The Indian Medical Association (IMA) of Karnataka has planned a protest with “unconditional support from corporate hospitals” on November 13, coinciding with the first day of the state legislature’s winter session – against the proposed amendments to the Karnataka Private Medical Establishments Act (KPMEA). As part of ‘Chalo Belgaum,’ the IMA has planned a relay hunger strike and if the draft amendments go through, the members of the association are planning to “quit the profession” since they would 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 or not to support this protest.
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 in the intensive care unit, prolonged and unnecessary use of the ventilator, recommending irrational repetition of tests and unnecessary procedures, including surgeries.
The doctors and other medical professionals currently do not have access to a system that protects their professional ethics. The KPME offers a process to regulate medical establishments, prevent them from taking advantage of patients. A doctor, who is also simultaneously the owner of the medical establishment, would be held accountable for willfully violating a rule laid down under the new medical code. The KPMEA thus offers a system to protect private health professionals who want to practice in an ethical manner.
Secondly, 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 one-third of this body. The role of this body is to respond to complaints at the district level. 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. It will also inform the registration authority, comprised of the deputy commissioner, the district health officer, the district AYUSH officer and two members from recognised association, which can also register a private medical establishment. This decentralisation of registration will increase the convenience for those looking to set up establishments at the level of the district.
The third point, which is important, is that there will be an expert group that – with inputs from private medical establishments – will decide on uniform rates for procedures across the state. For instance, if the cost for cataract extract or lens implant procedure to the establishment is Rs 20,000, then the cost of that medical procedure throughout the state cannot exceed Rs 30,000-35,000, as decided by the expert committee. However, based on the facilities offered by the hospital – and this would include the quality of implanted lens – the rates can vary depending on the hospital. A charity hospital may charge an additional Rs 10,000 as consultant fees or room rates while a corporate hospital may charge around Rs 1,00,000 lakh for the same medical process.
Patients will have some degree of choice in that they can opt for the same procedure with lower room rates or choose more high-end facilities at higher rates. The rates, since they are fixed, can be informed to the patient in advance so that suitable arrangements can be 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 know that they have not been ‘cheated’ as there is a larger system in place which can be explained to them. Doctors are often the ones who reveal the exorbitant costs of procedures to patients. It is only fair to both professionals and patients that these systems of billing are transparent and rational.
Additionally, private medical establishments cannot withhold emergency treatment pending advance payment and cannot refuse to hand over a deceased patient’s body to the relatives unless bills are settled. Again this is not an issue between the health professional and the patient as much as it is between a medical establishment and a patient. It reflects establishment policies rather than the motivation behind the doctor’s decision. The doctor may be inclined to treat a patient in an emergency and waive off costs for a poor patient. But the establishment may not allow her to take that decision. The question health professionals need to raise here is whether a patient in an emergency situation 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 indeed 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 to make an advance payment. The state government has launched a reimbursement scheme for hospitals, that can go up to Rs 25,000 for all patients who have to access emergency healthcare. As far as handing over the body of a deceased patient is concerned, the state has mentioned that it will financially contribute to settle bills of deceased patients whose bills are not settled. Both these schemes have to be well in place to avoid undue burden and loss to private establishments.
These are the major amendments to the Bill. It poses fundamental questions before healthcare professionals working in private medical establishments, compelling them to decide if they want to be viewed as independent professionals or as part of profit-driven medical establishment.
It should also be noted that many of the schemes and benefits accrued by private hospitals go predominantly to three or four large corporates within Bangalore. Over 77% of the pre-authorisation amount approved by the Suvarna Arogya Suraksha Trust was cornered by hospitals in Bangalore Districts such as Bellary, Bidar, Gulbarga and Raichur, on the other hand, accounted for an almost insignificant proportion of that amount, even as Koppal and Yadgir do not even figure in this.
In Bangalore, super speciality hospitals such as Narayana Hrudayalaya, Sagar Hospitals, Vydehi Hospital and BGS Global Hospital have been the top four hospitals in terms of the number of pre-authorisation approved cases and the amount. In fact, these hospitals accounted for 40% of the treated cases and almost 43% of the approved amount. It is also won’t be a big stretch to say that these corporates are at the fore of the resistance against amendments to the KPME.
It is crucial to understand that the amendments are not targeting health professionals as is being articulated by vested interests. On the contrary, they facilitate a better doctor-patient relationship in factoring in the needs of patients who access services in critical situations. The amendments constitute a step forward for ethical and compassionate healthcare.
Sylvia Karpagam is a public health doctor and researcher based in Karnataka.