20 May 2024 – The Hindu

Reducing the Hospital Bill Burden

• Ayushman Bharat, Venture Capital Fund, National Health Profile, Indian Journal of Public Health, National Health Mission, Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), National Medical Commission, PM National Dialysis Programme, Ransomware Attack on AIIMS Delhi, One Health Approach, Public Interest Litigation (PIL), and Clinical Establishments (Registration and Regulation) Act, 2010 are the subjects of the preliminary examination.
• In February 2024, during the hearing of a Public Interest Litigation (PIL), the Supreme Court of India gave the central government instructions to devise measures for controlling the rates of hospital treatments in the private sector. The high procedure rates and wide regional disparities in recent years served as the impetus for the PIL and directive. The procedure expenses of cataract procedures, which only cost roughly Rs. 10,000 in a government setting and between Rs. 30,000 and Rs. 1,40,000 in private facilities, were used by the Court to illustrate the issue.
• Clinical establishments must “charge the rates for each type of procedures and services within the range of rates determined and issued by the Central Government from time to time, in consultation with State Governments,” according to Rule 9 of the Clinical Establishments (Registration and Regulation) Act, 2010 and the Clinical Establishments (Central Government) Rules, 2012.” If the government was unable to come up with a plan to control rates, the Court decided the Central Government Health Scheme rates as a stopgap remedy.

What are the Central Government (Clinical Establishments) Rules of 2012?

• The Clinical Establishments (Central Government) Rules, 2012 were created by the Central Government using the authority granted by section 52 of the Clinical Establishments (Registration and Regulation) Act, 2010.

Central Government appoints Secretary of the National Council:

• Ex-officio Secretary of the National Council for clinical establishments established under sub-section (1) of section 3 of the Act shall be the officer holding the rank of Joint Secretary in the Ministry of Health and Family Welfare, Government of India, who is responsible for matters pertaining to clinical establishments.

The National Council and the Committees Under It:

• The Central Government will need to approve the classification and categorization of the clinical establishments of recognised medical systems by the National Council. The National Council will designate each subcommittee, specifying its roles, the quantity and kind of members to be nominated, and the schedule for work completion.
• Efforts should be made to guarantee that each subcommittee has a sufficient number of representatives from across the nation, including experts in related fields from the private sector, public sector and its organisations, non-governmental sector, professional bodies, academia, and research institutions, among other sources.

Minimum Requirements for Diagnostic Medical Facilities:

• Any clinical setting that deals with the diagnosis or treatment of illnesses and in which laboratory or other medical equipment is typically used to conduct pathological, bacteriological, genetic, radiological, chemical, biological, or other diagnostic or investigative services must adhere to the Schedule’s minimum standards for facilities and services.

Other Requirements for Clinical Establishments to Register and Continue:

• It is required of every healthcare establishment to prominently display in both local and English the rates paid for each type of treatment and facility offered for the benefit of the patients.
• The rates that the clinical facilities charge for various operations and services must fall within the range that is periodically established and released by the Central Government, after consulting with the State Governments.
• The Central Government or the State Government, as applicable, may from time to time determine and issue Standard Treatment Guidelines, and the clinical institutions are required to assure conformity with them.
• Every patient’s electronic medical record or electronic health record, as determined and issued by the federal government or the state government, as applicable, shall be maintained and made available by the clinical establishments on a periodic basis.

What Are the Main Causes of India’s Increasing Healthcare Expenses?

India’s Profit-Driven, Unregulated Health Sector:

• Private providers, whose rates are set by the market, provide the majority of healthcare services in India. Because of their imperfections, the health care markets need to be regulated to prevent inefficiencies and injustices.
• Health care providers prioritise profit through higher prices and overprovision of care in an unregulated market-driven environment (supplier-induced demand). “Yardstick competition” is one possible remedy, in which regulatory bodies establish benchmark pricing based on market findings.
• However, the lack of strong regulatory frameworks, inconsistent pricing data, and a variety of patient profiles provide difficulties for this strategy in India. Because of lengthy wait times, perceived problems with service quality, and gaps in patient information, depending only on competition from government institutions is insufficient and increases the likelihood of supplier-induced demand.

