Interview: How should India regulate private healthcare to avoid pitfalls exposed by the pandemic?

First person accounts of private hospitals fleecing patients for Covid-19 treatment continue to flood social media. While more than a dozen state governments have instituted policies to regulate charges for Covid-19 treatment in private hospitals, the implementation leaves much to be desired.

A writ petition has been filed seeking directions from the Supreme Court on the regularisation of treatment tariff. The All India Drug Action Network is an impleader in the case.

Malini Aisola of AIDAN spoke to Scroll.in about the challenges of regulating private healthcare, the influence of lobbies on policy making and your rights as a patient.

The limited efforts by state governments at price regulation and capping are reportedly being sidestepped by corporate hospitals. Take us through what AIDAN’s analysis of bills from corporate hospitals in three metropolitan cities shows.
Even prior to the pandemic, overbilling in private hospitals has been a commonly accepted phenomenon. In fact, the National Pharmaceutical Pricing Authority had documented the trend of profiteering by private hospitals in respect of more than 1,700% margins on drugs and consumables.

Unfortunately, not only has this trend continued into the Covid-19 pandemic, but there is also evidence to suggest that overcharging may have intensified with private hospitals treating the pandemic as open sanction to loot patients.

In the absence of billing transparency, hospitals are just able to freely inflate charges. Some hospitals have levied charges of Rs. 10,000-15,000 per day for just PPE, without providing any breakdown of quantity or price. Even though the costs of PPE should be shared across multiple patients admitted in the same ward, patients are being billed for the same PPE individually.

A number of arbitrary charges have also appeared in bills such as RMO [Resident Medical Officer] charges, biomedical waste disposal, admission charges, medical history assessment charges, equipment use charges, universal precaution charges and even parking charges.

We have also observed disturbing conduct on the part of private hospitals which have since the beginning of the pandemic, been rampantly administered a variety of experimental treatments – favipiravir, HCQ, tocilizumab, lopinavir+ritonavir, remdesivir, etc – without taking informed consent of the patient.

What do insurance claims reveal?
We have dealt with several cases where insurers have refused point blank to reimburse the Covid-19 rates of some of the hospitals because the charges and billing are arbitrary and unreasonable.

Initially, there was a lot of resistance from insurance companies to reimburse costs for PPE because it is not used on the patient per se but rather to protect healthcare staff from infection. Now insurance companies have come around to covering the costs of PPE. Yet, patients are being billed at inflated charges and for quantities of PPE that could not reasonably have been used for the patient.

Even several months into the pandemic, PPE remains one of the highly billed components in Covid-19 treatment for which patients, even insured patients, are paying large sums of money out of pocket.

In remarkably candid disclosures before the Supreme Court, the GIC [General Insurance Corporation] has noted inconsistencies in billing by private hospitals and lack of transparency and uniformity such that privately insured patients are being billed on a higher schedule of charges than uninsured patients. GIC has claimed that because limited insurance cover is not enough to take care of exorbitant charges being levied by private hospitals, patients are becoming uninsured for a period of time during treatment and sustaining substantial out of pocket expenditures.

There is also variation in states policies regarding the applicability of government rates to insured patients. For example, in Karnataka and Telangana, insured patients are excluded from access to capped rates. In Delhi, despite the order [passed by Delhi government on June 20 to fix the rates for Covid-19 treatment in private hospitals] not excluding insured patients, hospitals have unilaterally decided that privately insured patients cannot avail government rates.

There are concrete implications to disallowing privately insured patients from availing government rates.

When we think of privately insured patients, we often think of corporate employees and one may get the impression of good policy coverage. In fact, very often families have policies with low cover and which may even be extended to multiple members of the family. Excluding patients under government rates means that this coverage can become depleted extremely fast at the exorbitant rates being billed by private hospitals.

What have state governments done to enforce price regulation?
Some states and local administrations have taken proactive steps like constituting committees and teams of IAS [Indian Administrative Service] officers to audit hospital bills or deal with patient grievances. In Mumbai, Bengaluru and Hyderabad this has worked to a degree. In Mumbai and Telangana, authorities have publicly shamed private hospitals for overcharging and even forced them to stop Covid-19 treatment.

This works because it costs the hospital in terms of its image. Also, in Mumbai and Bangalore there have been recoveries in lakhs and crores of rupees and that money has been refunded to patients after examination and audit of bills.

In Delhi, there has been no interest in enforcing the policy and there are no instances of action being taken against hospitals for violations.

From the start of the pandemic, there were complaints of overbilling and exploitation in private hospitals in Delhi. Based on recommendations of the expert committee led by Dr VK Paul, the June 20 order was passed fixing the rates for Covid-19 treatment in private hospitals. Not only was there no attempt to publicise the order, but the government also failed to implement transparent mechanisms to provide public information regarding availability and occupancy of rate capped beds in each hospital, in real time.

From a patient’s point of view, it is extremely difficult to avail of the rates because if you end up in a private hospital seeking Covid-19 treatment, you would not even know the breakup of beds of a certain category such as in the ICU [Intensive Care Unit], that come under the government rates.

Private hospitals are leveraging the lack of information available to patients to cheat them. The clause requiring hospitals to take written informed consent from patients to charge them as per hospital charges is completely meaningless.

