Akkriti Bhatia and healthcare services in our schools

Here is the tragic case of Akkriti Bhatia, a 17 year old school girl, who died yesterday after collapsing in her school. The Hindustan Times reports that Akkriti complained of breathlessness to her classmates, who then called her mother to send a car to fetch her. Apparently when the car arrived, Akkriti requested her teacher’s permission to go home. The teacher realising that she was seriously ill sent her off to the nearby Holy Angels Hospital, where she was declared ‘brought dead’. Akkriti, it seems died on her way to the hospital.

This is a tragedy that could have been easily averted. Akkriti was an asthamatic child. This was known to the school authorities. Yet it seems there was no one in the school, who had the sense to realise that the girl was in acute respiratory distress and someone needed to call an ambulance. Apparently the school by way of medical support had a medical room and a nurse, and the young girl was administered oxygen in the medical room. Curiously enough when her mother’s car came to pick her up, she was taken off the oxygen cylinder and was sent to the hospital gasping for breath accompanied by the school nurse and another student!

How is it that no one realised how ill Akkriti really was? Why did no one summon an ambulance and trained paramedics? Why was she sent in a car, without oxygen to the hospital? Who should be held accountable for these lapses? Are our children safe in schools?

I believe that the school was just not equipped to take care of an emergency. There was no one including the nurse, who understood the gravity of the problem. I also suspect seeing the child’s condition deteriorating, the school authorities paniced and failed to act rationally. There was neither a person nor any system to deal with a situation like this and in the ensuing confusion, a patently wrong decision of not calling an ambulance and attempting to transfer Akkriti in her mother’s car without oxygen was taken, pretty much sealing her fate.

This is scary.

Particularly, when I know hospitals routinely approach schools requesting them to manage their medical rooms professionally with well trained staff (doctors and nurses), equipment and supplies and emergency hotlines being available all the time. While working for both Max Healthcare as well as Artemis Health Institute in Gurgaon I have myself in the past proposed such arrangements to various schools. I am afraid not a single school responded favourably. The school authorities usually fobbed us off by saying that they had a nurse and at times a doctor, who visited the school two hours a day and they believed that this was more than adequate for their needs. The hospital was always looked upon with suspicion of making money off the school. Many a times, I would request our paediatricians to accompany me to help convince the school head mistresses but all to no avail. They just could not look beyond their noses and my old fear of school authorities would make me beat a hasty retreat.

The blame for this tragedy must lie squarely with the school authorities. A child, while in school is their responsibility. In an emergency they must have set protocols and trained personnel to handle the situation in an orderly and efficient manner. That a well known school like the Modern School, reacted in a manner that cost one of their student’s her life is not only tragic but downright shameful.

Pricing Healthcare Services

The pricing of services in a hospital is perhaps one of the most complex and difficult exercise undertaken by the hospital managers. Pricing is  usually a Marketing function in most industries and the final call would usually rest with the Marketing chief. However, in hospitals this seldom happens. Pricing issues are generally discussed and debated in the executive committees and the leadership teams, views are sought from senior medical leaders and usually a consensus is arrived at. l,

Many hospitals follow a ‘market based’ pricing model, which simply means they comb through the pricing policies of their competitors, get pricing data from various labs and other diagnostic centres through their referral sales teams and establish their pricing either basis a premium or a discount from their chosen competitors.

Very few hospitals have a ‘cost plus’ pricing system. Developing an accurate costing of all medical procedures is next to impossible. This is simply because the medical consumables used vary from doctor to doctor and also depend on the complexity, age and general condition of the patient. The cost is also invariably a function of the training and competence of the concerned doctors and medical staff attending on the patient. Thus the cost of a bypass surgery may vary dramatically depending on the condition of the patient, the competence of the surgeon and his team and co-morbidities like diabetes.

The calculation of a price is usually based on a ’surgeon’s fee’. On top of this is added the cost of anaesthetic gases, the anesthetist’s fee, an OT fee and OT consumables. The surgeon’s fee is usually checked with the hospital’s surgeons and if it is Rs. X, the fee for surgery inclusive of gases, anaesthetist’s fee and the OT charges usually adds up to Rs. 2X. 

The patient on top of this is charged room rent depending on his choice of the hospital room, the cost of medicines and room/ward consumables and all diagnostics. The hospital also charges exorbitant consultant’s visiting fee every time he/she visits a patient in the hospital. (Some hospitals like Artemis cap this to a maximum of two chargeable visits). Strangely all hospitals charge a premium on all services if a patient chooses a single or higher category rooms. This simply means that if one opts for a single room one pays higher for everything, the surgeons fee, the cost of surgery and diagnostic tests. Most people do not know this and believe that the hospitals charge a premium only on room rent. Many would consider this a pernicious practice simply because a surgeon’s skill and time, which are the determinants of his fee has nothing to do with the room category a patient is in.  

