Taking creative liberty with Mary Poppins, “when you deposit your tuppence” in a hospital, you expect prudence, frugality and eventual fruitfulness. Essentially, a hospital owes to the patient good faith (honesty) and trust. This faith and trust has been eroded and lost over the last many years and a culmination of this deterioration is being witnessed now.
It’s said “study the past if you would define the future”. Doctors and hospital systems in India need not look too far behind in time to solve the present deficit in trust that exists between patients and physicians. We need to look at the mecca of ‘capitalistic’ medicine, the United States, to learn our lessons.
India’s Current Situation Reminds of US’ Past
The story of the genesis of socialised medicine in 1965, in the US has a feeling of déjà vu, as it is similar to the beginning of the trust deficit in India.
In the US, prior to 1965, hospitals and doctors grasped for gold, akin to the gold rush of the nineteenth century. The most common “entrepreneurial” excesses were fee splitting, where a specialist and hospital paid a kickback to the referring doctor, and ghost surgery, where a surgeon secretly paid a colleague to operate on an anaesthetised patient.
The first surgeon paid the “ghost” a small part of the total fee and pocketed the difference.
Even worse was rampant surgical overuse, where common excesses included appendectomies for stomachaches and hysterectomies on young women with nothing more than back pain. These stories sound frighteningly similar to those swirling around now in India.
Professional societies like the American Medical Association (AMA), similar to the Indian Medical Association (IMA), failed miserably in their efforts to stop these excesses. In 1955, the AMA, in a blunt report, slammed the greedy physician and felt that doctors “display a constant preoccupation with their economic insecurity”.
AMA ReportThey think about money a lot – about how to increase their incomes, about the cost of running their offices, about what their colleagues in other specialties make, about what plumbers make for house calls and what a liquor dealer’s net is compared to their own.
Opinion polls showed that a majority of Americans felt doctors charged too much, a view also reflected by the press in those days.
Despite the public’s unhappiness, policymakers refused to intervene, explaining that outsiders could not judge the quantity or quality of services provided by the healthcare providers. The gluttony continued unabated, prompting President Richard Nixon to declare the first healthcare “crisis”.
His cabinet made an announcement which rings true in India now: “In the past, decisions on the healthcare delivery were largely professional ones. Now, the decisions will be largely political.”
These political announcements sound discomfortingly familiar to Indians doctors in 2017.
Reinvent Or Follow Known Failures?
The introduction of the West Bengal Clinical Establishment Act is a step in the direction which Nixon took in 1969. Under the Act, the state will monitor private healthcare institutions, deciding for them what they can charge. It also says that they have to provide treatment in emergency cases regardless of an individual’s ability to pay.
But the eventual failure of socialised medicine has resulted in modifications and the introduction of Obamacare.
The richest country in the world is still finding its way around a solution to the trust deficit and to a way to provide prudent and frugal care.
From 1969 to 2017, the United States has failed to rein in the greed of hospitals and doctors. Their initial steps, especially the Emergency Medical Treatment & Labor Act (EMTALA) Act, is very similar to the West Bengal Act. So, do we follow or try to reinvent the wheel?
Primary Interests of Hospitals Have to Shift
If we need to act and learn from history, we need not condone capitalism in medicine or the entrepreneurial skills of the healthcare industry. Capitalism should ideally be about rational economic behaviour that promotes growth and creates an environment for promoting methods to alleviate diseases.
The first step in re-establishing fiduciary duty – or the highest standard of care – is genuine accountability. Genuine accountability is an alien concept to the corporate world. Enron, Lehman Brothers, Satyam – all of these are synonymous with the victory of greed over good. Good corporate governance, along with clinical governance (systematically improving and maintaining the quality of healthcare), is the way to achieve accountability in the medical field.
The primary interest of the hospital boards has to shift from financial well-being of the hospital to being a champion of patient safety and quality service. The hospital boards have to be accountable to the public, must disclose safety and quality data to it, and understand that financial growth will follow prudent, quality healthcare.
Fixing Prices Isn’t the Answer, Physicians Need to Feel Responsible
Using clinical governance to rationalise diagnostic testing and management options is the thorny issue. In the past, healthcare delivery involved a single physician and clinical governance was the prerogative of the physician.
However, with complexity in medicine increasing, healthcare delivery has become a team effort. Every member of the team behaves like a patient advocate. However, physician responsibility will still have to drive this change.
A physician is the only one in the clinical care team who can take this uttardaitva – responsibility.
A critical fact about hospitals is that very little happens in the healthcare system without a physician’s order. By virtue of physicians’ legal authority, which is broader than that of any other actor in the healthcare scene, almost all actions in healthcare are derived from their decisions and recommendations. The responsibility of care is the physician’s and governance too should be the physician’s responsibility.
Accountability becomes transparent when we can answer a fundamental question: what can be considered a “fair” payment for a physician or hospital? Fixing prices, controlling rates is not a solution; it will only give rise to ingenious methods for fraud. These methods of control have been tried in the US, with the only result of increasing fraud.
However, to change the landscape of healthcare delivery, and to make it prudent and cost effective, we need to think of solutions beyond the usual rhetoric. Do we need a new social contract?
The Journal of General Internal Medicine has proposed a new social contract, one that ensures appropriate income and autonomy for physicians in return for embracing genuine accountability.
Are we ready to think of a new solution or follow the failures that history has already thrown up?
(Dr Suresh Ramasubban is Senior Consultant, Pulmonary and Critical Care Medicine. This is an opinion piece and the views expressed above are the author’s own. The Quint neither endorses nor is responsible for the same.)