Health Insurers Vs. Hospitals-Patients Pay

So the health insurance companies have started tightening the screws on private hospitals in India. The tussle between health care services providers and the health insurance companies have been on the cards for a while now. The sordid affair burst into the limelight last week, when India’s 4 largest general insurance companies, all owned by the government of India, refused cashless services to patients in these hospitals. The insurance companies can easily do this, by throwing out these hospitals from the network of hospitals, whose patients are entitled to this benefit. The fine print that you and I sign, while buying an insurance policy says that we are entitled to cashless services in select hospitals only and the insurance companies can change this network at their sweet will.

Well, for the uninitiated here is what the problem is. Health Insurance companies believe that hospitals overcharge patients who have an insurance cover simply because the money is to come from the insurance companies. Insurance companies for long have been asking hospitals to agree to fixed rates for some common procedures and surgeries. The hospitals have been resisting this as they believe that these rates are too low and in medicine, it is quite impossible to have fixed packages for surgical procedures etc. Large private sector hospitals, who offer high standards of medical care and pride themselves on their state of the art equipment, doctors, nurses etc. believe that at the rates offered by these PSU insurers, they will not be able to maintain their standards and lose money. Thus the impasse.

Now, here is the truth. The insurance companies by and large are right in accusing the private hospitals of overcharging patients who have an insurance cover. However, in many hospitals this is not deliberate. It is just that if a doctor is in doubt about ordering a test, he invariably would ask for the test, if the payor is not the patient but is an insurance company. This is largely because he wants to be sure of his diagnosis and reduce the risk of his clinical judgement being wrong. Now one may argue that the additional test, constitutes better healthcare and the doctor is well with in his right to ask for it and viewed from this perspective, this would hardly qualify as ‘overcharging’.

The other reason for inflated bills is that we as consumers do not feel the pinch even if the hospital bill is more than what we had thought it might be at the beginning of the hospitalisation. Since the insurance company is paying we would insist on top of the line stuff for ourselves. It hardly matters, whether we really need it or a cheaper option might have been just as effective, things that we would surely consider if we were paying out of our own pocket. I recall when my father underwent a prostate surgery last year, we ran up a bill of close to Rs. 200000, which I thought was on the higher side. However, since we had insurance, I hardly felt the need to either question the doctor or the hospital. I believe, mostly this apathy of the hospital as well as the consumers towards insurance payouts inflates the bills.

Apart from inflated bills the insurance companies also believe that hospitals defraud them by manipulating patient histories and making claims on behalf of the patients, who would otherwise be ineligible for the claim. This mostly happens if a patient has a pre-existing condition (ordinarily not covered), which the hospital’s doctors would try to hide from the insurance companies. Well, there is a grain of truth in this as doctors occasionally do try to ‘help’ their patients. This is mostly on the request of patients, who desperately want to make a claim even when they know that they are not eligible. The doctors try to oblige their patients either because they have an existing relationship with the patient or when they fear that if they do not ‘help’ the patient he will go to another doctor, who will do the needful. Thus losing a patient for something like this makes little sense to them.

The insurance companies on the other hand are always looking at ways and means of denying hospitals claims, which are perfectly payable. They arbitrarily make deductions citing obscure and often questionable reasons. Many a times they release the hospital’s payments without even informing them that they have deducted part of the money. The payments are rarely made on time, the third-party administers (TPA’s) working for the insurance companies are given targets to reduce payouts to hospitals and the system is hugely inefficient. Hospitals have to incur costs by hiring people, whose only job is to follow-up with the insurance companies and TPA’s about the money owed to them.

A summary cessation of cashless facilities in private sector hospitals is hardly the solution that works. The insurance companies need to work together with the hospitals to sort out their differences on a case to case basis. The hospital as well as the insurance companies must appoint reasonably experienced and mature people to manage these relationships, who should regularly meet and discuss all cases, where the insurance company feels that the hospital has overcharged. These cases should be thoroughly investigated and if a doctor is found complicit, he should be asked to explain. The insurance companies and the hospitals should organise training programs for the doctors, making them aware of how ‘helping’ patients helps no one. If the insurance company finds a hospital’s administration itself involved in shady practices than of course they must throw the hospital out of their network. On pricing, the insurance companies must accept that hospitals have a right to price their services as they deem fit. Most hospitals will price themselves according to the quality of their services, the pull of their brand and the existing market realities. The insurance companies must accept these prices and maybe they can ask for some discounts based on the volume of business they conduct with a particular hospital. Dictating prices to a hospital is bad policy as the hospital when squeezed hard will cut corners thus compromising on patient care.

