Bitter Pill: Why Medical Bills Are Killing Us #healthcare


By Feb. 20, 2013
brill.pill9.indd

1. Routine Care, Unforgettable Bills
When Sean Recchi, a 42-year-old from Lancaster, Ohio, was told last March that he had non-Hodgkin’s lymphoma, his wife Stephanie knew she had to get him to MD Anderson Cancer Center in Houston. Stephanie’s father had been treated there 10 years earlier, and she and her family credited the doctors and nurses at MD Anderson with extending his life by at least eight years.

Because Stephanie and her husband had recently started their own small technology business, they were unable to buy comprehensive health insurance. For $469 a month, or about 20% of their income, they had been able to get only a policy that covered just $2,000 per day of any hospital costs. “We don’t take that kind of discount insurance,” said the woman at MD Anderson when Stephanie called to make an appointment for Sean.

Stephanie was then told by a billing clerk that the estimated cost of Sean’s visit — just to be examined for six days so a treatment plan could be devised — would be $48,900, due in advance. Stephanie got her mother to write her a check. “You do anything you can in a situation like that,” she says. The Recchis flew to Houston, leaving Stephanie’s mother to care for their two teenage children.

About a week later, Stephanie had to ask her mother for $35,000 more so Sean could begin the treatment the doctors had decided was urgent. His condition had worsened rapidly since he had arrived in Houston. He was “sweating and shaking with chills and pains,” Stephanie recalls. “He had a large mass in his chest that was … growing. He was panicked.”

Nonetheless, Sean was held for about 90 minutes in a reception area, she says, because the hospital could not confirm that the check had cleared. Sean was allowed to see the doctor only after he advanced MD Anderson $7,500 from his credit card. The hospital says there was nothing unusual about how Sean was kept waiting. According to MD Anderson communications manager Julie Penne, “Asking for advance payment for services is a common, if unfortunate, situation that confronts hospitals all over the United States.”

Sean Recchi 

CLAUDIA SUSANA FOR TIME 

Sean Recchi
Diagnosed with non-Hodgkin’s lymphoma at age 42. Total cost, in advance, for Sean’s treatment plan and initial doses of chemotherapy: $83,900. Charges for blood and lab tests amounted to more than $15,000; with Medicare, they would have cost a few hundred dollars

The total cost, in advance, for Sean to get his treatment plan and initial doses of chemotherapy was $83,900.

Why?

The first of the 344 lines printed out across eight pages of his hospital bill — filled with indecipherable numerical codes and acronyms — seemed innocuous. But it set the tone for all that followed. It read, “1 ACETAMINOPHE TABS 325 MG.” The charge was only $1.50, but it was for a generic version of a Tylenol pill. You can buy 100 of them on Amazon for $1.49 even without a hospital’s purchasing power.

(In-Depth VideoThe Exorbitant Prices of Health Care)

Dozens of midpriced items were embedded with similarly aggressive markups, like $283.00 for a “CHEST, PA AND LAT 71020.” That’s a simple chest X-ray, for which MD Anderson is routinely paid $20.44 when it treats a patient on Medicare, the government health care program for the elderly.

Every time a nurse drew blood, a “ROUTINE VENIPUNCTURE” charge of $36.00 appeared, accompanied by charges of $23 to $78 for each of a dozen or more lab analyses performed on the blood sample. In all, the charges for blood and other lab tests done on Recchi amounted to more than $15,000. Had Recchi been old enough for Medicare, MD Anderson would have been paid a few hundred dollars for all those tests. By law, Medicare’s payments approximate a hospital’s cost of providing a service, including overhead, equipment and salaries.

On the second page of the bill, the markups got bolder. Recchi was charged $13,702 for “1 RITUXIMAB INJ 660 MG.” That’s an injection of 660 mg of a cancer wonder drug called Rituxan. The average price paid by all hospitals for this dose is about $4,000, but MD Anderson probably gets a volume discount that would make its cost $3,000 to $3,500. That means the nonprofit cancer center’s paid-in-advance markup on Recchi’s lifesaving shot would be about 400%.

When I asked MD Anderson to comment on the charges on Recchi’s bill, the cancer center released a written statement that said in part, “The issues related to health care finance are complex for patients, health care providers, payers and government entities alike … MD Anderson’s clinical billing and collection practices are similar to those of other major hospitals and academic medical centers.”

The hospital’s hard-nosed approach pays off. Although it is officially a nonprofit unit of the University of Texas, MD Anderson has revenue that exceeds the cost of the world-class care it provides by so much that its operating profit for the fiscal year 2010, the most recent annual report it filed with the U.S. Department of Health and Human Services, was $531 million. That’s a profit margin of 26% on revenue of $2.05 billion, an astounding result for such a service-intensive enterprise.1

The president of MD Anderson is paid like someone running a prosperous business. Ronald DePinho’s total compensation last year was $1,845,000. That does not count outside earnings derived from a much publicized waiver he received from the university that, according to the Houston Chronicle, allows him to maintain unspecified “financial ties with his three principal pharmaceutical companies.”

DePinho’s salary is nearly triple the $674,350 paid to William Powers Jr., the president of the entire University of Texas system, of which MD Anderson is a part. This pay structure is emblematic of American medical economics and is reflected on campuses across the U.S., where the president of a hospital or hospital system associated with a university — whether it’s Texas, Stanford, Duke or Yale — is invariably paid much more than the person in charge of the university.

I got the idea for this article when I was visiting Rice University last year. As I was leaving the campus, which is just outside the central business district of Houston, I noticed a group of glass skyscrapers about a mile away lighting up the evening sky. The scene looked like Dubai. I was looking at the Texas Medical Center, a nearly 1,300-acre, 280-building complex of hospitals and related medical facilities, of which MD Anderson is the lead brand name. Medicine had obviously become a huge business. In fact, of Houston’s top 10 employers, five are hospitals, including MD Anderson with 19,000 employees; three, led by ExxonMobil with 14,000 employees, are energy companies. How did that happen, I wondered. Where’s all that money coming from? And where is it going? I have spent the past seven months trying to find out by analyzing a variety of bills from hospitals like MD Anderson, doctors, drug companies and every other player in the American health care ecosystem.

When you look behind the bills that Sean Recchi and other patients receive, you see nothing rational — no rhyme or reason — about the costs they faced in a marketplace they enter through no choice of their own. The only constant is the sticker shock for the patients who are asked to pay.

(iReport: Tell Us Your Health Care Story)

Gauze Pads 

PHOTOGRAPH BY NICK VEASEY FOR TIME 

Gauze Pads: $77
Charge for each of four boxes of sterile gauze pads, as itemized in a $348,000 bill following a patient’s diagnosis of lung cancer

Yet those who work in the health care industry and those who argue over health care policy seem inured to the shock. When we debate health care policy, we seem to jump right to the issue of who should pay the bills, blowing past what should be the first question: Why exactly are the bills so high?

