Vision of a reformed healthcare

Ravi Mariwalla

A more unified focus on health will have to be intense or the country may silently slip into a coma. The issues being highlighted in the media are often isolated reports, critiques and mere descriptions of what is wrong and in a piecemeal manner. There is need to direct our energies to improve the delivery of health services.

There is an appalling difference between the large corporate hospitals and the 3-10 bed nursing homes even in large cities where surgeries are performed without air conditioning, anaesthesia equipment and proper instrumentation. Malpractice extends from incorrect to inadequate sharing of information whether about procedure benefits, known complications, pricing alternatives or giving patients proof of the procedure done and prostheses implanted.

We could be followers of ideas experimented with in the West or we could think afresh, innovate. We do not seem to have experienced thought leaders, and the funds required to innovate. Instead, we could study western trends, even rejected ideas and current thinking and choose the way forward.

The National Accreditation Board for Hospitals (NHAB) needs to be given teeth to significantly impact hospitals. Sadly, about 50 per cent of this country’s medical and paramedical professionals haven’t heard of the NHAB. Another 40 per cent have no clue to what the acronym stands for. Most of the 10 per cent who do know refuse to participate. Only 29 hospitals have obtained accreditation while only 85 have applied for it. That is one per cent of Indian hospitals.

What can we emulate from the West? The U.S. government spends 21 per cent of the GDP or $2.3 trillion to help ensure the health of its citizens with a special focus on its geriatric, disabled and underprivileged populations.

Though the U.S. is a market economy, Medicare, Medicaid, NCQA, HHS, JCAHO are very active and work on patient safety enhancements by public web sites such as “Hospital compare” publicly and objectively listing hospitals in your county/region compared on process and outcome measures you can select.

The Joint Commission accredits over 90 per cent of American Hospitals (a total of 4250 hospitals) and assesses compliance on over a thousand standards in areas such as patient education counselling and patient rights to information (medical, financial), protocols for prescription of drugs and tests, closed loop medication administration with checks on drug route, frequency, dose, allergies, patient safety in all aspects of hospital care, assessment, ordering, documentation, treatment and follow up.

Apart from this, there is infection control, tracking and minimising nosocomial infections, reporting adverse events and near misses. Medical documentation includes discharge summaries, instructions, facility design, space allocation, signage and qualifications of staff, and ratios of patients to staff. Quality and performance improvement programme includes committees for ethics, pharmacy, surgical procedures, mortality and clinical trials.

Managed Care includes health insurance initiatives to rein in reimbursement by utilisation and quality reviews, prescription reviews and reimbursement strategies such as capitation that delink actual consultations from compensation.

Empowering patients by health information on interactive portals, websites and the creation of tax free health savings accounts free them from the tyranny of insurance fine print and moving care out of hospitals into physician offices and ambulatory centres that are less expensive than hospitals.

Will emulating these methods and practices solve all our ills? Maybe, not. However these will constitute a first step in our movement towards a safe, reliable and monitored health services delivery.

This may not impact physician referral fees or “cuts”. But they will definitely institutionalise the “must have” features for a minimum standard of care across the nation, reducing practice variation and enabling clinicians to practise safe medicine while empowering the consumer to exercise his choice.

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