The severity of the second wave of COVID-19 has brought death and tragedy to the doors of lakhs of grieving families in India. Ours is one of them.
We all witnessed how a steady rise in cases during the months of April and May overwhelmed India’s already crumbling public healthcare system with shortages of oxygen, ventilators, and intensive care beds in hospitals.
In the third week of April, our entire family tested positive for the coronavirus infection. Then onwards, we were literally on our own and dependent on the goodwill and support of friends and relatives. Except for my 51-year-old wife, Mankeerat Lamba, the rest of us soon recovered at home after experiencing mild-to-moderate symptoms.
When Mankeerat’s blood oxygen levels dropped to dangerously low levels, below 90%, on April 23, she was rushed to the Delhi Heart and Lung Institute (DHLI) with the help of a close relative who informed us of the availability of an ICU bed there. At the DHLI, she remained in a COVID-19 ICU until May 4 and was then moved to a non-COVID-19 ICU after recovering.
After shifting her to a private room on May 9, the hospital doctors repeatedly told us that Mankeerat was in recovery mode and all her lung problems had been clinically resolved. What she needed was moral support and physiotherapy treatment to recover fully at home, we were told. Their initial plan was to discharge her from the hospital on May 11, which got postponed to May 12 when we raised concerns over her oxygen levels immediately hitting the levels 81-82 even with a slight reduction in oxygen flow and her inability to stand or sit up without assistance.
Trauma after trauma
In the early morning of May 12, we were informed by hospital authorities that Mankeerat had experienced a pneumothorax and was rushed to the ICU with ventilator support. Her lungs could not work well enough to use the oxygen from the ventilator. After that, bacterial infections set in, and she passed away on May 18 due to multiple organ dysfunction syndrome and acute respiratory distress syndrome (ARDS), according to the hospital-issued death certificate. Since her passing away, our family is facing acute traumatic stress. We are all emotionally raw and struggling to get through the trauma.
As if Mankeerat’s passing away was not enough, the DHLI issued a 22-page bill of Rs 19,03,953 (approximately $26,000) for her treatment at the hospital. The invoice issued by the DHLI is available here. Undoubtedly, the cost of Rs 19 lakh is terrifying to a salaried middle-class family like ours.
A cursory glance at the bill shows some glaring instances of potentially inflated charges, including Rs 11,85,693 charged for pharmacy items (ranging from face masks and PPE kits to syringes and experimental drugs); pharmacy charges included Rs 4,24,974 for 108 units of Ulicrit Injection; Rs 37,500 for miscellaneous charges without any description of services rendered; and charges for two visits per day by cardiology team and two visits per day by the respiratory team.
In all major hospitals, a single visit is the norm and is billed accordingly. Also, why should the cardiology team visit a COVID-19 patient twice daily? There is also no need for 1-2 visits every day by RMO. All such unnecessary charges have contributed to excessive billing.
At the outset, let me make two things very clear: First, I have no intention to bring a bad name to DHLI in particular or privately owned hospitals in general. Based on our experience with the DHLI, I am bringing some unfair practices to public notice and raising some broader policy issues to strengthen the regulation and supervision of privately owned hospitals.
Second, I am not against legitimate profit-making by a hospital or any business entity. I am only against profiteering which means taking advantage of unusual circumstances to make unreasonably high or unfair profits. I believe private hospitals can make a reasonable margin of profit without profiteering. I also think that not all private hospitals indulge in unfair and unethical practices.
On its website, the DHLI claims its mission is to provide “quality healthcare at affordable costs,” but our experience tells another story. It also purports to be a super-speciality hospital offering state-of-the-art facilities for cardiology, cardiac surgery, pulmonology, and critical care with fully equipped modern Cath Lab and operation theatres.
These claims look hollow when we, later on, discovered that the DHLI does not have a basic CT scanner considered essential for diagnosing COVID-19 in critically ill patients. To conduct CT scans on critically ill patients undergoing treatment for COVID-19 (and other ailments) at DHLI, the hospital transports patients to an imaging centre in Delhi, potentially increasing the risk of contracting secondary infections during transit or at the imaging centre.
We came to know of the absence of an in-house CT scanner when the hospital staff informed us about their plan to take Mankeerat to an outside facility on May 12 for conducting a high-resolution CT scan. The revelation was not merely shocking but also hit our confidence in the hospital’s ability to treat critically ill COVID-19 patients as we were concerned about the potential risks of secondary infections.
One wonders how government authorities can allow DHLI to treat critically ill COVID-19 patients without having an in-house CT scanner. What about accreditation agencies such as NABH and NABL that have issued accreditation to DHLI? Do these agencies accredit hospitals without physically examining the facilities available?