What are the reasons, good or bad, that cancer means a half-million- or million-dollar tab? Why should a trip to the emergency room for chest pains that turn out to be indigestion bring a bill that can exceed the cost of a semester of college? What makes a single dose of even the most wonderful wonder drug cost thousands of dollars? Why does simple lab work done during a few days in a hospital cost more than a car? And what is so different about the medical ecosystem that causes technology advances to drive bills up instead of down?

Recchi’s bill and six others examined line by line for this article offer a closeup window into what happens when powerless buyers — whether they are people like Recchi or big health-insurance companies — meet sellers in what is the ultimate seller’s market.

The result is a uniquely American gold rush for those who provide everything from wonder drugs to canes to high-tech implants to CT scans to hospital bill-coding and collection services. In hundreds of small and midsize cities across the country — from Stamford, Conn., to Marlton, N.J., to Oklahoma City — the American health care market has transformed tax-exempt “nonprofit” hospitals into the towns’ most profitable businesses and largest employers, often presided over by the regions’ most richly compensated executives. And in our largest cities, the system offers lavish paychecks even to midlevel hospital managers, like the 14 administrators at New York City’s Memorial Sloan-Kettering Cancer Center who are paid over $500,000 a year, including six who make over $1 million.

Taken as a whole, these powerful institutions and the bills they churn out dominate the nation’s economy and put demands on taxpayers to a degree unequaled anywhere else on earth. In the U.S., people spend almost 20% of the gross domestic product on health care, compared with about half that in most developed countries. Yet in every measurable way, the results our health care system produces are no better and often worse than the outcomes in those countries.

According to one of a series of exhaustive studies done by the McKinsey & Co. consulting firm, we spend more on health care than the next 10 biggest spenders combined: Japan, Germany, France, China, the U.K., Italy, Canada, Brazil, Spain and Australia. We may be shocked at the $60 billion price tag for cleaning up after Hurricane Sandy. We spent almost that much last week on health care. We spend more every year on artificial knees and hips than what Hollywood collects at the box office. We spend two or three times that much on durable medical devices like canes and wheelchairs, in part because a heavily lobbied Congress forces Medicare to pay 25% to 75% more for this equipment than it would cost at Walmart.

The Bureau of Labor Statistics projects that 10 of the 20 occupations that will grow the fastest in the U.S. by 2020 are related to health care. America’s largest city may be commonly thought of as the world’s financial-services capital, but of New York’s 18 largest private employers, eight are hospitals and four are banks. Employing all those people in the cause of curing the sick is, of course, not anything to be ashamed of. But the drag on our overall economy that comes with taxpayers, employers and consumers spending so much more than is spent in any other country for the same product is unsustainable. Health care is eating away at our economy and our treasury.

The health care industry seems to have the will and the means to keep it that way. According to the Center for Responsive Politics, the pharmaceutical and health-care-product industries, combined with organizations representing doctors, hospitals, nursing homes, health services and HMOs, have spent $5.36 billion since 1998 on lobbying in Washington. That dwarfs the $1.53 billion spent by the defense and aerospace industries and the $1.3 billion spent by oil and gas interests over the same period. That’s right: the health-care-industrial complex spends more than three times what the military-industrial complex spends in Washington.

When you crunch data compiled by McKinsey and other researchers, the big picture looks like this: We’re likely to spend $2.8 trillion this year on health care. That $2.8 trillion is likely to be $750 billion, or 27%, more than we would spend if we spent the same per capita as other developed countries, even after adjusting for the relatively high per capita income in the U.S. vs. those other countries. Of the total $2.8 trillion that will be spent on health care, about $800 billion will be paid by the federal government through the Medicare insurance program for the disabled and those 65 and older and the Medicaid program, which provides care for the poor. That $800 billion, which keeps rising far faster than inflation and the gross domestic product, is what’s driving the federal deficit. The other $2 trillion will be paid mostly by private health-insurance companies and individuals who have no insurance or who will pay some portion of the bills covered by their insurance. This is what’s increasingly burdening businesses that pay for their employees’ health insurance and forcing individuals to pay so much in out-of-pocket expenses.

1. Here and elsewhere I define operating profit as the hospital’s excess of revenue over expenses, plus the amount it lists on its tax return for depreciation of assets—because depreciation is an accounting expense, not a cash expense. John Gunn, chief operating officer of Memorial Sloan-Kettering Cancer Center, calls this the “fairest way” of judging a hospital’s financial performance

SOUND OFFAre Medical Bills Too High? Tell Us Why

 

‘India needs a fresh approach to health sector’


Amartya_Sen, Indian economist and Nobel prize ...

 

18 February 2013

 

statesman news service

 

KOLKATA, 18 FEB: The country needs a “completely fresh approach” to health care Nobel laureate Amartya Sen said today, as an over-reliance on the private sector and lack of commitment from the state means it has gone “really, badly wrong”.

 

At a press conference this evening at the Taj Bengal hotel in Alipore to round off two days of discussions as part of his Kolkata Group workshop ~  an annual brainstorming session on pressing social issues for policymakers and activists ~ Mr Sen said the state needs to express a commitment to universal health care for all.

 

This could come in the form of legislation setting out a right to health, along the lines of the Right to Education Act, he said, although this wouldn’t in itself solve everything. “It alone will not cure the problem, and it will not become a perfect right to health just through the declaration. A number of ancillary things have to happen, including greater allocation of public funds to health care, which are woefully poor now.”

 

While other countries are moving to spend more resources on healt care, India is “totally stationary,” he said. “India is an outlier. I mean very little government commitment on expenditure and delivery.”

 

He said there is also “a very nasty and costly misunderstanding” that private health care can step in to bridge any health services gaps. There are also problems with relying on private medical insurance as a model, he said, pointing to difficulties that some people have been getting coverage if they have pre-existing conditions. “The reliance on private health care and the illusion that that can solve the problem is a major issue,” he said. “No country has been able to have a transition from bad health to good health on the basis of private healthcare.”

 

There are many good doctors working in the country, Mr Sen said. But he also expressed concern over “lack of professionalism in the medical community,” a problem he says needs to be tackled.

 

Mr Sen and his colleagues at the Kolkata Group also issued a declaration based on the debates they have had over the last couple of days. It not only called attention to the “abysmal state of health care” in the country, but also “the slow and very limited progress in women’s rights that includes a host of inequities, insecurities, and injustices.”The group in its declaration called upon the government to “recognise the recommendations of the Justice J S Verma Committee Report promoting women’s bodily integrity, dignity, and sexual autonomy.”

