attempt to curtail the costs artificially and
excessively, it may lead to deterioration of quality and lead to excessive frauds in the delivery ecosystem, leading to soaring monitoring and auditing costs, increasing human intervention and resultant rise in corruption and undermining of policies and
processes. With the Indian Medical Association recently rejecting the schemes as dangerous to patients due to its extremely low costing structures, the concerns that whether the scheme can be implemented at all have risen manifold. While there may be many shortfalls in the ideation and costings of the scheme, it is a step towards addressing the concerns of the population at large towards achieving affordable healthcare and thus we must devise ways and means to deliver the scheme to the community, while at the same time responding to the issues raised by the IMA in particular and the entire medical community in general.

To address these concerns on both sides of the spectrum, our recommendations are as follows

 Set up an empowered committee to address and facilitate costing structure of healthcare procedures and services to scientifically determine the costs of services and products, thus preventing profiteering while at the same time encouraging
investments and sustainability in the sector. This committee must have representations from the Niti Ayog, Public Healthcare Professionals, IMA and private Healthcare providers, along with policy makers, civil society organisations, pharma
industry representatives and members of the general public.

 In the meantime, to encourage established institutions to participate in the scheme, and ensure delivery of high quality healthcare to the maximum number of beneficiaries, we should devise an interim payment, empanelment and engagement
module which caters to the concerns of the healthcare providers, while at the same time focusing on preventing frauds, unethical practices and profiteering.

 This module should be in place right from the time of application process to disbursal of final amount for services rendered.

 The application process should be completely online. There should be no human interface for inspection, documentation or any other purposes. We recommend to grant the panel to NABH accredited hospitals automatically once they submit an online application, since these healthcare institutions have already undergone an exhaustive inspection for NABH purposes.

 The institutes should implement an Electronic Health Record System and should upload all the patient files for processing and expenditure reimbursement electronically. The files should be visible in an online dashboard and should be processed or queried electronically. Lack of human interface in the processing of these files for financial reimbursement is of utmost importance to prevent corruption and frauds in treatment files.

 The money should also be disbursed electronically into the accounts of the healthcare provider and there should be no human interface at this point.

 There should be intensive auditing of healthcare providers, including visits by auditors to personally see the patients and interact with doctors, patients and their attendants. All cases with billing of above Rupees fifty thousand should be audited, while a random sample of 10% of the remaining cases should be subject to intensive auditing.

 The Criteria for empanelment should be thus

o NABH Accreditation, minimum Entry Level.

o Minimum 25 Beds for multispeciality purposes. The bed Criteria can be waived off for single speciality hospitals

To encourage higher quality healthcare delivery to the community, we should attempt to reward quality and educational initiatives of the healthcare delivery institutes partnering with us for this scheme. The reward system should be graded as follows

1. 20% Higher than base rates of Central Scheme for NABH Entry Level hospitals

2. 30% Higher than base rates for Central Scheme for Full NABH accredited Hospitals

3. 10% Extra reimbursements for hospitals providing educational courses like DNB, MBBS and MD/MS

4. 10% Extra reimbursements for Hospitals with more than 50 beds

5. 20% Extra Reimbursements for Hospitals more than 200 beds

6. 10% Upward Revision of all prices every year to keep up with inflationary pressures.

The payments should be time bound and the payer should bear interest costs for payments which are delayed beyond 90 days from submission of documents.

We hope these measures will ensure the highest levels of quality while keeping the healthcare expenditure in check and ensuring the prevention of frauds and unethical practices.

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