Further, to seek second opinions from outside medical experts, twice (on May 9 and 11) we approached the hospital authorities to seek access to Mankeerat’s medical records. According to the law, seeking medical records of a patient by her family members is a matter of right. But our requests were denied by hospital doctors and management on flimsy grounds such as, “What would you do with records after 17 days?” and “Seeking medical records signals a breach of trust”. After great persuasion by us, the hospital shared a two-page case summary, a couple of X-rays, and some test reports on May 15.
In view of the second wave, the National Human Rights Commission (NHRC) on May 4 issued an advisory on the right to health, considering ground reports highlighting the denial of accessible and affordable treatment to COVID-19 patients. The advisory recommended all hospitals (public and private) must prominently display information about the availability and costs of COVID-19 treatment, the number of beds available under price cap regulations, and the contact number of grievance redressal authority. To our surprise, we found that no such information is on display in the entry or reception area of the DHLI.
We are still waiting for information from the DHLI regarding the status and availability of all COVID-19 beds (both under price cap regulations and hospital rates) on April 23 — the day Mankeerat was admitted to the hospital.
What I have briefly described above is our experience with the DHLI. Media reports suggest that hundreds, if not thousands of patients are getting inflated bills every day across the country. Our personal tragedy underscores the need to bring these important issues to the public domain and initiate a conversation with all stakeholders.
The limits of price capping regulations
On June 20, 2020, the Delhi government issued an order capping prices for COVID-19 treatment in private hospitals in Delhi. The order prescribed maximum per day package rates for treatment between Rs 8,000 and Rs 18,000, depending on the category of hospitals, beds, and ICU facilities.
The order clearly stated that the package rates include “all expenses related to bed, food and other amenities, monitoring, nursing care, doctors’ visits/consults, investigations including imaging, treatment as per the national protocol for Covid care and standard care for co-morbidities, oxygen, blood transfusion, etc. The package rates would include costs of medical care of underlying co-morbid conditions including supportive care and cost of medications thereof, for the duration of care for Covid. Since many of the Covid patients have conditions such as hypertension, diabetes, cardiovascular problems, etc., the charges for medical care of such co-morbidities will be a part of the package. This would include short term haemodialysis as a part of acute care during the current admissions.”
One welcomes the noble intention behind this government order, but there are two inherent problems with its proper implementation, rendering it ineffective. First, the package rates only apply to 60% of the total beds available in a hospital, thereby allowing the management to charge their own rates (usually much higher than the capped ones) for the remaining 40% of beds.
The NHRC has recommended accessible healthcare at regulated, affordable rates in private hospitals in its advisory. It called upon all governments to direct private hospitals to provide treatment to COVID-19 patients at regulated rates that should be “applicable to the maximum proportion of beds, at least two-third of all available beds or as per local requirements.” In Maharashtra, for instance, government-mandated price caps apply to 80% of beds at all private hospitals. What stopped the Delhi government from imposing price caps on 80% or even 100% of total beds (permissible under the Disaster Management Act), especially during the second wave of the pandemic?
Second, due to a lack of transparency by private hospitals and little or no on-site monitoring by the state health department, it is not easy to assess whether or not hospitals are charging packages rates for 60% of their total beds. Similarly, we do not know whether or not COVID-19 patients are being charged separately for expenses such as doctors’ visits, investigations, oxygen, blood transfusion, etc.
The All India Drug Action Network (AIDAN) has documented several cases of fraudulent practices by private hospitals in the city that include: not informing patients about the government capped rates or obtaining false consent at the time of admission; charging additionally for medicines, doctors’ visits, investigations, PPE kits, and gloves despite such expenses part of the government package rates.
Only a periodic audit of patient bills can reveal an accurate picture of the implementation and effectiveness of the government order. So far, the Delhi government has not initiated periodic audits (weekly or monthly) at the DHLI or other private hospitals. Nor has it directed private hospitals to release such information publicly. Therefore, it raises a pertinent question: What is the point of issuing such well-intentioned orders if the state government does not have the capacity or willingness to ensure its implementation?
Some suggestions for the Delhi government
Pandemic or not, protecting the health of citizens should be the priority of any government. The governments must ensure that citizens get affordable treatment and any unfair practices by private hospitals and other entities are curbed. Hence, our message to the Delhi government is clear: please exercise all powers at your disposal to curb undue profiteering practices carried out by private hospitals in the city.
After all, overcharging and other unfair practices by private hospitals are neither new nor accidental, but by design because of a combination of factors that include: weak regulatory framework, poor monitoring and enforcement of government orders, lack of transparency by private hospitals, and absence of a robust grievance redressal mechanism. With health being a state subject, the Delhi government is duty-bound to ensure responsible behaviour and accountability by private hospitals.
Here are our concrete suggestions. To begin with, the Delhi government must regularly monitor the implementation of its June 2020 order by making surprise visits to the private hospitals and checking their billing records to determine whether or not the price caps for COVID-19 treatment are being implemented in letter and spirit. If not, initiate prompt actions in the form of show-cause notices, inquiries, and audits against private hospitals violating government order. Besides, substantial financial penalties must be imposed to deter erring private hospitals.