Some hospitals like Max Hospitals create price bands for surgeries based on their complexity and average duration. Thus all surgeries in a particular band has the same basic surgeon’s fee. On top of it is added everything else.

Healthcare Pricing in India is still very unscientific and subjective. This is a far cry from the pricing models prevalent in the US, where ICD and other scientifically designed parameters help assess the cost of a procedure and patient billing. Health Insurance companies have been able to push through accurate and scientific billing procedures.

The need for a better system for patient billing in hospitals is acute. The government must establish a regulatory body to help fix the basic billing rules for all hospitals. The hospitals should than be allowed to price themselves as they wish keeping in mind their expenses etc. I would reckon once insurance companies gain prominence as payors, they would start dictating their terms to the hospitals.

And that would be a different story altogether.

Compulsory Rural Postings After MBBS

The Hindustan Times reported a few weeks ago that the Union Health Minister Dr. Anbumani Ramdoss has announced that young medical graduates, fresh out of medical schools will now have to mandatorily serve one year in rural and semi-urban centres in India.

Dr. Ramdoss believes that this will help in augmenting healthcare services in these parts of the country. It is well known that in the Indian hinterlands the availabilty of healthcare services is pathetic.  In villages, where more than 66% of India lives, it is rare to find a qualified doctor. In semi-urban centres too modern, good quality and reliable healthcare is largely unavailable.    

The government has set up a network of Primary Healthcare Centres in the rural areas. However, these centres are mostly crumbling buildings with poor or non existant medical infrastructure. The doctors posted in these back of the beyond places are mostly conspicuous by their absence. District Hospitals established in all district head quarters are also in a bad shape. The medical infrastructure is poor, doctors are poorly paid and are mostly buried under an avalanche of patients. 

While good quality healthcare remains out of the reach of most Indians living in rural and semi-urban India, their does seem to be a crying need for qualified doctors. However, I am not sure if a compulsory posting of young doctors is the solution.

The minister must recognise that young doctors passing out of India's medical colleges aspire to a career in medicine, which can afford them a modern and comfortable life. They see their peers passing out of fancy business schools choosing high profile careers in business . A doctor toils much harder-many years at the medical school to earn a grduate degree, followed by a gruelling post graduate course and than the struggle for a job in an intensely competitive medical world. Now to send them for one more year to the inhospitable Primary Healthcare Centres and District Hospitals appear to be cruel.

Moreover, one is not sure how competent fresh medical school graduates are and what quality of care will they be able to deliver in ill equipped and distant rural and semi urban medical centres, where they might have to work unsupervised. While, they may be much better than what we have today (assorted quacks), they will hardly be able to do justice to the demands of their profession.

While the minister might argue that since medical education in India is largely subsidised by the government and therefore it has a right to ask these young graduates to spend one year of their professional life working for the government in far flung inaccessible areas, this would hardly cut any ice. By the same logic shouldn't engineers, business and science graduates passing out of government owned colleges and Universities be also required to serve in remote areas. This can never work.

I do believe that there are no easy answers here. It will take many years for good quality healthcare services to 'trickle down' to these remote rural areas. For the moment, the government must provide roads and communication infrastructure, which allows patients to be quickly transported to urban centres, where relatively better healthcare is available. The government must offer incentives such as an option for subsidised post graduate education, health insurance and guaranteed employment for doctors, who choose to serve a year or more in rural hospitals. 

Last but not the least the government must improve its healthcare infrastructure. It must invest in better equipped facilities, ensure better hygiene and provide a better professional work environment. It can even experiment by involving private players in a model which guarantees minimum returns on private capital and the franchisee will guarantee far better and more efficient care.

At the end of the day, the government must try and attract young doctors rather than force them into rural postings.

Homeopathy in a Modern Hospital

A few days ago I received an sms from Artemis Hospital exhorting me to check out their Homeopathy services! This seemed strange as Artemis Hospital is one of the most advanced centres of medical care in North India and boasts of the highest level of medical advancement. It has invested tonnes of money on advanced imaging equipment such as a 3T MR, a 64 slice CT scanner, a PET CT and a 4D Doppler amongst other fancy stuff.

Artemis has highly experienced doctors and surgeons who literally operate on the cutting edge of technology. Amongst all this Homeopathy seems to be a little out of place.

Ask any doctor worth his salt about homeopathy and other alternate systems of medicine common in India and he will be downright derisive or at best will say that he is not sure of their efficacy. Doctors are trained in the science of medicine and surgery and rely on scientific evidence proven in laboratories and tested on animals and humans in scientifically designed and executed clinical trials. For them to accept homeopathy, ayurveda or the yunani system of medicine as effective treatment is difficult. Yet we have a modern hospital offering the services of a homeopath. I am intrigued.