 

 

#India- Court issues order on right of pregnant prisoners to access MTP #womenrights #reproductiverights


MADHYA PRADESH HIGH COURT AT INDORE ISSUES ORDER ON THE RIGHT OF PREGNANT PRISONERS TO ACCESS MEDICAL TERMINATION OF PREGNANCY

 

INDORE - The High Court of Madhya Pradesh at Indore issued an order allowing Hallo Bi, a pregnant female prisoner, to exercise her reproductive rights under the Medical Termination of Pregnancy Act (Act). Hallo Bi had been sold into prostitution by her husband and after months of continuous instances of rape, she became pregnant.

In the order, the Court wrote, “We cannot force a victim of violent rape/forced sex to give birth to a child of a rapist. The anguish and the humiliation which the petitioner is suffering daily, will certainly cause a grave injury to her mental health.” This is a positive development for Hallo Bi and sets an important precedent for similar circumstances by affirming rape victims’ right to lawful termination of pregnancy under the 1971 Act. Unsafe abortions are one of the leading causes of maternal mortality in India with approximately 6.7 million abortions performed every year at unregulated facilities, often by medical practitioners untrained in abortion services.

In early December 2012, Human Rights Law Network (HRLN) Reproductive Rights Unit Assistant Director, Ms. Karla Torres, read an article in the Times of India about a pregnant woman who was in prison for murdering her husband and had been ordered to make a written application to the High Court for a termination of pregnancy. After communicating with HRLN advocate Mrs. Shanno Shagufta Khan in Indore and meeting with Hallo Bi, HRLN filed a petition requesting the High Court to allow for a medical termination of pregnancy.

The petition also stressed the Act’s silence on this issue and asked the High Court to issue guiding directions. As both the Act and the jail manual are silent on this aspect, the High Court had requested Hallo Bi to submit a written application for a medical termination of pregnancy. The High Court subsequently denied Hallo Bi’s application. HRLN’s petition stressed that the High Court had erred in not allowing Hallo Bi’s application as the power to refuse the same did not lie with the High Court.

Under the Act, the decision to terminate a pregnancy is between a woman and her doctor(s). As such, once a medical practitioner is of the opinion that the pregnant woman falls within the conditions laid down in the Act, a medical termination of pregnancy can take place. A court, therefore, does not have authority to determine whether a woman can or cannot terminate her pregnancy. Instead, a court can ensure that a woman who requests a medical termination of pregnancy under circumstances that satisfy the Act is provided with adequate medical care and services to fulfil her right to a termination of pregnancy.

Although the High Court found that Hallo Bi’s circumstances satisfied the MTP Act, the Court did not include guiding directions. Notwithstanding, HRLN plans to request a review of the petition so that this issue is taken up afresh and guiding directions are issued.

Download the full order here

 

#India- Acute shortage of mental health care staff #humanresources


      SPECIAL CORRESPONDENT, The Hindu Jan 14, 2013

India faces an acute shortage of mental health care professionals, including psychiatrists, considering the high prevalence of mental health disorders.

Studies suggest that approximately 13 per cent of the entire population may actually be suffering from some kind of mental disorder — 10 per cent with minor ailments such as stress, anxiety and depression while the remaining with serious disorders such as schizophrenia. Alcoholism and psychotropic addiction are also included in this.

According to a Mental Health Survey carried out by the Directorate General of Health Services in 2002, there were only about 2,219 psychiatrists in the country, against the required 9,696. The number of clinical psychologists was 343, against the desired 13,259. Similarly, psycho-social workers available were only 290, against the required 19,064, while the number of psychiatric nurses was not available, though over 4,000 such trained nurses were required then. Also, while there were about 21,000 beds for mental health patients in the government sector, the number was just about 5,100 in the private sector.

The country has 43 government mental health facilities, though a huge number of private facilities, known as psychiatric nursing homes, have come up. Delhi alone has 16 such facilities. The State governments are authorised to register these private facilities.

The number of psychiatrists and nurses may have marginally gone up since then and the number of patients too would have gone up substantially.

“I think we need to address mental health issues, both by addressing demand for and supply of services, and by services I mean evidence-based medical and psycho-social interventions that can address a wide range of mental health problems, including their prevention,” said Dr. Vikram Patel, eminent mental health expert and Professor, London School of Hygiene and Tropical Medicine.

This required multiple actions, from awareness building in communities and in the health workforce, to the creation of new community-based human resources skilled in providing psycho-social interventions and building capacity of primary health workers for delivery of medical interventions, he told The Hindu.

There is a huge debate going on in the country over the nature of treatment that must be provided to people with mental disorders. While a majority believes it should be home and community based — considering the condition of mental homes and public facilities — there are others who believe institutional care is also required, particularly for women, as people with mental health issues are often disowned by families and hence vulnerable to exploitation.

 

#INDIA- Mental Health Law Reform: Challenges Ahead


by Aditya Ayachit

mentalMental disorders are complex physiological infirmities of the nervous system. While they continue be the tough riddles in the field of medical research, they pose even more daunting challenges in the socio-economic and legal contexts. In recent times the mental health laws across the world have undergone a significant change. A policy of segregation has been abandoned in favor of a policy of integration and protection. Theprima facie reason for this shift appears to be the increasing influence of the Human Rights discourse over laws and policy making. Thus, a new mental healthcare paradigm has emerged which advocates that the mentally ill are not objects of charity or social protection but are subjects with rights and States and the International bodies are under an obligation to provide them with the means of enforcing these rights.The international consensus about the new paradigm was strongly conveyed by the near unanimous acceptance of theUnited Nations Convention on the Rights of Persons with Disabilities 2006(commonly known as the Disability Convention’) and Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care (or simply the MI Principles).

India is a signatory to the Disability Convention. However, it has failed to bring its laws and institutions in tune with the standards set by the convention. To fulfill its commitments under the Disability Convention, 2006 and MI principles of 1991, India needs a major overhaul of its disability laws and policies dealing with mental health care. The Ministry of Health and Family Welfare (MHFW) recently came out with the Mental Health Care Bill 2012 responding to this formidable legislative challenge. The reactions to this bill were mixed with some groups lauding provisions decriminalizing attempted suicide by a mentally ill person, ensuring the availability of insurance for treatment of mental illness at par with physical illness and prohibition of certain medical procedures like the Electro Convulsive Therapy (in case of minors), Sterilization and Chaining, while others opposing the bill on the ground that its provisions curtailed patient autonomy and liberalized the laws for involuntary admissions to mental institutions. This post does not aim to comprehensively review the bill. Rather, it attempts to map the issues that the Bill appears to address and contrasts the status quo with the regime the bill seeks to establish.