Elevated Outside-of-Pocket Expenses (OOPEs):

• OOP accounts for more than half of all health spending in India. The remaining half is derived from a variety of jointly owned and controlled resources. The majority of small-scale providers make up the private sector. Rates may be standardised, but there may be uncertainty surrounding their application.
• The lack of clarity surrounding the enforcement methods for adhering to mandated rates raises concerns regarding the practicality of certain regulatory actions. Concerns have been raised about providers not following the recommended procedure rates, similar to how they have objected to the rates in other health plans.

Weak Law Implementation:

• Price limits and other financial controls that impose command and control on actors can quickly change their conduct by forcing them to abide by the declarations made. But these impacts are fleeting because the environment as a whole doesn’t change when enforcement mechanisms are lax.
• There are significant obstacles to the proposed measures’ enforcement. The Clinical Establishment Act of 2010 has only been notified in 11 States and seven Union Territories. Its implementation is still in its infancy, and there is scant or nonexistent data regarding its effects on provider behaviour, care quality, and affordability.

Problems with Medical Device Capping:

• The National Pharmaceutical Pricing Authority’s decision to control the cost of stents and implants since 2017 as well as the numerous directives requiring physicians to prescribe generic medications have been effectively impeded by capacity issues related to design and implementation. Rate standardisation by price caps might not be able to solve the underlying issue of unbalanced incentives among stakeholders.

Healthcare Corporation Privatisation:

• Over the past thirty years, India’s tertiary care landscape has undergone significant transformation. Large tertiary healthcare providers in India used to be part of charity trusts or foundations, which put patient care ahead of business, in contrast to the current system, which is sometimes criticised for “corporatization” of healthcare. These hospitals provide better healthcare by using the newest, most advanced technologies. The patients bear the expense of these.
• Conversely, private practitioners are subject to relatively minimal regulations concerning the fees they charge. The Clinical Establishment (Registration and Regulation) Act, 2010 attempted to greatly increase patient transparency in the process of obtaining treatment; however, numerous medical societies nationwide attempted to block the law’s passage.

Insufficient Funding for Public Hospitals:

• Given the population’s size and healthcare needs, investments in public hospitals and primary healthcare facilities are insufficient. The Drug Price Control Orders, 2013, which cap the price increase of pharmaceuticals, especially for common and life-threatening conditions, are a historical means by which the State has managed the prices of medications. However, because they are not funded by the State, medications still account for a sizable portion of the OOPE.
• Remarkable cases of physician absence in public health exist, most likely as a result of meagre financial incentives. The World Bank reports that there is only one bed available for every 2000 people, due to a lack of dependable infrastructure and technologies.

Not Given Enough Political Priority:

• Worldwide, the pharmaceutical industry’s rise has made medications more affordable for individuals, but in India, the subtle spread of dishonest business practices is making medications less accessible.
• Urban agglomerations offer top-notch healthcare, but public healthcare is nevertheless overburdened and underfunded. The adoption of insurance is sluggish, and many continue to liquidate their possessions to cover medical expenses. These significant limitations on the availability and price of healthcare demonstrate that political priority always extends to health, which is not the case in India.

What Are the Various Strategies for Stopping India’s Healthcare Costs from Rising?

 Standard Treatment Guidelines (STGs) formulation:

• The Supreme Court has noted that any conversation about pricing needs to begin with a standard by which prices are determined. The nature and scope of care, the prices of all necessary inputs, and pertinent clinical needs can all be established with the aid of STGs.
• Confounding factors that explain different standards of care for different hospital procedures can be addressed by STGs while maintaining clinical autonomy to meet the requirements of each patient. As such, it makes it possible to accurately determine the cost of various operations when assessing the health-care resources used.
• The creation and deployment of STGs necessitate that providers’ revenues be linked to a smaller number of payers due to limited regulatory capability. In order to cover the majority of the population with low OOP payment levels, providers must rely on reimbursements from pooled payments.

A Comprehensive Strategy for Health Financing Reform Is Needed:

• Rate standardisation by price caps might not be able to solve the underlying issue of unbalanced incentives among stakeholders. Without a comprehensive plan for reforming health funding that is based on thorough and continuous study on the best ways to develop and implement benchmark standards, real pricing can be controlled and rationalised in any way.
• Hospitals with lower average revenue per bed, for instance, can raise their prices by highlighting the greater calibre of their care. Objectively verifying such claims will be next to impossible without common standards.

