Riding an Unbridled Horse to War

Corporate hospitals in India have enjoyed a checkered reputation. 

They had entered the market to fill a great void in quality medical care.  They were considered a boon in the 1990s in view of being internationally accredited hospitals with 5-star facilities, state of the art technology and several layers of safety checks. These were the very characteristics that were lacking in the government hospitals. They soon hired all the revered and legendary professors from apex government medical institutions, luring them with hefty salaries. These hospitals were thus an instant hit with those who could afford them. Not only did they offer luxurious facilities, they were also real game changers in terms of quality of care, providing excellent results. This resulted in doctors of Indian origin migrating back from the USA and the UK to work in India. These hospitals started attracting medical tourism and claimed that they were helping the Indian economy!¹

While corporate hospitals were emerging as  the benchmark of medical care, the government hospitals failed to put a creditable competition due to dismal funding for health in India. The government has not been serious about upgrading healthcare services in the public sector.²,³ A recent event, as many others,  underline this fact. When Delhi’s health minister needed plasma therapy, he was admitted to a private hospital rather than a public sector hospital.⁴ The result is obvious. Over time, corporate hospitals have proliferated and have converted what was once a vocation into an ‘industry’ (the healthcare industry). 

The right to a healthy life and  healthcare has been recognized as a fundamental right of every citizen of India.⁵ The onus of providing it, therefore, lies on the State, especially if an individual cannot afford it. The fact is that the state has failed to ensure this. Indian healthcare is dependent on private medical setups. Over 60% (hospital) beds are in private hospitals. The out-of-pocket expenditure (met with by individual citizens) as a proportion of the total health expenditure was as high as 65% in 2015.⁶ With the gross shortage of beds and facilities in public sector hospitals, the government has enacted laws (various Clinical Establishment Acts or CEAs), which place the onus of providing medical care to the public on private hospitals too. The Law Commission of India, in its 201st report in 2006,⁷ was the first to moot the idea of mandatory provision of health services in an emergency. However, it had also stressed on a mechanism to reimburse the private establishments for the treatment provided—something that the state has royally ignored. The private hospitals were originally created to earn profit, and therefore, are opposed to the very idea of CEA.⁸ ,⁹

In almost every sector, private organizations are better, faster and more efficient than state-run monoliths. However, several principles of economics and competition do not apply to healthcare. The private initiative in this field is replete with mines, namely excessive medical intervention and iatrogenic harm. Corporate hospitals, just like the pharmaceutical industry, are more obsessed with marketing newer and costly techniques, rather than community care.¹⁰

The darker side of corporate hospitals started to become apparent within a decade or so. Corporations are basically financial arrangements for a common goal. Thus, corporate medicine has two dimensions—financial and clinical. How one balances the two makes all the difference. Today, corporate hospitals are mostly business ventures, which either hire doctors on salary to see patients for them or enter into agreements with doctors to see patients on a profit-sharing basis. Doctors have no say in corporate policies; however, they continue to have personal liability to individual patients.¹¹

A peep into the anatomy and functioning of a corporate hospital will give you some insight. Doctors form only 10%–15% of the hospital’s workforce, with technicians, nurses, secretaries, managers, marketing, finance, housekeeping, security and legal services forming the rest. Not to forget hospital administrators, who often draw salaries much higher than that of an average doctor. Where does the money for the infrastructure and salaries of all these people come from? Obviously, from the patients! And who has the honour of taking it out of the patient’s pocket? In the patient’s eye, it is the man on the frontline—the doctor. It is not unusual for a patient to pay a hospital bill of Rs. 1 million, which may include only Rs. 10 000 as doctor’s fees. But in the patient’s mind, it is the doctor who has charged Rs. 1 million. Damn the greedy doctor!