Few Mental Health Practitioners and Institutions in India

A recent statistic from the MHFW indicates that about 7 percent of the Indian Population suffers from some form of mental disorder. Another startling statistic is that 90 percent of these disorders remain untreated. The leading cause behind this paradox is the acute shortage of mental health institutions and qualified mental health practitioners in India. Our large and populous country of 1.2 billion people has about 40 mental health institutions, 3,500 psychiatrists, 500 clinical psychologists, 300 psychiatric social workers and 1,000 psychiatric nurses to treat its mentally ill citizens. In addition to this, most of the institutions and practitioners are located in urban areas. This creates a serious problem in a country like India where over 70 percent of the population lives in rural areas.

mAccording to the National Family Health Survey, the private medical sector remains the primary source of health care for the majority of households in both urban areas (70 percent) and rural areas (63 percent) of India. While private players contribute immensely to the health care industry, it remains the case that they generally shy away from investing in mental health institutions.  This is mainly due to low policy priority given to mental health sector, strict licensing requirements under the Mental Health Act 1987 and the lack of any special incentive for investing in this sector. Today in India, government health policies mainly focus on communicable diseases like HIV/AIDS, malaria and tuberculosis or on child malnutrition or on reproductive healthcare. Mental healthcare rarely finds mention in the policy. This underscores the importance of this sector and makes the investment environment in such services unattractive and discouraging.

Another factor that reduces the likelihood of private investment in mental health care is the strict licensing regime set up by the Mental Health Act 1987; the legislation that currently governs the mental health sector. This Act lays down a complicated procedure of issuing a non-transferable and non-heritable license to a person who wishes to open a mental healthcare institution. The act further discriminates between government established institutions and privately maintained institutions by exempting the government institutions from the statutory requirement of obtaining a license. If private participation is to be encouraged, this system of licensing needs to be rationalized.The Mental Health Care Bill 2012 goes a long way in this regard. The bill replaces the stringent licensing system with a simpler system of registration. The registration unlike a license is not linked to a particular person and is freely transferable for instance on the sale of the institution. It also allows the institution an appeal to the High Court if the grant of registration or renewal of registration or cancellation of registration is refused by the appropriate authority. While the bill seeks to relax the laws governing the setting up of mental health institutions it must ensure via its provisions that this does not in any way affect the quality of health care provided in these institutions. The issue of quality of health care will be taken up further in this post.

mental_health_disorders_other_issues_that_fuel_substance_abuseTo ensure that rural areas also benefit from private investment, the incentives given to invest in rural areas could be greater than those given for investment in urban areas. Another way in which the presence of mental health facilities in rural areas can be increased is by proper implementation of the District Mental Health Program which was initiated by the Government of India in 1996. Currently, the program is under implementation in only 123 of the total 657 districts of the country. A proper implementation of the program would go a long way towards ensuring that rural areas have adequate mental care facilities in near vicinity.

Poor Quality of Mental Health Institutions

The second core issue in this area is the unacceptable quality of medical care provided to the mentally ill in the existing mental health institutions in our country. It would not be an overstatement to say that the patients who receive mental health treatment in India are treated in a most inappropriate and inhuman way in our mental institutions. The institutions usually resemble prisons where the mentally ill are debased and deprived of their dignity. They are made to live in unacceptable living conditions and are shackled down in chains for long hours. They are fed unhygienic prepared unwholesome meals, are subjected to painful medical procedures without their consent, are regularly beaten and in some cases are also subjected to sexual assault. Sometimes they are sterilized on the basis of a medical myth that sterilization cures mental disability. In essence, the patients never receive adequate treatment. Rather the treatment aggravates their condition and makes them sick and infirm for life completely eliminating any hope of rehabilitation or a chance of leading a normal life (see here and here for more). Any mental health care legislation must develop a structured mechanism for ensuring that our mental health institutions do not fall short of the internationally accepted standards of treatment and care. The Mental Health Act 1987 and the State Mental Health Rules 1990 provide detailed safeguards to ensure that the health institutions meet the statutory standard. While building upon this legacy, any new legislation must incorporate the minimum standards laid down in the Disability Convention of 2006 and the MI Principles of 1991. Further, steps must be taken to bring government maintained institutions under the purview of these regulatory procedures. It may be noted here that the Mental Health Act 1987 is quite inconsistent with the principles and safeguards laid down in the aforesaid international instruments and as government hospitals are deemed to be licensed institutions under the act, it is unclear whether the procedures laid down for revocation of license in cases of non-compliance are applicable against  government facilities.

Consent of the Mentally Ill Patients

depression-4Another aspect that would have to be substantially addressed in mental health legislations is with respect to consent of the patient to receive treatment. It is a cardinal principle of medical science that no one may be subjected to any medical procedure without his/her express consent and such procedure may not continue after the person has withdrawn his consent. Mental Healthcare raises complex questions regarding consent. The Mental Health Care Bill 2012 provides innovative solutions to the problem of consent. The bill allows persons to register an ‘advance directive’ with the appropriate mental health board. An ‘advance directive’ is a legal document containing details of the kind of treatment a person wishes to receive or does not wish to receive in the event of mental illness. It also contains the details of the person’s nominated representatives who are entitled to give consent on the person’s behalf when he is not in a position to give consent. The bill provides procedures for amendment or cancellation of advanced directives and also gives powers to the Central or State mental health board to review advance directives and to suspend or amend them in some special cases (for instance when the advance directive has been made under force, coercion, undue influence etc. or when it was made without proper knowledge). While many groups are touting advance directive as a foolproof solution to the problem of consent, it remains to be seen how this statutory tool would operate in real life. This provision has been opposed on the grounds that it would be susceptible to gross misuse especially in rural areas where the patients are illiterate and are not aware about their rights.

Rehabilitation and Social Awareness

Another issue that the bill attempts to address is rehabilitation and social awareness. These concepts are inter-related. The extent to which a patient can be restored back in his life (family, community and occupation) depends on the social understanding of mental illness and the attitude of the society towards the mentally ill. A society which rejects the mentally ill or which despises them cannot possibly assist in rehabilitation of the patient. As societal attitudes are shaped to a large extent by education, an awareness program which aims towards creating social understanding about mental illness can directly assist in making the society more suitable for rehabilitation of the patient. Mental Health Act 1987does not contain any provisions regarding social education or patient rehabilitation. The Mental Health Care Bill 2012 addresses this lacunae and creates an obligation on the Central and State governments to spread awareness about mental illness and its appropriate treatments. The Bill lays emphasis on lowering the stigma associated with mental illness so that a patient’s rehabilitation in the society may be facilitated. It may be noted here that a proper implementation of the aforesaid provisions may go a long way in debunking the long standing myths about mental illness (like mental illness is caused due to demonic possession or that mental illness is incurable) and make the society a better place for the mentally ill.

socialHuman well-being in a country cannot be ensured unless its citizens are physically and mentally fit. Mental health is prone to neglect because it is difficult to detect, difficult to cure and also difficult to explain to the people. The Mental Health Care Bill 2012 appears to be a commendable effort towards addressing the long standing problems encountered by patients and practitioners alike in the sector of mental healthcare and restoring the long lost dignity of the mentally ill.

