Private healthcare must fuse ethics with efficiency

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Some years ago, I was participating in a discussion on the future of healthcare, at a leading institute of health management. I heard many of the panellists affirming that healthcare and public health must absorb and apply the efficiency-enhancing practices of business management. I agreed, but only partially. I said “the mantra of business management is efficiency and profit, while the mantra of healthcare and public health management must be efficiency and equity.” While underscoring this vital difference in the goals of these two practice disciplines, I should have added ethics too alongside equity. I politely let it be assumed that healthcare management would ideally be bound by ethics, even as it pursued efficiency and profit.

However, that reserve was dissolved a few months ago by the angry complaints of a leading doctor in a large private hospital in Hyderabad. He complained to me about the way private hospitals were being ruthlessly run by management graduates who had no medical background. He said they lacked empathy and their only objective was to maximise profits for the investors who owned the hospital. The situation is worsening, he said, with foreign investors gaining control of established Indian hospitals. Their representatives were squeezing the doctors to generate more and more revenues, often through unnecessary tests and procedures as well as over-billing. These complaints were not new, but to hear it from a leading doctor in a private hospital who felt oppressed and revolted by the unethical practices revealed the extent to which mercenary management had derailed value based medical practice.

I was reminded of this when I received a Whatsapp forward of an anonymous post by “An Indian Doctor”. A highly anguished and critical denunciation of the state of private hospital management by non-medical MBAs was the theme of that post. A sampler of the views expressed (from milder portions of that trenchant critique): “No manager knew the sinking feeling of looking into the eyes of the un-affording patient and telling him that you have to bring more money to live.” He complained that, apart from oppressing patients, some hospitals were also charging doctors for their car parking slots!

The post also listed the other evils of commercialised private healthcare whose practices were being shaped by non-medical managers: doctors being criticised for partial payment exemptions granted to poor patients, with threatened deductions from their salaries; bullying on the level of revenue brought through tests and procedures, with coercion to prescribe and more of those even when unnecessary, and over billing on the sly. A fervent appeal of that post was that doctors must regain control of hospital administration from non-medical MBAs.

I forwarded that post to the senior private doctor in Hyderabad, who had earlier vented his feelings to me. His response was sharp — “We cannot exonerate doctors who turned entrepreneurs and commercialised all places.” His contention was that many hospitals were started by reputed doctors who did bring in a high quality of care. However, as they looked to attract more investments for expansion, they let financiers take control. Values receded as valuation came to the fore. Some of the medical entrepreneurs cashed in on the high market value and sold out to international and Indian businessmen. The former had no emotional or ethical commitment to Indian patients while the latter saw the control of hospitals both as a high revenue opportunity and as a route to social and political influence. Interests of the patient did not matter any longer.

There are two broad segments of the private sector who provide healthcare. One is the unorganised private segment of individual healthcare providers (both qualified and unqualified). In the organised healthcare sector, we have the not-for-profit, for profit and for profiteering segments. Many in the first two segments have performed well in service provision and respected ethical norms. It is the third segment that brings disrepute to private healthcare. Presently, there is worry that many institutions in the second category are moving into the third category.

I received my undergraduate and postgraduate medical education before the large corporate hospitals emerged. The ethos of medical practice was distinctly different then. With the advent of corporate hospitals, access to quality healthcare improved for those who could afford to pay. The poor could not afford such care, while those in the middle class who accessed high end private care suffered severe financial strain.

In recent decades, governments too are purchasing services from the organised private sector, through publicly financed health insurance schemes. The government also provides several concessions to the private sector for establishing or expanding their facilities – land, water, electricity, customs duties etc. There is both a need and an opportunity for Central and state governments to exercise their regulatory powers to ensure ethical and cost-optimising practices by the private sector.

Overuse of healthcare, involving inappropriate induced demand, has also been a feature of health systems in the US. A recent study of 676 US healthcare systems reported that those which were overusing healthcare had more beds, had fewer primary care physicians, had more physician practice groups, were more likely to be investor owned and were less likely to include a major teaching hospital. Of these, investor ownership and lack of primary care physicians are factors particularly relevant to India.

Unfortunately, public sector healthcare providers too are treading the same path as private healthcare. Many doctors who are formally employed in government hospitals also work in private hospitals, often to the detriment of their clinical and teaching functions in the public hospitals. Up to the early 1990s, doctors working in government hospitals of many states did private practice in the evening, after their regular working hours. They never neglected patients or students during their daytime commitment to government healthcare institutions.

The growth of corporate hospitals changed that. Once government doctors started moonlighting in private hospitals during their working day, attention to patients as well as bedside clinical teaching suffered, as very little time was spent in the public hospital which was their place of duty. It is time we pay our government doctors well, while barring them from private practice. Having trained and worked at AIIMS, Delhi, I know the value that dedicated time commitment brings to the quality of patient care. That would not have been possible if AIIMS had permitted its doctors to do part time private practice.

The voluntary sector in India can proudly claim to have several excellent healthcare institutions. Even though some of them are labelled as private, they cross-subsidise care provided to the poor and have excellent ethical standards. However, these institutions are not geographically well distributed and do not have the financial resources to rapidly extend their reach and expand their services. Even among such institutions, those which have medical colleges attached to the hospitals or have credible post-graduate training programmes tend to practise ethical, evidence-based care. Usually, their hospitals are not run by non-medical MBAs. Their management teams are led by doctors.

India’s mixed health system has evolved by default, not by design. We cannot turn the clock back. We need to make the best use of all our healthcare providers to provide optimal healthcare, which avoids exploitation of vulnerable patients. To improve access, affordability and quality of healthcare in India, we need the public sector to be more responsive, the private sector to be more responsible and the voluntary sector to be more resourceful.

(Prof. K. Srinath Reddy, a cardiologist and epidemiologist, is President, Public Health Foundation of India (PHFI). The views expressed are personal)





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