Health services in the country could improve if the use of costly technologies is reduced and “free treatment” is abolished
Consider the following:
• There is an over-crowding of specialists in cities, and this needs to be reduced
• The expenses are becoming unmanageable even to the upper middle class, while the quality is declining. At the same time, there’s a dearth of general practitioners.
• Primary health-care and the public sector health-care are being neglected. It is in our own interest that primary care improves and public sector expands. That will absorb more general practitioners (GPs) that will help expand the medical field, especially in rural areas.
• There is no referral system, no functional demarcation—compartmentalization, if I may call it. The resulting insecurity and confusion explains the morbidly increasing heart attacks among young doctors.
• The concept of free treatment for the poor is creating havoc not only for doctors but also for the very poor who are supposed to benefit.
The most important challenge ahead is to offer improved services at a reduced cost. Majority of the population is below poverty line and depends on public sector, while the upper class is well covered and prefers high-tech hospitals. Medical treatment and products are mainly sold bulge of the middle class, however, as incomes of the lower middle-class and the poor fall due to inflation, and such, the number of specialists in cities is increasing,
Also, a report by DHS (Directorate of Health Services) in 2005 indicates inadequate space, untrained staff and gross underutilization of equipments, dirty & unhygienic operation theatres, and several other deficiencies in nursing homes in Mumbai. Additionally, regulations have been tightened and public expectations simply too high, which makes most places difficult to run, especially nursing homes.
However, what is barely mentioned is the conflict of interest between the owners and freelance practitioners, wherein the latter have no stake and can shift their allegiance elsewhere easily, for personal gains. The only remedy is group practice. For instance, a small hospital of 50 beds by ten or more specialists will bind them together. The hospital will be able to afford qualified staff and modern equipments. This will induce specialists to train the staff and resident medical officers (RMOs). This will increase the overall infrastructure. The inflow of patients would guarantee full utilisation of space, equipments and staff. Over time, freelance practitioners will lose their importance.
A linkage with major tertiary hospitals, on well-defined terms, can become mutually beneficial. A case in point is Fortis. It has offered to take up difficult cases, treat and re-transfer patients from nursing homes with para-medical assistance. This is a step in the right direction. In turn, nursing homes ought to demand that Fortis reduce its general ward beds and admit only major cases therein.
Simultaneously, general specialists will have to assert their importance by treating the middle class. The biggest task is to fight the high-tech market and maintain our biggest asset namely cost-effective technologies, which will reduce costs, lead to early decisions and shorten stay of patients. The abuse of costly technologies and medical practices need to be denounced. It will be necessary to flood the press and medical journals with articles to show where and when patients can be treated successfully, without them. I believe patients can be persuaded to accept such protocols. However, maintaining meticulous records is a must, for this. It is possible that insurance companies and foreign funds from the UK and the USA would strongly support such an approach.
The central government has passed the Clinical Establishment Act, 2010, and accreditation is on the cards soon. The association along with FEQH of Mr Gadgil is already on the job. Accreditation will be good for us, but it can spell disaster if we remain careless and ignore the aggressive high-tech-high-cost market. The insistence of costly equipments, with unproven merits, can result in many nursing homes being declared ‘inadequate’. Plenum ventilation, high efficiency particulate air (HEPA), 6-channel monitor, etc. are but a few examples of expensive equipments. We will have to insist that well-maintained records showing adequate results for the patients treated should be important criterion of ’adequacy’.
Similarly, we must continuously attack the concept of “free treatment”. The first step would be to denounce free medical camps as an unethical practice, except in cases of disasters and calamities. Also, working as an honorary, without per case minimum payment or free health check-ups, ought to be condemned outright.