Adhering to the Tamil Nadu and Rajasthan Models:

• Some states, like Tamil Nadu and Rajasthan, buy inexpensive, unbranded generics from manufacturers and sell them straight to patients through centralised agencies in order to finance medical care and avoid profit margins for supply chain participants.
• OOPE for medications would also be drastically altered if this were extended to private providers. Implementing insurance programmes is a sensible and forward-thinking move, considering the prevailing private healthcare market.

Preserving Openness in Rate Standardisation:

• Among all the commercial services in India, private healthcare providers may be distinctive since their fees are typically not openly accessible to the public. This has to do with the vast range in prices that can be paid for the same surgery or treatment by different hospitals in the same area as well as by different people receiving care at the same facility.
• According to the Clinical Establishments (Central Government) Rules, 2012, healthcare providers are required to display their prices and charge standard rates that are periodically set by the government. Surprisingly, though, these legal restrictions have not yet been put into practice, twelve years after they were passed.

Stopping Senseless Medical Interventions:

• Standard methods must also be put in place to verify irrational healthcare interventions, which are currently widely supported because of financial concerns.
• As an illustration, in India, the percentage of caesarean deliveries in private hospitals (48%) is three times more than that in public hospitals (14%). The percentage of caesarean sections performed in private institutions is significantly higher than the medically advised range (10–15% of all deliveries).
• Not only will rationalising treatment methods and reducing needless medical procedures reduce the exorbitant costs that many private hospitals charge, but they will also greatly enhance patient outcomes.

Putting Patients’ Rights Into Practice:

• There are significant knowledge and power disparities between hospitals and patients; therefore, certain rights are widely acknowledged as necessary to safeguard patients. These include the right to a second opinion, informed consent, confidentiality, and the freedom to choose the provider from whom to obtain tests or medications; guaranteeing that no hospital should hold a patient’s body for any reason; and the right to learn basic information about their condition and course of treatment.
• Additionally, considering the incapacity of current mechanisms such as Medical Councils to provide fairness for patients with grave grievances pertaining to private hospitals, it is critical that easily navigable grievance redressal systems be implemented at the district level and overseen by multiple stakeholders.

Managing College Commercialization:

• It is really necessary to take certain complementary efforts regarding medical education in addition to these private healthcare procedures. Controlling commercialised private medical colleges is desperately needed, especially when it comes to requiring that their costs not exceed those of government medical colleges. Public colleges must be the primary target of future medical education expansion, not for-profit private universities.

Restructuring NEET and the National Medical Commission:

• Considering the concerns levelled against the National Medical Commission over its overly centralised decision-making, lack of participation from a variety of stakeholders, and tendency towards increasing commercialisation of medical education, the commission needs an impartial, multi-stakeholder evaluation and reform.
• Restructuring the National Eligibility-cum-Entrance Test (NEET) is necessary since it disproportionately disadvantages applicants from less affluent families and infringes on the states’ right to choose their own medical admission procedures.

What are the Different Healthcare-Related Government Initiatives?

• Mission of National Health
• Bharat Ayushman
• The AB-PMJAY is the Pradhan Mantri Jan Arogya Yojana.
• Commission on National Medicine
• PM National Dialysis Initiative
• Karyakram, Janani Shishu Suraksha
• Karyakram, Rashtriya Bal Swasthya
• Budget 2021 Allocated More for Health.
• The Swasth Bharat Scheme of PM Atmanirbhar
• Mission for National Digital Health
• The 2019 National Medical Commission (NMC) Act.
• Bhartiya Janaushadhi Pariyojana Pradhan Mantri.
• Observing the Supreme Court provide a chance to develop efficient procedures to address a significant issue facing the health system. Policies for rate standardisation must be workable, simple to execute, and compliant with accepted methods for price discovery. Subsequent endeavours have to expand upon prior and current health financing improvements, tackle projected obstacles, and guarantee increased involvement from stakeholders.
• Creating a healthcare system that upholds each person’s rights and dignity is equally as important as offering medical care at an affordable price. It calls for providing healthcare services that are easily available, reasonably priced, and sensitive to cultural differences, as well as attending to the various needs of all individuals, particularly the marginalised and vulnerable. To improve health outcomes for everyone, inclusive healthcare is not only a practical need but also a moral obligation.