Image Courtesy: herehereherehere and here

(Aditya Ayachit is an Assistant Editor with the Journal of Indian Law and Society)

 

Medicare Is Faulted on Shift to Electronic Records


From the New York Times

November 29, 2012

By 

The conversion to electronic medical records — a critical piece of the Obama administration’s plan for health care reform — is “vulnerable” to fraud and abuse because of the failure of Medicare officials to develop appropriate safeguards, according to a sharply critical report to be issued Thursday by federal investigators.

The use of electronic medical records has been central to the aim of overhauling health care in America. Advocates contend that electronic records systems will improve patient care and lower costs through better coordination of medical services, and the Obama administration is spending billions of dollars to encourage doctors and hospitals to switch to electronic records to track patient care.

But the report says Medicare, which is charged with managing the incentive program that encourages the adoption of electronic records, has failed to put in place adequate safeguards to ensure that information being provided by hospitals and doctors about their electronic records systems is accurate. To qualify for the incentive payments, doctors and hospitals must demonstrate that the systems lead to better patient care, meeting a so-called meaningful use standard by, for example, checking for harmful drug interactions.

Medicare “faces obstacles” in overseeing the electronic records incentive program “that leave the program vulnerable to paying incentives to professionals and hospitals that do not fully meet the meaningful use requirements,” the investigators concluded. The report was prepared by the Office of Inspector General for the Department of Health and Human Services, which oversees Medicare.

The investigators contrasted the looser management of the incentive program with the agency’s pledge to more closely monitor Medicare payments of medical claims. Medicare officials have indicated that the agency intends to move away from a “pay and chase” model, in which it tried to get back any money it has paid in error, to one in which it focuses on trying to avoid making unjustified payments in the first place.

Late Wednesday, a Medicare spokesman said in a statement: “Protecting taxpayer dollars is our top priority and we have implemented aggressive procedures to hold providers accountable. Making a false claim is a serious offense with serious consequences and we believe the overwhelming majority of doctors and hospitals take seriously their responsibility to honestly report their performance.”

The government’s investment in electronic records was authorized under the broader stimulus package passed in 2009. Medicare expects to spend nearly $7 billion over five years as a way of inducing doctors and hospitals to adopt and use electronic records. So far, the report said, the agency has paid 74, 317 health professionals and 1,333 hospitals. By attesting that they meet the criteria established under the program, a doctor can receive as much as $44,000 for adopting electronic records, while a hospital could be paid as much as $2 million in the first year of its adoption. The inspector general’s report follows earlier concerns among regulators and others over whether doctors and hospitals are using electronic records inappropriately to charge more for services, as reported by The New York Times last September, and is likely to fuel the debate over the government’s efforts to promote electronic records. Critics say the push for electronic records may be resulting in higher Medicare spending with little in the way of improvement in patients’ health. Thursday’s report did not address patient care.

Even those within the industry say the speed with which systems are being developed and adopted by hospitals and doctors has led to a lack of clarity over how the records should be used and concerns about their overall accuracy.

“We’ve gone from the horse and buggy to the Model T, and we don’t know the rules of the road. Now we’ve had a big car pileup,” said Lynne Thomas Gordon, the chief executive of the American Health Information Management Association, a trade group in Chicago. The association, which contends more study is needed to determine whether hospitals and doctors actually are abusing electronic records to increase their payments, says it supports more clarity.

Although there is little disagreement over the potential benefits of electronic records in reducing duplicative tests and avoiding medical errors, critics increasingly argue that the federal government has not devoted enough time or resources to making certain the money it is investing is being well spent.

House Republicans echoed these concerns in early October in a letter to Kathleen Sebelius, secretary of health and human services. Citing the Times article, they called for suspending the incentive program until concerns about standardization had been resolved. “The top House policy makers on health care are concerned that H.H.S. is squandering taxpayer dollars by asking little of providers in return for incentive payments,” said a statement issued at the same time by the Republicans, who are likely to seize on the latest inspector general report as further evidence of lax oversight. Republicans have said they will continue to monitor the program.

In her letter in response, which has not been made public, Ms. Sebelius dismissed the idea of suspending the incentive program, arguing that it “would be profoundly unfair to the hospitals and eligible professionals that have invested billions of dollars and devoted countless hours of work to purchase and install systems and educate staff.” She said Medicare was trying to determine whether electronic records had been used in any fraudulent billing but she insisted that the current efforts to certify the systems and address the concerns raised by the Republicans and others were adequate.

The report also takes to task another federal agency that certifies the software systems used to qualify for the Medicare incentive payments, saying it should do more to ensure the systems’ reports are accurate and meet the “meaningful use” criteria.

Medicare has not audited any of the $3.6 billion payments it has made to date, according to the report, which faults the agency for its lack of prepayment review and reliance on self-reporting after money has been spent.

In their written response to the report, federal officials said they agreed with some of the inspector general’s recommendations that they clarify what hospitals and doctors need to do to qualify for the payments. But Marilyn Tavenner, the acting administrator for Medicare, strongly disagreed with the idea that the agency should do more to ensure payments are appropriate before writing a check.

Requiring an audit before paying hospitals and doctors “could significantly delay payments to providers,” she said, and these reviews “would also impose an increased upfront burden on providers.” Ms. Tavenner said Medicare took some steps to make sure providers were eligible for the payments but “does not believe prepayment audit is necessary at this juncture.” Medicare maintains that it has systems in place to verify the information being submitted.

Medicare has developed plans to audit payments it has made since the program started in 2011 and says it expects to issue additional guidance for hospitals and doctors.

The other federal agency, the Office of the National Coordinator for Health Information Technology, agreed with the inspector general’s recommendations and said officials were already working to improve the process of certifying systems.

The inspector general said Medicare should be able to review at least some payments before they were made to determine whether the hospitals and doctors actually qualified. The investigators suggest identifying a small number of providers where the information provided was inconsistent and conducting a review or audit.

 

Healthcare Models in the Era of Medical Neo-liberalism #mustread


A Study of Aarogyasri in Andhra Pradesh, EPW

By-N Purendra Prasad (purendra.prasad@gmail.com) teaches at the department of sociology, University of Hyderabad

and P Raghavendra (raghavendra868@gmail.com) is a research scholar in the department of sociology, University of Hyderabad.

The experiment in restructuring the healthcare sector through the Aarogyasri community health insurance
scheme in Andhra Pradesh has received wide attention across the country, prompting several states
governments to replicate this “innovative” model, especially because it supposedly generates rich electoral
dividends . However, after a critical scrutiny of this neo-liberal model of healthcare delivery, this paper
concludes that the scheme is only the construction of a new system that supplants the severely underfunded
state healthcare system. It is also a classic example of promoting the interests of the corporate health
industry through tertiary hospitals in the public and private sectors.