What explains the inability of state governments to enforce price regulation?
We have to look at what historically makes it difficult for state governments to bring in regulation in the first place. The answer is related very closely to the lobbies.

We have never seen this level of organising of the industry lobbies as we are seeing during Covid-19, led and driven by large corporate hospitals and hospital associations operating at both the national and state levels.

You have in the recent past, referred to a campaign underway to subvert efforts of state governments to cap private hospital charges. Who are those leading this campaign and what is the nature of influence they hold on policy making during this pandemic and otherwise in healthcare? Can you also provide examples of conflicts of interest in the policy making space.
Associations such as Association of Healthcare Providers India, Healthcare Federation of India, also known as NATHEALTH, Federation of Indian Chambers of Commerce and Industry, or FICCI, have actively attempted to obstruct regulations to rationalize the charges for Covid-19 treatment. The hospital industry lobby is driven by the large corporate hospitals. Often the same persons are involved across the associations. For example, FICCI and CII [Confederation of Indian Industry] are presently led by Dr Sangita Reddy and Shobana Kamineni, respectively, who both also happen to be promoters of the Apollo group.

Prominent hospital entrepreneurs and corporate chain owners are also involved in policy making at national and state levels. Dr Naresh Trehan and Dr Devi Shetty serve on the High Level Group on Health Sector under the 15th Finance Commission, not in spite of their deep conflicts of interest but rather because of them. Even though this group has been charged with evaluating the regulatory framework in the health sector, no recommendations have been made regarding regulation of the private healthcare sector.

The private health sector today is accountable neither to the government nor to the public.

The private hospital sector has enjoyed unbridled growth because of government subsidies and the absence of regulation. Massive integration, both into horizontal healthcare segments like pharmacies, diagnostics etc, and in vertical integration through buying up of smaller private hospitals and nursing homes and integrating them into larger chains, has led to restructuring in healthcare. The whole model in India is of ever intensifying corporatisation of healthcare driven by commercial interest. There is no doubt that to have a realistic chance to bring regulatory reforms and a greater focus on public health strengthening, as the pandemic has taught us is necessary, the undue influence of the powerful industry and its lobbies must be checked.

Those opposed to regulating private healthcare have argued the government should focus on fixing public healthcare first. And that regulatory efforts in the private sector will only perpetuate more corruption and inspector raj, in effect, stymie the larger healthcare system.
If you study the experience of any of state governments that have attempted or brought a clinical establishments act, be it Maharashtra or West Bengal or Karnataka, the same arguments are recycled.

The pattern of doctors, the local IMA [Indian Medical Association] chapter going on strike calling for a rejection of the proposed legislation is par for the course. This is part of the strategy to undermine and dilute the draft legislation by the time it is passed.

In fact the public health system and private healthcare operate on two diametrically opposite logic – whereas the public health system is mandated to safeguard and promote the health of the people, the private health sector on the other hand operates within the market paradigm where its services are provided for a cost with the objective of making profit.

Where the accountability mechanism for the public health system definitely requires strengthening, more often than not the cause of deficiencies and gaps are a consequence of the government’s low public investments, significant vacancies, and various other bottlenecks.

The private sector is currently wholly unused to being regulated, having flourished in a regulatory vacuum. So how can one take the inflated claims of creating inspector raj be taken seriously?

On the other hand there is a preponderance of evidence that the lack of regulation has resulted in inflation of costs of healthcare, unnecessary burden on patients, exploitation, a whole host of unethical behavior on part of private hospitals. Patient rights’ violations in the private sector have reached epic proportions.

You would have read of cases of medical hostage taking, even before the pandemic, where hospitals have held dead bodies or detained patients for non-clearance of hospital bills, which is completely illegal.

Patients’ rights are being trampled even worse during the pandemic – patients are not being given access to their medical documents during admission, denied detailed bills. In some cases, they are being discharged with just one or two sheets of paper and without their entire medical record. Families do not even have a mechanism by which they can deal with their own anxieties about the status of the patient or take a second opinion if needed.

Another issue is the need for billing transparency. Telangana has issued orders for itemised billing after it became evident that there was a huge problem with private hospitals that were refusing to comply with orders and were billing any which way they wanted. The Central government can also take a lead role in mandating transparent and itemized hospital billing.

What is the advice you have for the general public when interfacing with private hospitals during this pandemic?
Given the unique circumstances of the pandemic, my advice to the public would be to try and be aware of and alert to any local policies, guidelines, rules which may come in handy.

While it is nice to say that patients and families should arm themselves with information when approaching private hospitals, this is not practically possible. Patients are approaching hospitals in desperate circumstances and there is a massive power differential between patient and the hospital.

However, remember that patients do have some rights. If you feel that you have been overcharged, subjected to unethical treatment or worse, there are avenues to pursue complaints including by speaking to the hospital directly in the first instance.

We do recognize that it is not always possible. Families can be constrained in taking up issues by the medical circumstances of the patient who is admitted or might require future care at the institution. When one has a patient to worry about, you do not want to ask a lot of questions of the hospital. Even talking to doctors can be intimidating, let alone engaging with the billing department.

I will only add that for each person who does pursue a genuine grievance, provided they have the ability to do so, it usually helps improve things for other patients.