Abhed Govil took the prescription from the nurse’s hands and said, “Sure, this will get done right now, thank you!” Dr Prashant Massey, the orthopedic surgeon, had scribbled a whole lot of medicines and dragged the last alphabet down diagonally to the left hand of the sheet and written, “MRI”.
Abhed bobbed his head in assent and asked the nurse which floor the MRI department was. Laughing, she said, “No floor and all… right outside the gate. All outside!”
Abhed took Paritosh, his injured friend, and stepped out. Right at the gate of the hospital were six MRI centres, bursting at the seams with patients. Abhed groaned. It was clear to him that the paper work alone would take him an hour. But he could not help wondering why the hospital did not have an in-house MRI.
Later, he asked Dr Massey, “How come you do not have an in-house MRI? Don’t patients need it?”
Prashant (smiling): It is. That is why there are six on the street outside, no? Maybe it is beneficial not having one in-house?! Don’t quote me, but these things are common. (Then, on a serious note) The owner has appointed family members in important positions. His nephew, who is the local hawk on capex, gets bullied easily. At every capex, meeting his proposal for an MRI machine is shot down on some pretext on the other...
Abhed: So, then what about implants? Who decides what ortho implants to buy and stock here?
Prashant: Each category has a different system. The ortho department for example, has three specialists. Dr Karunakaran is also the head of the department. We have between us 17 beds for ortho patients — from fractures to joint replacements. The A-class items for joint replacements, are procured by Dr Karuna. But it is possible that Dr Thomas, the other consultant, may have a preference for a different brand, in which case he will buy for his patients himself.
Sorry, I have to leave, have OPD now... will send the list of supplies to be bought for the surgery, soon.
Abhed reflected on the various hospitals his mother had been operated at. Why Paritosh, 21st Century’s victim, he too was paying thrice the price for an MRI outside the very hospital which should have had its own... Paritosh who had fractured his arm during a rock climbing event, and whose surgery had not helped the bone heal. Or his mother who underwent three surgeries for her right arm fracture each of which only worsened her condition until a small town doctor with best practices found the right implant of the right quality that brought about the union of her bones.
It’s all about best practices, thought Abhed. It’s about systems, controls, measures, integrity... The fact that Plus Care’s first attempt on Paritosh’s arm was a failure, had later been traced to a poor quality X-ray that did not report a displaced fracture. Consequently, even two weeks after being in cast, Paritosh was unable to move his fingers. Why were the X-ray machines so poor at Plus Care? Why did his doctors not call him back for a review? Why did surgical teams not admit that the X-rays were faulty?
Then, there were his mother’s fractures. The bone plates they had used on her were fake. Their metal was poor and he was sure it was corrosion but Dr Surya had pacified him with, “It could also be their poor biomechanical strength, because remember the plates were not gripping her bone. Same thing.”
Dr Madhav Surya was the small town surgeon who had homed in on her problem. Now, Abhed felt helpless. His mother went through this 12 years ago. Today, as he watched Paritosh, it seemed nothing had changed in India. So then, if the bone plates were not holding her bones well — and Surya had mentioned that she may have already been osteoporotic then, how come EFG Hospital used the wrong plates? Ah! The wrong plate thing was a function of not knowing what plate to use — this is what the Kyosin man had told him. OK, so was that a function of a system that lacked controls on process? Where lay the control weakness at EFG?
Abhed had a 15-minute taxi ride to the campus. He called Dr Surya and sharing his views on Plus Care’s MRI decision-making, he asked, “That EFG Hospital where Ma had her bone surgeries, what is their organisation structure like?”
Surya (laughing): The bee has not left your bonnet, I see! OK, EFG, from what I know, is an owner-owned, professionally managed hospital but the owner is dominant. It’s what they call widely held management but prominent owner. Sorry? No, no, the owner is not a professional, but he is a significant business person. No, even if he were a doctor, in a multi speciality hospital, he may be close to healthcare as a doctor, but for other specialities you need the help of other specialists, you see! Purchase department? Let me think. His son used to be in charge, non-doctor, actually a chartered accountant, so, he was management for all intents and purposes.
Abhed: Suppose the EFG owner was a doctor, a professional, would the place have run differently?
Surya: See, in all cases, the owner will try to protect himself. He will try and put trusted people in charge of key functions. Dhanwantri is my hospital, I am owner, doctor and administrator. Yes top and bottom line is critical for me, but reputation is my asset. I will be very careful not to allow anyone to cut corners.
Abhed: That is your leadership style. I am sure there are owner-doctor run hospitals that cut corners with glee.
Surya: I do not know of them, but I guess so. The toughest model is one where you have an owner held, professionally managed hospital. Here the employee doctors are not attached to the bottom line, see?
Abhed: So, do doctors collude with suppliers and in exchange for recommending their brands, get rewarded?
Surya: Very rare. There is a disclosure requirement incumbent on doctors and on vendors. See, the clinical aspect of any product is more important for the doctor than for the purchase department, let’s face it. He does need to interact with the vendor!