If need be, the Delhi government should not hesitate to cancel the permission of private hospitals to treat COVID-19 patients if found violating government orders. Similar to what the Telangana government did a few days ago when it cancelled the permit of five hospitals for the violation of COVID-19 treatment protocol and overcharging of COVID-19 patients. Last week, the Tamil Nadu government issued show-cause notices to 22 hospitals and cancelled the permits of 10 private hospitals for violations (including charging exorbitant rates) of government stipulated rates for COVID-19 treatment. If the governments of Telangana and Tamil Nadu can do it, so can the Delhi government.
Secondly, few Delhites know about any grievance redressal mechanism available to them for lodging complaints against profiteering private hospitals. Currently, there is so much confusion about where to lodge a formal complaint — should it be a police station or DM office or consumer court or state health department?
The Delhi government needs to strengthen grievance redressal mechanisms urgently. According to a report published in Hindustan Times on May 13, a division bench of Delhi high court comprising Justices Vipin Sanghi and Rekha Palli asked the Delhi government not to turn a blind eye to overcharging by hospitals merely because there were no complaints by patients. Our submission is that patients would come forward to lodge complaints if user-friendly grievance mechanisms are made available and widely publicised. The NHRC has also recommended the establishment of a grievance redressal mechanism by all governments.
The Delhi government must set up a dedicated helpline number and a dedicated email address to file complaints against erring private hospitals. In Tamil Nadu, for instance, patients can also lodge complaints on exorbitant charges through helpline number 104. The Delhi government has established a dedicated helpline number 1031 for COVID-19 related matters. However, when we called this helpline to complain about the DHLI, the executive told us they do not deal with complaints related to private hospitals.
In addition, the Delhi government could establish a dedicated portal for COVID-19 patients to file complaints online with the facility to upload bills and medical records.
The advisory issued by the NHRC has recommended that the governments should randomly audit bills of higher amount (more than Rs 150,000) for ensuring implementation of regulated rates for COVID-19 patients by private hospitals.
As suggested by AIDAN, the Delhi government must also establish an audit committee comprising serving bureaucrats, doctors, retired judges, civil society representatives, and prominent personalities that could periodically conduct audits of COVID-19 treatments and bills in private hospitals.
Is it too much to ask from the Delhi government?
Broader policy concerns
This brings me to the bigger question of regulating and supervising private hospitals in India. The increasing number of media reports highlighting rampant profiteering by private hospitals in India have exposed the limits of an over-reliance on the self-regulation model. The self-regulation model has failed to enforce discipline and accountability in the privately-owned hospitals and other entities operating in the healthcare industry. We cannot continue with the self-regulation model any longer.
Especially during pandemics, the state governments cannot abdicate responsibility when regulatory failures require a government response. Article 21 of the Indian constitution guarantees the right to health, which also includes affordable treatment. It is the duty of all governments (Central and state) to ensure affordable treatment to all citizens and restrain rampant profiteering by private entities operating in the healthcare sector. With health being a state subject, the primary responsibility lies with respective state governments to beef up the regulation and supervision of the privately owned hospitals to ensure responsible behaviour and accountability.
Issuing government orders on fixed package rates for COVID-19 treatment by state governments is meaningless unless adequate mechanisms are in place to ensure its implementation. At the same time, all state governments must address the problems of human resource and infrastructure shortage in hospitals and health centres run by it.
As part of collective responsibility, the central government should also coordinate and supplement the efforts of state governments in developing a regulatory environment at the national level. In India and elsewhere, governments have introduced anti-profiteering measures to protect consumers. For instance, India’s Goods and Services Tax (GST) regime also contains anti-profiteering clauses. Why can’t anti-profiteering measures be introduced in the private healthcare sector that is particularly prone to market imperfections due to information asymmetry?
When the world is rethinking the future of capitalism amid the growing calls for making private corporations accountable to all stakeholders, one could only wish that India’s privately owned healthcare industry should also rethink its purpose. Should money-driven values solely guide its business model? Do human values matter?
Unlike other businesses, the reward-risk ratio in privately owned hospitals is highly skewed towards rewards for the owners and top management of private hospitals while the patients face multiple risks. The consequences of failing to strike a balance between reward and risk are real.
The status quo has assuredly contributed to the false notion that private hospitals and their senior management are untouchable. It is time to change the status quo. The Delhi government has a choice. It can keep quiet, and the complaints filed by patients can get lost in bureaucratic red tape. Or it can launch investigations based on public complaints and on-site inspections.
One might reasonably ask, what if no strict actions are taken against the DHLI and other erring private hospitals? Well, that would only reconfirm a growing public perception that the Delhi government lacks the political will to protect COVID-19 patients from overcharging and undue profiteering by private hospitals.
Kavaljit Singh is director of Madhyam, a policy research think-tank, based in New Delhi. Views expressed are personal.