Medical neo-liberalism is characterised by the commodification of health that transforms individuals
from patients to consumers. Unlike patients, consumers who seek healthcare bear the responsibility for the
choices they make or fail to make regarding their health. As consumers are positioned to make choices about healthcare,
they also have the obligation to utilise products and services that are available to ensure good health or to treat illness and
disease. Fisher (2007) points out that patients as consumers have embraced the neo-liberal logic of healthcare so that they
too see illness in reductionist terms and seek pharmaceuticals as targeted magic bullets. With growth in customised products
and medical costs, access and affordability to healthcare has become a key issue across the world.
In the Indian context, the increased disease burden on the poor along with rapidly growing healthcare costs has been the
subject of debate for sometime now. Services in government healthcare institutions have declined over the past two decades
at the primary and secondary level, leaving the sick-poor with no option but seek private healthcare services. Several
studies have pointed out that rising expenditure on health and education is one of the main contributory factors to high
indebtedness and subsequent suicides among peasants in different parts of the country in the last 10 years (Sarma 2004;
Ghosh 2006).
Clearly, healthcare has assumed huge political signifi cance for the neo-liberal state with new and innovative (populist)
healthcare programmes being launched in several states in different forms. Among these, Rajiv Aarogyasri, a community
health insurance scheme introduced by the Government of Andhra Pradesh (AP) on a pilot basis in 2007 and implemented
in 2008 is being hailed by many experts as a model to be emulated – the scheme covers 6.55 crore people belonging to
183 lakh below the poverty line (BPL) families.Aarogyasri needs special attention as it is supposed to have mobilised a large number of voters for the ruling Congress Party during the 2009 assembly elections who helped it return
to power for a second term. This scheme’s popularity is so huge that several delegations from different states in India have
been regularly studying its logic in order to replicate it and reap similar political benefi ts. States such as Kerala, Tamil
Nadu (Kalaignar Scheme), Delhi (Apka Swasthya Bima Yojana), and Karnataka have already formulated a similar template
and are in the process of implementing it. The Maharashtra  government too announced the Rajiv Gandhi Jeevandayee Arogya Yojana, a free medical care scheme for the poor in 2011, committing Rs 800 crore in the fi rst phase to benefi tnearly 50 lakh families earning below Rs 1 lakh per annum ineight districts.

A national social health insurance scheme called the Rashtriya Swashthya Bima Yojana (RSBY) waslaunched as a centrally-sponsored scheme in 2008 to cover 2.3 crore families and seven crore benefi ciaries. The AP government has already announced that Aarogyasri will soon become a  universal health scheme and cover non-BPL families as well.

Given the pre-eminence of the scheme, it is important to assess the scheme by locating it in the historical evolution of healthcare systems in India in the context of its underlying socioeconomic and political dynamics.

Read full article here

 

# India-Mental illness, choice and rights


October 20, 2012

Harsh Mander, The Hindu

  • Until recently, the law treated persons with mental illness not as persons who deserve treatment and care, but as people who are vaguely dangerous. File Photo: S. James
    Until recently, the law treated persons with mental illness not as persons who deserve treatment and care, but as people who are vaguely dangerous. File Photo: S. James
  • Members of Disabled Rights Group (DRG) and National Alliance on Access to Justice for People Living with Mental Illeness (NAAJMI) staging a protest outside Health Ministry against the Mental Health Care Bill. File Photo: V. Sudershan
    The Hindu Members of Disabled Rights Group (DRG) and National Alliance on Access to Justice for People Living with Mental Illeness (NAAJMI) staging a protest outside Health Ministry against the Mental Health Care Bill. File Photo: V. Sudershan

The new Bill should pitch for free care to mental health patients in public hospitals.

Persons with mental illness have long been subjected to cruelty, neglect, ridicule and stigma. In the last half-century, medical science has made significant strides in finding some cures and palliatives for afflictions of the mind – of emotion, mood, thinking and behaviour. Parallel to this is the evolution in our ethical frameworks: of human rights, and acknowledgment of the equal dignity of all human beings. But changes in the law, social attitudes, and the work of healthcare institutions and psychiatric professionals, have not kept pace with these scientific and normative advances.

The Mental Health Care Bill, 2012, recently released by the government, is an exceptional State-led attempt to correct many of the historical wrongs to which persons with mental illness have long been subject. The draft emerged after a long and engaged process of consultation with persons with mental illness, their care-givers, their organisations, and professionals.

The Bill met immediately with fierce opposition from some radical disability and mental health organisations. Many of their concerns and fears are legitimate. But I believe that this is on balance a humane and progressive Bill, bravely and compassionately navigating difficult ethical and professional terrains.

Until quite recently, it was routine to lock away people with mental illness in jails or jail-like mental hospitals, kept naked or in prison-like uniforms, bound in chains, abandoned and often forgotten for lifetimes. The number of beds in mental hospitals were, however, minuscule, and the large majority of patients were denied any kind of care, except those offered by faith healers and untrained practitioners.

The new Bill contains many protections to persons with mental illness. It bars prolonged hospitalisation, chaining, compulsory tonsuring, forced sterilisation, and electro-convulsive therapy without anaesthesia, and defends rights of patients to privacy, personal clothes and protection from abuse. It also prescribes that all persons with mental illness have the right to dignity, and to live in, be part of, and not segregated from society.

The Bill also mandates that mental health services shall be integrated into general health services at all levels – primary, secondary and tertiary, and that these services shall be available in the neighbourhood. If enforced, this will draw a curtain on the long tragic history of injustices and abuses which characterised large, segregated mental hospitals.

The opening sections of the Bill are forthright in admitting that persons with mental illness suffer discrimination, and that the current law has failed to protect their rights and promote their access to health care. It goes on to assure all persons the right to ‘affordable’ good quality public health care.

I believe this guarantee does not go far enough. In these columns last fortnight, I recounted the story of Rajesh, a young man suffering from hallucinations from full-blown psychosis, badly injured, who was repeatedly refused admission by many major public hospitals in the capital. The story underlines the general experience of growing abdication by professionals and public institutions to take care of impoverished and difficult patients. I believe that the Bill must guarantee nothing less than free care in all public hospitals for all patients who seek or need care, and prescribe deterrent punishments for hospitals and professionals who refuse to provide care.

Against their will

Despite its many progressive and humane features, the Bill is still attacked by some radical associations of persons with mental illness, mainly because it retains provisions in rare cases to admit patients for care, even against their will. This debate has an important history.

Until as recently as 1987, the colonial Indian Lunacy Act, 1912, prevailed, in which persons with mental illness (described as ‘lunatics’ and ‘idiots’), were admitted into mental hospitals through the order of Magistrates. The law treated persons with mental illness not as persons who deserve treatment and care, like any other person who falls ill, but as people who are vaguely dangerous, and therefore it in effect primarily aimed to protect other people from persons with mental illness.