Evaders need to be charged (i.e. need to pay for the services). Who are the evaders? For example, government and municipal servants treated in public sector do not pay at all, if they are treated in their respective hospitals. If they were to be treated in approved hospitals, the government pays even if the patient does not. Collectively, the medical fraternity gets to lose the most. Please realize that families of the public sector make up to roughly 15% of the total population. Other kinds of “evaders” are:
• Accident victims—despite third party insurance, the public hospital fails to collect the money; the insurance company gains and both the hospital and the doctors lose.
• Foreigners—sometimes they do get admitted in a public hospital; yet they are treated free of charge. An Australian lady was charged Rs300 for fracture radius and her ulna treated was with Elizarov method.
• My study in Goa indicated that at least 40% of the patients who attend public hospitals for emergencies belong to be affordable class. In fact, they don’t mind paying but there is no provision to collect the charges.
• And, of course, politicians, MLAs, corporators, etc. The less said about them, the better.
Public sector professional services must be charged. For the common man it works out to be only 5% to 12% of what is being charged by the private sector. This will increase revenues and expand the public sector. Work-based incentive payments to service doctors could be mooted.
Despite poverty, 80% of the people are reported to utilize private services for their primary health needs. This is mainly because everyone who wants to specialise gets training and experience in teaching hospitals. But there is not a single day’s training for someone who wishes to become a GP. We must demand that there should be a two-year diploma course in general practice in every medical college and at least 20% of the MBBS graduates be absorbed therein. Similarly there is a need to define the roles of GPs and freelance practitioners. In my opinion, GPs should be prohibited from prescribing very costly antibiotics and other drugs or advise expensive investigations and therapy. Such cases must be referred to the specialists. The Food & Drug Administration (FDA) can easily prepare a schedule of such drugs and investigations. Specialists, in turn, must not see any patient unless he is referred by or was at least treated first by a general practitioner. Compartmentalization will make clinical practice more peaceful.
I believe we have a strong case to make CPA non-applicable to health services, because it is a contract based on faith and not just a contract. Suffice it to say we should anticipate problems and advise the policy makers or the authorities to correct their policies before rules are framed. If we do not act now, the negative influences of the market will exert their influence. We ought to spread the word to the masses and convince authorities.
(Dr Sadanand Nadkarni, 80, is former Dean of Sion Hospital, author of several books, a serious thinker of medical issues and hugely respected for a series of path-breaking ideas on improving the delivery of medical services to the aam aadmi. His book “Management of the Sick Healthcare System” is among the first to speak out about medical malpractice and other issues. He can be reached at [email protected].)
It is quite possible that Governor Romney will not only catch up with President Obama in fund raising but may well overtake him. There is no shortage of money. The war has just begun
As Reuters reported last week “Republican party grandees gathered in the shadow of Wyoming’s Majestic Grand Teton mountains on Thursday for a high dollar fund raising event that will add to presidential candidate Mitt Romney’s brimming campaign coffers.
Hosted by former vice-president and native son Dick Cheney who often goes fly fishing for trout in nearby streams, the country club reception and dinner is expected to bring in $4 million for Romney in one of the biggest fund raising night of the 2012 election season.
Business and party figures will huddle at Jackson Hole, a rugged valley settled by beaver trappers in the nineteenth century i.e. now a playground for the rich who come for winter skiing and for summer outings on the Snake River and a glimpse of buffalo, moose and elk.”
The week before that there was a gathering in the Hamptons where a large group of well-heeled Republicans had to wait for several hours to get a glimpse of Mitt Romney. Suddenly Governor Romney is every where and is matching the star power and fund raising ability of President Obama. Not only are the well-heeled lining up for Governor Mitt Romney, they are opening up their wallets and contributing substantially to the Republican war chest. Further the Supreme Court decision in the healthcare case which saved Obama care has so charged up the Conservative base that they have been contributing large amounts of money to Mitt Romney and the Republican National Committee. A week after the Supreme Court decision the Republican National Committee announced a haul of another $5 million. Similarly the Obama endorsement of gay marriage fired up the gay community with enthusiastic gay men and women stopping of on the highway to send money to the Obama campaign. Similarly President Obama’s announcement of amnesty for Hispanic voters who were educated in the United States of America or joined the military has considerably enthused the Hispanics and I will be very surprised if that has not been converted into Hispanic voters contributing more to the Obama campaign.