Finally as consumers, it also devolves on us to be more prudent about our healthcare spends in a hospital. We should be as careful with the insurance money as we would be with our own. If we don’t and the insurance companies keep bleeding we will either end up paying higher premiums or worse, will have no cashless services in spite of having an insurance cover.

The Need for Better Corporate Health

It was 7 PM in the evening in our Mumbai office. The day was winding down and it had been a hectic day for the sales people. The CEO wanted to review the sales plans and he had asked each sales person to present their targets and plans. We have a reconstituted Mumbai sales team and the CEO wanted to use the opportunity to interact with each sales person and also do a first hand assessment of the talent we had on b0ard. He was done with the junior most team members and now he was planning to have one final round of meetings with the supervisors to share his views and provide feedback.

As the meeting with the Managers got underway, one of our most experienced sales person, Alvin started feeling a little uncomfortable. Alvin is 36 years old and is a veteran in the industry. He has been working for us for close to 3 years now. Alvin started sweating profusely, was breathing in great gulps and was clearly distressed. He complained of tightness in the chest, heaviness all over and seemed to be unable to keep his eyes open.

As Alvin collapsed no one seems to know what to do. Someone got him down to a car and they rushed him to the nearest hospital. The Mumbai roads were as usual clogged and it took them at least 45 mins to reach the hospital. During this time, there was no one who could provide first aid and everyone prayed that nothing should happen to Alvin before they reach the hospital.

Scary isn’t it? But this is how most offices in India are. There are hardly any provisions for managing an untoward incident in the office. There are no trained personnel, who can provide basic life support till help arrives and there are no emergency protocols defined or practiced, which may help in managing a medical emergency at the work place.

There is no denying the fact that work place health is amongst the most neglected in most corporates in India. With increasing levels of work stress, sedentary lifestyles late nights and weekend business parties, corporate India today offers a lifestyle, which is fast paced and quite deadly. Coupled with pressures at home with nuclear families and live in helps being the norm, life for most people in big cities is a roller coaster and this is taking a gradual toll on everyone’s health.

Lifestyle diseases including cardiac diseases, diabetes and hypertension are catching their victims young and often by surprise and corporate India is just not equipped to handle this.

It is imperative that corporates start paying serious attention to the health of their employees. Annual health checks must be mandatory and should be taken a lot more seriously than now. It would also help if the companies could hire the services of professional counselors, who can interact with the employees regularly and shepherd them through periods of heightened stress either at work or home. There is no harm or shame in having shrinks at the workplace to help employees cope with a crisis that may be lurking round the corner. An organisation must maintain a health register of all its employees detailing their existing conditions, their risk factors, lifestyle choices, allergies, emergency contacts, family physicians et al. This information should be maintained and updated on an annual basis and should be immediately available if required.

It would also be a good idea to train a few employees in Basic Life Support techniques. I would recommend at least 1 trained person per 50 employees would be a good ratio. Everyone should know that they need to call in case of a medical emergency at the work place. Hospitals in Delhi usually help train employees and they rarely charge a fee. While, I worked in the hospitals, we made a special effort to organise these trainings. Yet, I recall, we struggled to get corporates to allow to conduct these. Most corporates looked upon these as a waste of time and a kind of marketing activity for the hospital happening on their premises.

It would also help if the corporates had a clearly defined emergency protocol and people identified who would coordinate the medical evacuation. In Alvin’s case, we rushed him to the nearest hospital. As luck would have it, this hospital did not have a cardiologist in the emergency, it did not have a cath lab, a 3 D echo any other kind of emergency cardiac support. While, they managed Alvin as best as they could and stabilised him, we were plain lucky that Alvin was not having a heart attack. Investigations later revealed that Alvin suffered from hypertension and had a deranged lipid profile. We also knew he smoked like a chimney, loved alcohol and led a wholly sedentary life. He was under immense work pressure, spent more than 3 hours commuting from Thane everyday and was trying hard to juggle personal and professional life as best as he could.

For him this was a warning sign. His body is protesting against constant neglect and abuse. For the corporate too it is a big red light. We should have known about Alvin’s medical condition in advance. More importantly we should have been better equipped to handle the kind of medical emergency we faced all of a sudden.

This unfortunately is not just our story alone. It is happening all too often in many organisations. We need to sit up, take notice and try to create a healthier and medically better prepared workplaces.

To protect the privacy of the employee, I have changed his name.