The Mental Health Act of 1987 partially corrected this, by allowing for voluntary admissions, but Magistrates still retained a central role for patients who were admitted to mental hospitals against their will. Mental health activists rightly campaigned against this provision, as it was undignified and stigmatising; and it was on occasion misused to abandon and ‘tame’ assertive and non-conforming women and men.

Radical mental health activists are dismayed because the new Bill still allows involuntary admissions of patients against their will. They are uncompromising that the will of the patient should be absolute regarding whether or not she wishes to accept treatment and care.

On the other hand, many persons with mental illness, and their care-givers, recognise that there are occasions when it is in the paramount interest of some patients to be given care forcefully, even when they refuse it, if the person is in imminent danger of causing harm to herself or to other people. The Bill limits involuntary admissions to only such cases, with many checks and balances. Forced admission is only for 30 days at a time. The Magistrate is removed from the picture completely, and is replaced by mandatory reviews of all such cases by mental health panels, which comprise judges but also administrators and persons with mental illness and their care-givers.

There are moments I have observed – among loved ones, friends and the young people from the streets who are now in our care – when a person is suicidal or hallucinatory, abandons home or is suspicious of loved ones, is compulsively manic, spending or gambling life savings, violent and dangerous to himself or to neighbours. In the name of human rights, no hospital or professional offers them care. But there are deeper human rights in these moments, which cumulatively may temporarily override the right of free choice. These are the rights to empathy, protection, dignity and care. I believe that the Bill is right in the delicate balance it has found, retaining the provisions for involuntary admissions, but limiting these severely with many cautions and checks.

These debates are important, and we need to listen to each other more. But while we discuss, we must welcome a draft law which promises to reverse the cruelty, ignorance and abdication, which still characterises ways the State and professionals still treat people battling demons in their minds and souls, while guaranteeing them empathy, respect, protection and care.

 

Anybody ill here and seen a doctor yet?


 

KRISHNA D. RAO,  The Hindu

GLOOMY PROGNOSIS: For the hardship that rural doctors have to endure, government service offers relatively little in terms of quality of life. Photo: Singam Venkataramana
The Hindu
GLOOMY PROGNOSIS: For the hardship that rural doctors have to endure, government service offers relatively little in terms of quality of life. Photo: Singam Venkataramana

Addressing the scarcity of medical practitioners in rural India is fundamental to achieving universal health care in the country

The Planning Commission’s draft 12th Plan for health has attracted much debate and controversy. Critics have been quick to direct their attention at two issues in it — the proposed increase in government health spending from one per cent to 1.58 per cent of GDP, and the “managed care model.” The spending increase was rightly felt to be grossly inadequate to move India towards achieving universal health care. The “managed care” model was expected to relegate the government’s role to a purchaser of services and undermine its role in the service provision. By focusing on these two issues, the debate on the 12th Plan for health, and indeed the Plan’s approach paper itself, ignores some of the more fundamental obstacles to achieving universal health care in India. For one, the scarcity of rural doctors currently prevents the delivery of even basic clinical services to needy citizens. Simply spending more or changing the way health services are purchased will not solve this problem.

Urban-rural divide

People deliver health services. Urban Indians can be forgiven for thinking that there are enough doctors in the country. Indeed, our cities are abundant with all manner of clinics, diagnostic centres and hospitals. But having a qualified doctor nearby is a rarity for the vast majority of Indians who inhabit the country’s rural spaces. According to the 2001 Census, there is a tenfold difference in the availability of qualified doctors between urban and rural areas i.e. one qualified doctor per 8,333 (885) people in rural (urban) areas of India. Addressing this rural scarcity is fundamental to efforts for achieving universal health care in India.

There are several notable reasons why doctors are reluctant to serve in rural areas. Fundamentally, the professional and personal expectation of medical graduates is not compatible with the life of a rural doctor. Their ambition lies in becoming medical specialists. Once they specialise, the professional, income, lifestyle, and family life opportunities in cities make rural jobs unattractive. Moreover, with private medical schools and their high fees dominating medical education, it makes little sense for medical graduates to take up jobs that don’t offer them the opportunity to recover their investment.

The scarcity of rural doctors places an important responsibility on the government. However, its efforts to place government doctors in rural posts have been largely unsuccessful. For the hardship that rural doctors have to endure, government service offers relatively little in terms of remuneration, quality schooling for their children and a chance at a decent family life. Human resources in the State health services are also poorly managed.

For instance, there is little transparency about transfers and postings because they are a source of both corruption and political patronage in the health system. Absenteeism is another issue. Indeed, most of the court cases facing State health departments have to do with human resource issues. However, given the professional and personal expectations of doctors, it appears unlikely that large increases in salaries and management changes will attract adequate numbers to government jobs and rural posts.

Situation abroad

Interestingly, many high, middle, and low-income countries also face a scarcity of rural doctors. Many of them have ameliorated this problem by using non-physician clinicians to deliver basic health services. In the United States, the United Kingdom, many countries in Africa, and even in South Asia, individuals such as nurse-practitioners or medical assistants, who have some years of basic clinical training, perform many of the clinical functions normally expected of fully qualified doctors. In sub-Saharan Africa and many parts of Asia, clinical services in rural areas are possible only because of these non-physician clinicians. They provide a range of clinical functions, including basic clinical services, manage deliveries, caesarean sections and abortions. Importantly, assessments from a variety of settings have shown that they perform as well as doctors.

Clinician cadre

India, however, has had an uneasy relationship with mid-level clinical cadres. At the time of India’s independence, licentiate medical practitioner (LMP)s, who underwent three years training, comprised nearly two-thirds of the qualified medical practitioners (the other one-third being doctors) and they mostly served in rural areas. LMPs were abolished after Independence but doctors never really occupied the space that LMPs vacated. Now, the shortage of rural doctors has forced some States to look towards non-physician clinicians for relief. Clinicians with around three years of clinical training currently serve at government rural health clinics in Chhattisgarh and Assam. Importantly, assessments of their performance in Chhattisgarh have shown them to be as competent as doctors for delivering basic clinical care. And because their training focuses on serving as rural clinicians and their career ambition is to have a government job, these clinicians, as the Chhattisgarh experience shows, have a greater likelihood of staying and serving in rural areas. The Central Health Ministry has proposed to expand this clinician cadre nationally through the Bachelors of Rural Health Care (BRHC) course. Unfortunately, expanding this cadre has met with considerable opposition and a former health minister even labelled them as “qualified quacks.”

The road to universal health care in India necessarily requires a serious assessment of basic problems that afflict the health system like the lack of human resources in rural areas. While this piece has focused on doctors, the rural scarcity of other health worker cadres such as nurses, lab technicians and pharmacists is equally acute and equally deserving of serious attention.

