Healthcare is business with a cause: it’s a telling statement. It reflects a blend of both the business of care delivery and the cause of human suffering/healing. Across this case study, as Abhed Govil probes deeper, he unravels the mismatches and dilemmas around the balance between the business and the cause. It is unfair to assume that the cause of human suffering is the driver for sustainable hospital business. Similarly, there are many scenarios of multiple conflicting rights here choices are not clearly available. For instance, the motivation for innovation in medical technologies will be diminished without the profitability gains attached to it. Therefore, the solution lies in the blend of the business and the cause. The point is: how we balance and make the blend effective. In the context of this case, stated below are 10 key areas to ponder.
- Responsible Purchasing: The ever evolving dynamics of the power triangle between doctors, owners and management in any hospital cannot be ignored. What it takes to arrive at the meeting point is to first define the clarity on standards of medical quality and ethics for everyone to abide by. Balancing between cost/margins and quality of care is valid as long as it does not compromise safety. There is no need to overdo quality. Likewise, one cannot underdo it either. Safety is the point that differentiates acceptable quality from others. Surgeons must be given the first and last right to make the choice of device in the interest of the patient. While their decision must be upheld over the motives for profitability, they must be able to justify their decision to the purchase manager.
- Influence In Prescribing: I discussed this in the previous analysis as well. It is hard to tell if the influence is positive or negative. Extreme views do not work. Tipping point here is to make disclosures. If payments to physicians were disclosed to public, then Abhed would have a means to assess if there is a conflict of interest due to commercial dealing between the surgeon and the supplier. Banning an activity also kills its upside along with its downside. Disclosures will moderate it.
- Referral Bonus: What if the MRI was actually established inside the hospital and the surgeon got a bonus for cross-selling services? All too suddenly this begins to look ethical. Absolute idealism is impractical and unsustainable. Tagging referral fee as a kickback or a cut does not resolve. Instead, it promotes black money dealings to settle the marketing alliances. Rather, we could consider regulating it at an ecosystem level. This is not to say that kickbacks are being legalised. Transparently incentivising referrals will encourage innovation of many more care delivery models – with needed collaboration and high levels of interoperability. Whereas what needs to stop is hospitals refusing to accept external diagnosis reports — isn’t that a forced internal referral?
- Managing Affordability Without Compromise: Plot the treatment options on a graph with timeline on the x-axis (from old to new technology) and price on the y-axis. Now, plot original and copies for a relative positioning. Based on available cash, it is wiser to shift to an older-but-original quality instead of a newer-but-fake. Metaphorically speaking, it is more assured to get an original iPhone4 instead of a fake iPhone6. When budgets are limited, choose reliability of the old-original over the advancements of the new-fake. Likewise, shift to a reliable value segment brand instead of a copycat of the top brand either way stick to reliable quality.
- Know Your Options: This phrase is relevant at all levels — for decision by purchase manager, for decision of choice by surgeons or for patients to make their choices. The most comprehensive way to address this need is to start mapping it to a reliable and latest disease classification like ICD-10 with all options filtered by their availability status in the local area. This is unlikely without the regulators’ will. Else, best it can go is through a non-profit organisation adopting this as a mission. Universal listing is a foundational step in enabling informed choices.
- Health (care) Awareness: There is enough said about healthy eating. We all make our own choices based on a variety of information gathered through many means — reading, media, family/friends, internet etc. None of us are qualified nutrition experts. Nor are we training to become dieticians. We do this research and take active interest as a responsibility towards our own health or the health of our dears. Then, likewise, why are we not doing the same when it comes to healthcare? Even the regulator supports the standardisation of nutrition facts on labels across food items to aid our endeavor to stay healthy. Awareness of medical terms and options is equally important. When in need, credible information must be easily available. Professional associations for every specialty and the NGO/NPO sector have to play a key role here,in addition to suppliers and providers.
- Informed Consent: Is it just about a form to be signed? Unfortunately, the essence of this is lost when it simply boils down as requirement for paperwork. Do patients really understand the risks, benefits and alternatives of the proposed treatment options, before they sign the consent form? That is the difference between simple consent and informed consent. It is a legal and ethical right of the competent patient (or surrogate thereof) to direct the choices about her/his own body; and, in turn, the ethical duty of the physician to involve the patient in such decisions including but not limited to the nature of the decision/procedure, reasonable alternatives to the proposed intervention, the relevant risks, benefits, and uncertainties related to each alternative. In this case, Abhed needs to crucially examine the controls over the assessment of his mother’s understanding of her treatment and her acceptance of the intervention.
- Common Minimum Standards: The regulator needs to raise the bar for entry. Nip it in the bud — that’s the most effective way to keep the market free from sub-standard quality. Framework to regulate devices needs domain depth in every area plus a process of incorruptible independent validations. We have to treat the allowance of sub-standard devices into the menu, at the same level that we treat arms and bombs entering our society to kill our citizens.
- Error Reporting And Agile Active Vigilance: Consumer complaints and redressal mechanisms are an integral part of a continuous improvement process. We have to take a stronger stand on medical accountability with fair and appropriate consequences for negligence. If we really mean to make safety a priority, then cases of negligence must be dealt with the same level of harshness as those of dowry and other such heinous crimes. We have to offer whistleblower protection to encourage reporting. Enforcement is not an easy task.
Nabbing the malpractices will also need agile,active, non-corruptiblevigilance. Public participation is the most sustainable way to do this. Culture of accountability is a balance between rewards and sanctions – or carrots and sticks. Positive fear is an important watchdog. For simple examples, we can look at the DND complaints process supported by TRAI; or how the RTI Act has shown its worth in changing the tone of our democratic setup. The design of the road map that implements error reporting may reference such similar tried and tested formats. - Collective Accountability And Shared Decision Making: Healthcare delivery is a not a solo sport. Collaboration must pool expertise and resources for assured outcomes and improved patient care. Evolution beyond informed consent is shared decision making; where the doctor and patient participate with each other in collating/analysing all possible dimensions and variables to make decisions together. This open-dialogue-approach is the most effective in achieving optimized levels of care. It brings out the most intricate yet relevant aspects to personalise the decision.
End Notes
Communication and transparency are the most effective levers for assurance and accountability in healthcare delivery. This case clearly shouts out for the much needed emphasis on proactive accountability. Overly relying on blame can also make the physicians risk averse. We need to keep them empowered with adequate room for personal discretion and judgment — it will enhance their research with benefits only to society. While we may have incident-response-mechanisms in place to manage adverse events, to affix blame and to remedy the reported errors; agile active vigilance has a bigger upside that will deliver saved lives and alleviated sufferings. We have to shift from post-facto blame to proactive accountability for assured patient outcomes. This will inculcate mindfulness throughout the sector to move beyond events and occurrences to a robust culture of accountability. Needless to add, also raise our health quotients.
The author is MD, INHX (Indian Healthcare Exchange). He is a keen analyst of the healthcare industry with primary focus on supply chain, medical devices and patient experience
(This story was published in BW | Businessworld Issue Dated 26-01-2015)