Corporate philosophy is not in sync with the moral duties of a doctor. The former’s focus is on profits and not on the community’s needs. The management provides bonuses and incentives to those doctors who earn them larger profits. Every doctor who joins a corporate hospital is asked to take an indemnity insurance of at least of Rs. 5 million, preferably double that. In effect, the hospital sends the doctor a message that ‘every patient is a potential plaintiff—make sure you don’t miss anything! Cover every possibility; it is safer to over-investigate and over-treat.¹² This leads to excessive investigation and over-treatment. In corporate hospitals, it is commonplace to encourage doctors to conduct aggressive screening tests for diagnosing breast, lung and colorectal cancers, even though science says that such screening may not improve overall mortality.¹³,¹⁴,¹⁵ Working for a corporate hospital thus has an inherent conflict of interest for the doctor, if one has to toe the corporate line.

The intelligent public can see the balance tipping on the other side, and obviously, there is outcry about ‘over-care’.¹⁶ Problem is not peculiar to India.  Global medical profession, after writing 16.2 million prescriptions of antidepressants a year for longer than a decade, discovers that these drugs are no better than placebo in a majority of cases.¹⁷,¹⁸ Even in the USA, there is talk of surgeries being done which may not benefit the patient. Over-care may be a global phenomenon; but, its implications are harsher for poorer societies.¹⁹ 

In this scenario, an unprecedented COVID-19 pandemic unfolded earlier this year, as a public health emergency. Everyone expected the medical professionals to be the soldiers who will save them. Everyone also expected that corporate hospitals will rise to the occasion and take an active part in the public service. Free public service is okay as far as corporate social responsibility goes, but can a corporation survive without earning? Can it ignore that it has to pay the salaries of all the employees as well as humongous bills for various consumables and services?

Most corporate hospitals have senior doctors (retired from government service) as the heads of the department. As leaders of the team, they are expected to lead from the front.  And it is well known that COVID-19 is especially lethal in this age group. Government also announced that people above 65 years of age should stay at home. Some senior doctors decided to pay heed to this advice and abstained from coming to hospital. Many decided to take their leadership role seriously, and did come to hospital to lead their team from the front. These brave-hearts were cautious enough to significantly reduce their contact with patients and active management.

Patients with illnesses that were short of being an emergency, stopped coming to hospitals lest they may acquire the virus (SARS-CoV-2).  The revenues of corporate hospitals plummeted during the initial period of lockdown and the hospital administrators started panicking. While Indian Air Force was showering flowers on the front-line healthcare workers, their salaries were being cut due to the cash crunch.²⁰ The stress on doctors was increasing as they were expected to stay quarantined away from their family while they looked after COVID-19 positive cases. Particularly distressed were those doctor couples who had small children. This group was earlier managing to work due to the backing by the maid servants and nannies. Lockdown meant that maids and nannies would not be coming. The schools were closed and parents found it extremely difficult to attend to duties leaving children unattended.

Government’s response in various states was variable and made a lot of difference. It was obvious that the Governments did not have the resources to Nationalise all the healthcare facilities. At the same time, it could not do without the roping in the corporate and private hospitals. For example, in Delhi, all hospitals were asked to keep 20% or more beds reserved for COVID-19 patients.²¹ This resulted in confusion about isolating these patients within the general premises with common air-conditioning and other services. Non-COVID-19 patients started avoiding hospitals lest they may catch the disease. Hospitals started to  turn back sick patients once their 20% quota of COVID patients was full. Doctors were reluctant to see patients without adequate PPE, which was perpetually in short supply. Who will bear the cost of PPE in a private hospital? Obviously the patient, and the cost of care skyrocketed. 

Charges per day for admission being quoted were ₹25,090 for general ward, ₹27,190 on twin sharing, ₹30,490 for a private room, ₹53,050 for ICU without ventilator and  ₹72,550 with a ventilator.²² Many other charges including treatment of non-COVID-19 comorbidities were extra. Cost of PPE varies from ₹3,900 to ₹7,900 depending on which ward the patient is admitted. A PET scan costs separate ₹27,600, while a chemoport insertion costs as much as ₹42,000 and so on. (Bed charges in Hyderabad were even higher, ranging from 1-1.5 Laks/day)²³ The hospital charges are now subject of sarcastic editorial comments.²⁴ Delhi Government asked corporate hospitals to share the cost of treatment²⁵ and left them to fend for it. Corporate Hospitals said that they had limited resources, and from a financial point of view they may not be able to sustain operations.