Higher government spending on health or how health services are purchased will do little to ensure that all Indians have health care if there are inadequate numbers of trained health workers with the right skill mix. The experience of other countries and two States in India show that non-physician clinicians, whether they are three-year trained clinicians or nurse-practitioners, can be part of the solution.

(Krishna D. Rao is senior health specialist, Public Health Foundation of India, and visiting faculty, Department of International Health, Johns Hopkins University, U.S. The views expressed are solely his and not of his affiliated institutions.)

 

Immediate Release-Planning Commission of India to hand over Health Care to Corporate Sector


 

English: Montek S. Ahluwalia, Deputy Chairman,...

English: Montek S. Ahluwalia, Deputy Chairman, Planning Commission, India, speaks at the closing plenary of the World Economic Forum’s India Economic Summit 2008 in New Delhi, 16-18 November 2008 (Photo credit: Wikipedia)

 

 

 

 PRESS STATEMENT

 

 

Planning Commission of India to hand over Health Care to Corporate Sector

 

The draft health chapter of the 12the Five Year Plan document is being discussed for final adoption by the Planning Commission by the end of August, 2012. The Jan Swasthya Abhiyan (Peoples Health Movement – India) expresses concern regarding the present recommendations and plans outlined in the draft chapter. The chapter fails to build on the recommendations of the High Level Expert Group (HLEG) set up by the Planning Commission, misquotes the Group’s recommendations in many places and ends by proposing a plan for restructuring the country’s health system that would effectively hand over health care to the corporate sector. It is particularly problematic that the plan document invokes the concept of Universal Health Care, while actually proposing a strategy that is far removed from the basic tenets of Universal Health Care.

 

The Plan document recommends increase in public expenditure on health from the present 1% to 1.58% of GDP. This is in sharp contrast to the HLEG recommendation of increasing this expenditure to at least 2.5% of the GDP and also at variance with the earlier pronouncements by the Prime Minister. Secondly it proposes that the Central government’s (which collects most of the taxes ) share in the additional health expenditure would be less than half of what states would contribute and that Centre’s contribution would be conditional on states’ contribution!   The Planning Commission seems to have decided thatIndia will continue to be among the bottom 10 nations in terms of percent GDP spending on health.

 

What is of even greater concern is the strategy proposed for restructuring of the country’s health system in the document. The Plan document proposes a transition from: “….the present system which is a mixture of public sector service provision plus insurance, to a system of health care delivered by a managed network”. There is, thus, a road map envisaged where the Government will abandon its central role of providing health care and become primarily just a ‘manager’ of the new system envisaged.

 

The document’s vision of ‘universal provision of public health care’ includes two components.  “..preventive interventions which the government would be both funding and universally providing” (see annexure) and  “clinical services at different levels, defined in an Essential Health Package, which the government would finance but not necessarily directly provide”. What, in essence, this formulation proposes is that the Government would, over time, confine itself to providing a small package of services and would be primarily just a purchaser of virtually all clinical services from the  corporatised private sector. The Government would thus finance (with public money), strengthen and bolster an already resurgent corporate sector providing medical services. On the face of it, this appears an almost diabolical ploy to hand over the profit-making clinical services sector to corporate hospital chains. It would also decisively halt and eventually reverse the moderate achievements of the National Rural Health Mission, in expanding public health infrastructure and services in parts of the country.

 

The public health system will now be asked to compete with the private sector to attract patients. A system is envisaged where: “each citizen family would be entitled to an Essential Health package in the network of their choice. Besides public facility networks organized .. private and NGO providers would also be empanelled to give a choice to the families”. Even this truncated role of the public system is qualified by the proviso that” “..public facilities will have to be strengthened, networked, and their managers provided sufficient autonomy to purchase goods and services to fill gaps as per need”. In other words, public only in name, but would be vitiated by the logic of the market and by the incorporation of private players into its fold.

 

The HLEG had, in its report, commented that: “since there is virtually no focus on primary level curative, preventive, and promotiveservices and on long-term wellness outcomes, these traditional insurance schemes often lead to inferior health outcomes and high health care cost inflation”. Yet the Planning Commission’s document repeatedly talks about expansion of the health insurance scheme called RSBY and its vision of Universal Health Care is nothing but a more expanded version of the RSBY scheme.

 

The document announces another bonanza to the corporate medical sector in the form of grants to set up hospitals and private medical colleges. It says: “Health has now been included with other infrastructure sectors which are eligible for Viability Gap Funding up to a ceiling of 20% of total project costs under a PPP scheme. As a result, private sector would be able to propose and commission projects in the health sector, such as hospitals and medical colleges outside metropolitan areas, which are not remunerative per-se, and claim up to 20% of the project cost as grant from the Government”. It may be noted that the only eligibility requirement is the location, and not any contribution to public health goals.

 

This document proposes that  public health facilities will have “flexibility” to raise their own finances. The Plan document says: “Tertiary care facilities would have an incentive to generate revenues if they are provided an autonomous governance structure, which allows them flexibility in the utilization of self-generated resources within broad policy parameters laid down by the Government”. There are several ways in which such flexibilities can be misused, including in the form of levying of user charges and arrangements with private entities that seek to extract benefits that conflict with the public health goals of public institutions.

 

The HLEG  had recommended : “enforcement of price controls and price regulation on essential and commonly prescribed drugs”. However, this document does not even  mention drug price regulation, in spite of a pending Supreme Court directive that the Government should expeditiously put in place a system to control the prices of drugs. Neither is the recommendation of the Expert  Group, that the production of drugs and vaccines in the public sector be incentivised, reflected anywhere in this  Planning Commission’s chapter.

 

The ideological bias of the Planning Commission’s report is clear when it says: “A pure public sector delivery system involves funding a large public sector health system, with little incentive for the service providers to deliver a quality product”Such an assertion flies in the face of global evidence that the best performing health systems are those that are publicly financed and where health care is provided either almost entirely by the public sector or by a combination of the public sector and non-corporate  providers. Neighbouring Sri Lanka has been long held as an example of such a system, where over 90% of in-patient care and over 50% of out-patient care is provided by the public sector. Mortality and morbidity rates in Sri Lanka are far better than in India, in spite of the country having a lower per-capita GNP. Thailand, in recent years, has made rapid strides in providing universal access to health services by increasing public finances and by significantly expanding public provisioning of health services. In contrast, the United States, provides ‘choice’ between public and private providers but is by far the worst performing health system among all developed countries, in spite of spending over 8% of GDP on health care.

 

The Planning Commission’s recommendations, perhaps make some sense if seen purely in the context of neoliberal economic policies. Injection of public funds into a floundering economy through the financing of the private, corporate controlled, hospital sector may seem attractive in such a context. But the strategy is disastrous in public health terms, and is designed to finish of the vestiges of a public health system that still survives in the country.