In June the Obama campaign had one of its best fund raising months and collected $70 million but President Obama candidly announced “We got beat” as the Romney campaign collected $100 million. President Obama has more money in his war chest but has also been spending at a quicker rate. David Axlerod, President Obama’s advisor when asked on the State of Union programme by Candy Crawley as to why the Republicans were collecting more dollars then the Democrats, replied with a straight face “that our money comes from the grass-roots; their money comes from the wealthy who have been promised substantial tax benefits. But we will manage” and Candy Crawley said “I am sure you will”.
However it is quite possible that Governor Romney will not only catch up with President Obama in fund raising but may well overtake him.
Adding intrigue to all this is the Supreme Court judgement in the Citizens United case which makes it possible for the organisations not directly connected with the campaigns to raise and spend unlimited funds on behalf of the campaign as long as there is no co-ordination with the campaign. This is something new from the last election where unlimited funding was not permitted. This has led to several Super PACs being created such as Karl Roves American Crossroads or Restore our Faith, the pro Romney Super PAC or the VG Action Fund the Super PACs founded by former Aides to house majority leader Mickey Cantor. These Republican Super PACs are outspending democratic Super PACs like pro USA Action.
The Super PACs are playing and active role in the elections and are not only advertising in a big way but also will ultimately help their candidates strengthen their ground game. As the Wisconsin Governor Scott Walker’s recall election showed the Republicans have very deep pockets, unlimited resources and the wherewithal to spend the same in their cause. Trade unions and other democratic groups are unable to match the same.
Being out of the White House for the last three and half years seems to have led to the Republicans having a greater hunger than the Democrats to capture the White House and they will deploy whatever the financial resources are required to ensure the same. Protestors are already accusing the Republicans for wanting to buy the election. But how can President Obama complain? It is he who refused public funding in the last election and outspent John McCain by a margin of 2:1 and was the master of internet fund raising. And in the early going he has not been shy with spending. It is reported that a hundred million dollars have already been spent by the Obama campaign in swing states tying Mitt Romney to Bain Capital excesses. One-fourth of the money is in Ohio. And substantial funds have been spent in Florida and Virginia. The Romney Campaign says that 60% of the Obama advertisements are negative. The Obama campaign replies that 90% of the Romney advertisements are negative. There is no shortage of money. The war has just begun.
(Harsh Desai has done his BA in Political Science from St Xavier's College & Elphinstone College, Bombay and has done his Master's in Law from Columbia University in the city of New York. He is a practicing advocate at the Bombay High Court.)
EPFO has slapped a Rs54.57 crore demand notice on Ahluwalia Contracts, however the company said it will file an appeal with the tribunal for quashing the demand
New Delhi: Retirement fund body Employees Provident Fund Organisation (EPFO) has slapped a Rs54.57 crore demand notice on Ahluwalia Contracts (India), reports PTI.
Ahluwalia Contracts (India), which is into the business of construction, however, quashed the charge, labelling it "arbitrary".
"...The company has just received the demand notice of Rs54.57 crore for the period September 2007 to March 2009 from Employee Provident Fund office, New Delhi," it said in a BSE filing.
"The demand is hypothetical assumption and arbitrary. The demand notice is under study and the appeal will be preferred at competent authority to quash the demand," it added.
Ahluwalia Contracts (India) is one of the few firms belonging to the construction sector who pay provident funds on regular basis, Company Chairman & Managing Director Bikramjit Ahluwalia told PTI.
"We are among the 5% of the construction firms in India which pay provident fund regularly. The rest 95% don't. However, they are targeting us only. This is the result of inspector raj," Ahluwalia said.
"We are going to the tribunal and prove that we are not doing anything wrong," he added.