The question is, “Are corporate hospitals really bad or is it just a matter of perception?” Some one has said that China perceives His Holiness Dalai Lama as a terrorist, and Masood Azhar as a religious leader. Are we giving Corporate hospitals a bad name without understanding their SWOT?

In Mumbai, hospitals were asked to reserve 80% beds for COVID-19 cases and also capped the price of treatment.²⁶ Declining footfalls, rising consumables and staff costs led to a situation where private hospitals’ survival became difficult.²⁷ Soon, several hospitals closed down.³³ It was partly due to exposure of doctors to patients who were treated in routine facilities, but later turned out to have COVID-19, and partly due to problems with financial sustainability. Doctors started insisting that patients first be tested for the virus (SARS-Cov-2) before they took him/her up for treatment.  A patient coming for treatment of non-COVID-19 emergency, also had the right to ask that doctor be tested for Covid-19 before he touches him/her. Such tests could not be permitted as it was against National guidelines. Moreover testing capacity was limited and not enough to cope with such demands. And the question remained if the patient should be paying for all such tests? This situation places corporate hospitals at a great disadvantage.

Somehow, our Governments failed to empathise with the  working of private hospitals as well as that in Australia did. Corporate hospitals survive because of the revenue generated. If you are asking them to cut down their earnings, they need to be financially supported. If the Government does not support the hospital, all the financial burden will fall on the patient, which is the only source of revenue for a private hospital. Australia resorted to “a “once-in-a-century redesign” of the country’s hospital services and the federal government there decided to bear half of the cost of integrating the private hospital system with the public one in preparation for Covid-19.²⁸

National Guidance on the management of COVID-19 cases were very clear.²⁹ It asked for ‘Dedicated COVID Health Centres’ and ‘Dedicated COVID Hospitals’ for management of COVID-19 patients. The states that followed these guidelines (for example Odisha)³⁰ were much better off than those who did not (like Maharashtra and Delhi). There are several factors that have led to high incidence rates of this disease in some states, but a public-private partnership to create region-wise dedicated facilities (somewhat like the Australian model) may have been beneficial. Was the Governments’ hesitation to shake hands with corporate hospitals due to trust deficit?

However rapacious corporate hospitals may be, they are an asset that can be fruitfully utilised in an emergency. It is always better to have some hospitals designated as the COVID-19 hospitals region-wise. If a private hospital is taken up for public work, the Government may also arrange for its funding to a reasonable extent. The salaries of doctors who are under quarantine for performing their professional duties should not be cut. Doctors need more than applause at this difficult time. Sadly, some have been asked to vacate their rented flats if they continue working in a hospital!³¹,³⁴ Just like doctors, Corporate hospitals too need to be carefully handled. It is not impossible to modulate their behaviour.

It is clear that the Governments so far, do not trust any corporate hospital to be an honest and selfless service provider. They are willing to trust the doctors, who are governed by the medical ethics and can be penalized if they cross the line. No ethics has been mandated for corporate hospitals which in the eyes of the Government, are like unbridled horses. If doctors can not advertise, corporate hospitals can use the face of the same doctors to advertise. If doctors can not solicit patients, the hospitals can, through their marketing departments. And then there are dirtier practices too, that doctors have learnt from the corporate practices.³² Personally I think, it is high time that our planners thought of equating corporate hospitals with  doctors in terms of ethics. Knowing that they can be penalised for crossing the ethical boundaries, may add some self restrain in the corporate pursuit for profits.There is a huge capacity for medical care available out there which the Government can tap. The corporate hospitals will be too happy to be part of mainstream if the Government follows a win-win policy.