Now, I have nothing against any system of medicine. I am sure the practitioners of any of these alternate systems of medicine have their own methods of diagnosing and treating people and I would also concede that there are enough people who believe in them. However I do know that God forbid, if I ever need serious medical attention I would head straight to a doctor qualified and experienced in the western system of medicine.  To me that is a straightforward choice.

I am also against mixing the modern western medicine with the likes of homoepathy and ayurveda. They just do not mix well. I would think twice about referring a friend to a modern hospital, which also offers homeopathy and ayurveda. Somehow, it appears that the hospital and the medical folks do not have enough faith in their own system of medicine. It seems like a tacit admission of the fact that these ancient alternative systems of medicines have something to offer even when modern medicine has failed. This I personally find hard to believe.

Arguments about offering a choice of medical systems to patients are also common place. This to my mind is bunkum. The patient wants a cure for whatever ails him. He wants it fast,with minimal pain and with a certain degree of reliability. He cares two hoots about the choice of medical system. If he walks into a hospital, he has already professed his faith in the western system of medicine. Offering anything else to him is downright foolhardy.

Why would Artemis hire the services of a homeopath and than go about promoting it? I can only say that if they are serious about homeopathy, they can always consider launching a homeopathy institute and call it something appropriate. After all Artemis Homeopathy Institute does sound weird. 

The Time of the AOP

It is again that time of the year, when folks like me get busy churning out fancy annual operating plans (AOP). I dare say that some times this exercise turns into a great farce, a tug of war where there are no winners and everybody ends up on the floor exhausted.

Now don't get me wrong. An annual operating plan, which spells out the annual goals of the business enterprise, the revenue projections, the budgeting of costs, the complex analysis is an integral part of managing a business. The AOP is essential as it helps set the agenda, gives direction and helps allocate scarce resources in alignment with business goals.

However, while these objectives in themselves are laudable, the AOP often gets hijacked and becomes an exercise in conjuring up fancy numbers, which are no more than wishful thinking of the powers that be in an organisation. The AOP than becomes a football, which is kicked around and the spreadsheets keep spewing numbers till a set catches the fancy of the powers that be and voila, you have got an Annual Operating Plan.

Here are a check list of things that I would definitely do, while preparing an AOP. 

Align the Leadership Team: An AOP should be a collaborative exercise involving the leadership team of the organisation setting the agenda and direction, while senior managers providing inputs and doing the numbers. The leadership team of the organisation must meet and choose its overriding goals and percolate these down, so that everyone is aligned towards a common organisational goal. Hospitals, often do not know whether they will focus on the topline or the bottomline in a particular year, or whether they will drive a particular speciality, which is lagging or strengthen another area, which is already doing well. The leadership team must discuss all these choices before work on AOP commences and it should keep on fine tuning these goals as the real picture emerges from intense number crunching.

Not getting Lost in Numbers- I have seen this happening often enough. As one dives deep into numbers and analysis, one forgets the objective of the exercise. The deeper the dive, better the insights and more exhilarating the exercise. However, the entire effort becomes meaningless if the insights generated are of no real or practical value. I would strongly recommend that before commencing an analysis, it is best to write down a hypothesis, make a plan and than dig out the relevant numbers, which either prove or disprove the hypothesis. This will bring focus and perspective to the AOP.

Temper the AOP with a strong dose of Reality: Sometimes, while doing the AOP we tend to get carried away by what the numbers are indicating. This is a self defeating exercise. Sometimes numbers alone do not tell the entire story and often inputs from front line managers and sales people can bring about the much needed balance and realism in the AOP.

Never tailor the AOP to meet hypothetical goals: Business Managers, while planning the AOP sometimes tend to fit in numbers to make the AOP look rosy. This is nothing but an exercise in self deception. The assumptions that underpin an AOP must be realistc, based on past data and current market conditions. They should incorporate a reasonable stretch but putting up fancy numbers to make the big bosses happy is foolish and serves no purpose. Smart bosses will in any case spot the anomolies in a jiffy and those who don't certainly do not deserve to be where they are.

Never make this an Endless Exercise: The permutations and combinations possible, while preparing an AOP are huge. Conceptually if one wants to churn numbers one can go on endlessly. I would recommend setting a tight deadline and than work hard towards ensuring that the AOP is closed well in time before the next FY. I have known and worked in organisations, where AOP discussions, would stretch till July or more and by then the AOP becomes meaningless.

Use Judgement and Common Sense: Sounds silly but often immersed in numbers one tends to look at things very differently. It is always best to use judgement and common sense, when numbers are telling a tale, which seems unlikely. I personally believe that judgement based on experience counts for a lot more than what the numbers alone might be saying.