Does that process cross the line of ethics? Opportunity exists. A vendor can do ethical and scientific marketing of his brand, and the doc on the other side can take part in ethical and scientific transfer of knowledge. If all stays within this, great. But if the various brand offerings are undifferentiated how will a doctor make a choice? Realising this, the vendor exerts influence; that does breach the prescribed line of ethical marketing.
Abhed: So, a doctor can be influenced to prescribe a drug or an implant to his own advantage?
Surya: In the organisation structures I discussed, barriers are created by the owner to prevent interaction, but say a vendor takes you out for a meal. He says I am developing some products, I would like to request you to be a consultant during the product development stage. This is an open, clear commercial interest. The Physician Payments Sunshine Act in the US says, fair, do this, but disclose.
Yet when I think about it, I feel, if product developers had inputs from doctors, it would only result in better products. Even so, we are shifting the opportunity to be influenced from the doctor to the owner, isn’t it? If the organisation structure did not permit doctors to prefer a brand for their hospital, then someone else who is making the purchase is getting a chance to do so and he may prefer it for all the wrong reasons. If I am a purchase head and am being appraised for cost control as a KRA, then I will buy cheap!
Surya: I am not saying arrangements are not possible. A long time ago we had entertainment expenses — the vendor would send the doctor and his family on a vacation. Then the regulator started asking why are you paying for him to go to the Andamans? So then, from a vacation spot the vendor started sending the doctor to a conference spot. Now, MCI has started questioning even that. So, yes, the doctor is in a position to influence brand preference. For instance, a family doctor refers the patient to a hospital and hospital could pay the GP. If that GP’s recommendation is ethical and scientific, then paying for the recommendation is not improper if there is disclosure.
Therefore, what I am saying is it must be made naturally fair to reward a doctor for recommending a hospital. And, before you even say it, the reward has to be a fixed amount, unchanging, auditable. Whether I send a patient to Hospital A or B, I can be paid only a given sum. Hence there should be no incentive for me to prefer one over the other.
Then, what is the reason for a hospital to not use the best implant in a surgery for a patient, wondered Abhed. As luck would have it, Mankodi, Kyosin’s operations director, who he had met a few days ago, called. “How likely are you to go to Madurai? I am asking because you are in Chennai. Let me know. One of our doctor clients is doing a workshop for the surgeons in his township. If you can attend even one out of those three days, you will get a flavour for small towns’ hunger for learning!”
Abhed: I am trying to think what’s in it for you? If the doctors agree to use your product as well as stock your implants, only then it makes sense...
Vyom: Oh, I see. OK, first of all this workshop is not our initiative. This is being done by Dr Arumugam. We are providing him with the audio-visuals. His area of interest is facial implants and he is focussing on that for a paper he is writing. But he does not carry inventory of our implants.
You must understand, it is very rare for hospitals to carry inventory of implants. First of all, there are so many variants even for the same condition. Then again surgeons need more of the sub items like screws and stuff. Since the list is huge and diverse, hospitals have passed the onus to the brand’s distributor. If it is a high usage hospital, like say EFG, then the distributor might even leave his stocks in the hospital and bill based on consumption.
Abhed: So then, how do implants get ordered? What the patient needs or what she can afford?
Vyom: Based on affordability at one level, and basic minimum standards, on another level. Standards that the doctor feels are ‘must-haves’. But how much can you define? There are so many needs, and as many implants. Each comes with little accessories, some of which are outsourced. This means you have lost control on quality. And mind you, these accessories can make the difference between life and death. So, every one of these needs standards and regulation, which I daresay we don’t have.
Enforcing norms is very difficult technologies are many, patient needs are many. Norms cannot be standardised, and what is standardised is so broad that it is open to interpretation.
Abhed: Gosh, how haphazard the whole system is! What I see is a desire to have rules, but no desire to implement them. Medical devices cannot be covered in norms, norms can’t be enforced. Patients need the best but affordability rules! So, she does not get the best, does not get health, that means medical community is not accountable...! Is there a law that says the doctor is right in prescribing according to affordability? Or is he required to place before the patient all available options?
Vyom (laughing): I am NOT a doctor. But I do not take kindly to people not assuming responsibility for what is rightfully their duty. Patient consent must be taken, but is not done; it is assumed that patient consent is not needed. Signature is taken only for critical surgeries, where life is at risk. Say, in good faith you tell me, take this tablet. But I have some allergy that makes this tablet life-threatening. Who is responsible? The patient is. This is where patient responsibility comes in. And the doctor must give adequate decision-making support.
Abhed (interested and keen): But patient says, ‘I didn’t know I was supposed to ask’. By behaviour, the doctor has held out (under Law of Estoppels) that he will advise or that he will do what is right for my body.
