By- Sylvia Karpagam
The proposed amendments to the Karnataka Private Medical Establishments Act – including regulating fee and service charges at private hospitals – are not against doctors. Rather, they will facilitate a better doctor-patient relationship.
Leading up to the Assembly meeting in Karnataka on the 13th of November, 2017, the Indian Medical Association of Karnataka has planned a protest “chalo Belgaum’ to oppose the Amendments of the Karnataka Private Medical Establishments Acts being passed and with ‘unconditional support from corporate hospitals’. A relay hunger strike is being planned with the president of IMA, Karnataka, going on a fast ‘unto death’. In case the draft Amendments go through, the members of the Association are planning to ‘quit the profession’ as they will be ‘unable to practice under the rules and regulations of the KPMEA’
This article is an appeal to fellow doctors. In the back and forth between the government and the private hospital associations, the voices of patients, citizens and many doctors are being drowned. It is important for us to understand a few things before we make informed decisions about whether to support this protest or not.
Firstly, there is a distinction between private hospitals and medical professionals. Many doctors and nurses employed in private hospitals have been under pressure to do procedures and tests that violate patient rights and their own professional ethics. This could range from unnecessary investigations, compulsorily putting patients into the ICU, prolonged and unnecessary use of the ventilator, irrational repetition of tests and also unnecessary procedures, including surgeries. The doctors and other professionals currently do not have any functional recourse to a system that protects their professional ethics. The KPME offers a process to keep these medical establishments in check. It is only if a doctor has wilfully contributed to a violation, for instance by also being the owner of the establishment, that he or she will be held accountable. So the KPMEA actually offers a protective system for private health professsionals who want to practice in an ethical way.
Secondly, in the final draft, the district grievance committee will perform the role of a civil court and will not have the Chief Executive Officer of the Zilla Panchayat as its member (as has been widely quoted by PHANA). It will have the Additional Deputy Commissioner or Special Deputy Commissioner as chairperson, with the District Surgeon, District Superintendent of Police, one IMA member and one woman, with the last being decided by the state. Non formal members and IMA will not constitute more than 1/3 of this body. The role of this body is to register a private medical establishment and also to respond to complaints at the district level. This decentralisation of registration will increase the convenience for those looking to set up establishments at the level of the district. The complaints received will be reviewed and a recommendation sent to the manager of the establishment with a copy to the Karnataka Medical Council or the Ayush Medical Council.
The third point, which is important, is that there will be an expert group who will, with inputs from private medical establishments, decide on uniform rates for same procedures across the state. So if a cataract extraction and lens implant is planned then the procedure itself will not exceed a certain limit. For eg. For a cataract extraction and lens implant, if the cost to the establishment for just the procedure is Rs. 20,000/- the procedure across the state will not cost more than 30 or 35, 000 as decided by the expert committee. However, based on the facilities offered by the hospital, and this would include the quality of the lens implanted, the rates can vary based on the tier of hospital. So a charity hospital may charge an additional of Rs. 10,000 for consultant fees or room rates while a corporate hospital may charge around Rs.1,00,000 lakh for the same. These also have an upper limit but are flexible based on the facility offered. Patients have some amount of choice in that they can opt for the same procedure with lower room rates or more high end facilities at higher rates. The rates, since they are fixed, can be informed to the patient in advance so that suitable preparations are made. It is fair to say that patients would be better prepared if they know what the costs involved are for any procedure and also to know that they have not been ‘cheated’ as there is a larger system in place which can be explained to them. Doctors are often at the interface of having to break news of exorbitant bills to patients, even by unscrupulous medical establishments. It is only fair for both professionals and patients, that these systems of billing are transparent and rational.
The fourth point is that private medical establishments cannot withhold emergency treatment pending payment of advance and cannot refuse handing over a deceased patient body to the relatives unless bills are settled. Again this is not an issue between the health professional and the patient, as much as between a medical establishment and patient. It reflects establishment policies rather than the decision making of the doctor who may be inclined to treat a patient in an emergency and waive off costs for a genuinely poor patient. The question health professionals would need to ask here is whether a patient in an emergency should or should not be stabilised with basic emergency care and then referred to an institution that he or she can afford. This is an ethical question that private establishment professionals would need to ask themselves. As the first point of contact with a seriously ill patient, it is the healthcare professional who is faced with the difficult task of shutting the door on patients who cannot afford an advance. The state government has brought out a scheme of reimbursement to hospitals upto 25,000/- for all patients who access health care in an emergency. As far as handing over a deceased patient is concerned, the state has made mention that it will pitch in to settle bills of deceased patients whose bills have not been settled. Both these schemes have to be well in place, to avoid undue burden and loss for the private establishments.
These are the major amendments to the Bill. It brings health care professionals working in private medical establishments to a cross roads of sorts where they have to decide if they want to be viewed as independent professionals or part of a medical establishment.
It should also be noted that many of the schemes and benefits accrued by private hospitals goes predominantly to three or four large corporates within Bangalore. In terms of the pre-authorisation amount approved by the Suvarna Arogya Suraksha Trust, over 77 per cent was accounted by the hospitals located in Bangalore. The districts such as Bellary, Bidar, Gulbarga and Raichur have accounted for almost insignificant proportion of the amount, while Koppal and Yadgir do not even figure in this. In Bangalore, super specialty hospitals such as Narayana Hrudayalaya, Sagar Hospitals, Vydehi Hospital and BGS Global Hospital located in Bangalore city have been the top four hospitals in terms of the number of pre-authorisation approved cases and amount. In fact these top four hospitals accounted for 40 per cent of the treated cases and almost 43 per cent of the approved amount. It is also not a big stretch of imagination to understand that these corporates are at the fore of this resistance against Amendments to the KPME. It is crucial to understand that the Amendments are not anti-health professionals as articulated by vested interests. They facilitate a better doctor-patient relationship as they factor in the needs of patients who access services in a critical situations and is a step forward for ethical and compassionate healthcare.
The writer is a public health doctor and researcher based in Karnataka