Vyom: Nah! But Estoppel cannot be invoked even if Estoppel occurs when a party “reasonably relies on the promise of another party, and because of the reliance is injured or damaged”. Why? Because you have handed over your decision-making to the doctor, by conduct. You gave a blind consent! As a culture, we have never been encouraged to ask questions. We submit to superiority, to age, to seniority, but never to logic.
Abhed (a trifle confused): When the doctor showed mom that bone plate and said, ‘shall I use this plate?’, how was mom to know its metallurgy? Its biomechanical strength? Later when she developed neural unrest, the doctor said: ‘How can I say this is what caused the neural unrest?’
Vyom: From another standpoint, the enforcement cannot start with the doctor. He is not a chemical engineer. He says: ‘I had these purchase options in the market, I made a choice. The vendor showed me a certificate to say he has cleared the metallurgy. But if he has made a short cut there and obtained a certificate by paying bribes, how am I to know? Why am I being held responsible?’.
Abhed: This is rotten. Nobody is taking responsibility! Clearly, this is an enforcement issue. The entry barriers should be so tough that poor quality can never enter the market! But we allow poor quality because there is candy money in it!
A dozen women die after a sterilisation camp in UP; 92 people died in a Kolkata hospital fire; why? Because the system does not check the veracity of its processes and purchases. Bad vaccines, used gloves, third-rate syringes, expired drugs, ward boys performing surgeries ...this is not because we are a poor country. It is because we don’t educate our people, for fear they will ask questions!
Vyom: You said it. That was a long call, Abhed thought as he entered the campus. A note was waiting for him from Paritosh’s father. “Came here hoping to meet you. Met one Arjun Doraisami, in Plus Care’s admin, referred by a friend. He seems clued in to implants. Check how their implants are ordered.”
Arjun Doraisami was a young man. “I am a systems man,” he said proudly. “ Finally all life is about systems!”
Abhed: Sounds good to me, but I feel those systems make sense only if someone implements them. Does your hospital have a foolproof system that ensures the patient gets the best and not fakes?
Arjun: Usually good doctors won’t use fakes. That is part of the training. At Plus Care, we have central procurement; based on rate or service efficiency a brand is finalised.
For implants? No, we do not carry inventory. Our doctors have preferences, and they call the supplier and tell him to leave stocks in specific stores, usually nearest to the hospital. In your friend’s case, the attending ortho will tell you where to buy it from. See, implants do not form a big part of a multi-speciality hospital’s revenue-earning surgeries. That means, such hospital’s influence is low. In a multi-speciality hospital, the number of patients who need bone implants is a small percentage of the total. An owner-managed or professional hospital is more concerned about cure rate. They will leave it to the specialist to select the brand.
Abhed: Even larger hospitals? You can’t leave it to each consultant to choose brands! Won’t there be chaos?
Arjun: Exactly. Some hospitals opt for what is called ‘bundling’. Here, the supplier packages the accessories needed for different kinds of surgeries into bundles, and these he supplies at a low cost. This saves the patient’s family the stress of running around and buying specifics about which they don’t know enough.
Abhed: And saves the hospital inventory carrying costs!
Arjun: Hmm... fraught with control weaknesses though. It saves the patient the running around and stress. So a standard bill of material is the basis for bundling and the patient is asked to deposit say Rs 1 lakh before a surgery and against that the bundle is issued to the OT. I am under pressure to adopt that system here, but I have known suppliers to short-change.
Abhed: Isn’t inventory the reason for not carrying high value drugs and implants here at Plus Care? I was finally told to buy a titanium plate for Paritosh, but the doctor insisted that I buy from a specific shop. Why is that? Why can’t I buy from where I want to?
Arjun: I know. A patient could get the same implant anywhere but I will go one step further: even if the patient buys from elsewhere, the doctor will refuse. He fears complications.
Reason? Could be the doctor’s concern for avoiding spurious implants. You know that case of the fake heart stents that turned fatal? Same thing. Or a monopoly gets artificially created by the doctor through patronising a specific shop, and seller becomes free to charge whatever he wants.
Abhed: That alone is a recipe for malpractice! It may be a genuine preference for safety, maybe the vendor is known to stock genuine implants. Can’t say. But this is the culture we have encouraged in our country, where dependability is not natural. Corrupt practices are. And to circumvent that, we create sub systems which encourage malpractices! Like your outsourced MRI…
Arjun: Let me be frank, when you exist in an economy where you are not sure of getting the best, where there can be concealing, where there is rampant corruption, the doctor also plays safe. He is not a chemical engineer to know fakes when they come in pretty packages! Maybe that is why he insists ‘buy from this shop only’!
Abhed: Have you wondered why patients say, ‘give me the best’ even when they don’t know what is the best? It is a covert way of saying please don’t fit me with fakes and kill me. It’s like telling your captor, take whatever you want, but spare my life! Because there is no information system that tells you why brand B is cheaper than A.
Arjun: You are not wrong. If you ask questions, you can get answers. But patient never asks, and so doctors don’t tell!
(This story was published in BW | Businessworld Issue Dated 26-01-2015)
