We all know that prevention is better than cure, and this is one of the reasons that executive health checkups have become so popular. They promise to help your doctor to pickup medical problems early, so they can be treated more effectively.Unfortunately, even though the logic is very appealing, the sad truth is that in real life, health checkups are good for hospitals and diagnostic centers, but not for patients! In fact, most doctors never do a health checkup for themselves, because they know how useless they are!So what is your doctor not telling you ?Let's look at why hospitals promote health checkups so aggressively. The checkup is great way of converting well people into patients; and creates a constant stream of customers for the healthcare system.How ?It's a mathematical certainty that if you run a sufficient number of tests, you are bound to find abnormalities. Once you find an abnormality, then the person is snared into the healthcare system, and the vicious cycle starts.Abnormality = more tests = more consultations = more treatment - more surgery, often unnecessaryLet's consider a 40 year old asymptomatic woman who goes for a deluxe super-duper health checkup at a local 5-star hospital. Because she has opted for the Platinum scheme, the doctors does a vaginal ultrasound scan to check her uterus. She finds a 4 cm fibroid and then advises the patient to undergo surgery to remove it. Since most patients are (understandably!) reluctant to undergo surgery, the soft-sell is that this is going to be " minimally invasive" surgery done through a laparoscope, so that there is no cut and this can be done on a day-care basis. Also, the insurance will pick up the tab!It's very common to do this for ovarian cysts as well. Cysts are very common in women; and most are functional and will resolve on their own. However, the doctor scares the patient into doing surgery, using a number of fear-inducing techniques, such as : it may increase in size; it may burst; or, it may become cancerous. The sonographer is also a part of this scam, and magnifies the findings by highlighting them and by reporting the size in mm, instead of cm ( a 4 cm cyst is reported as a 40 mm cyst , to make it seem bigger!)The truth is that you cannot make an asymptomatic patient happier - and if she has no complaints to start with, she most probably does not need any intervention at all! The right advise would be masterly inactivity. However, few doctors have the maturity to advise this.In fact, they tell the patient that thanks to this checkup, they have picked up a problem which could have snow-balled in the future. The amazing thing is that patients are happy when an abnormality is picked up ( they can justify the money they spent on the health checkup !). Most patients are very pleased that the problem was spotted before it became a major issue.The truth is that most of these so-called abnormalities are not really problems at all - they are just incidental red herrings discovered with modern medical technology, which the patient would have happily carried to her grave if she had been unaware of them.All this overtesting is leading to an epidemic of overtreatment. Is this going to change ?No - it will just become worse as time goes by. Thanks to better technology , it's becoming easier and cheaper to produce high quality images of practically any nook and corner of the human body. However, better pictures does not equal better clinical outcome. A lot of these images will pickup problems, which are just anatomical variants, but which will be "treated" by over-enthusiastic doctors. There is too much money at stake !Also, remember that if an "abnormality" is detected, it requires a very courageous doctor to advise against treating it with surgery ! In reality, it's s much easier for the doctor to advise surgery and "fix" the problem. After all, if he does the surgery, no one will object ( whether the surgery was needed or not is never discussed). Find a problem - fix the problem, is a common knee jerk response. It's also much more profitable for him !However , if he advises against surgery and the problem worsens over time ( as it will in a very small minority of patients), the patient is quite likely to sue the doctor for not taking care of it when it was first pointed out ! Even good doctors will advise surgery to protect themselves, even when they know in their heart of hearts that this surgery is
not in the patient's best interests !
Dr. Aniruddha Malpani is a renowned IVF Specialist based out of Mumbai, India. He also runs the world's largest free patient library - HELP (http://www.healthlibrary.com). Dr. Malpani is also a Director on Board of a series of healthcare organizations and websites. He can be contacted at firstname.lastname@example.org
What is the first thing that the hospital staff asks you as you try to get your close one admitted? Along with the other questions about name, age, symptoms experienced, there is one question that they do not fail to ask, “Do you have health insurance?” The answer to this question has more implications on your final bill than you can imagine. We try to understand what goes behind if the answer to the question is yes!
The scenario today is that health insurance which is meant to relieve the financial burden incurred as a result of hospitalization actually has become a source of malpractice and mismanagement.
Due to the inefficiency of the Public healthcare system, patients have increasingly started to opt for the private health care institutions their health needs. In the absence of a body controlling their rates, some of the hospitals are found to charge their patients in an ad-hoc manner. There is no rate card that will serve as a bench mark for charging customers. Thus the hospitals have the liberty to charge different rates to different patients gauging their paying power.
Malpractice by Hospitals, Doctors
The gross inefficiency does not end here, some hospitals hike up their fees when it is clear that a patient is covered under health insurance.
Sometimes the doctors hike up their fees as much by 3 times when he is charging an insured patient as the medical charges do not come under the income tax purview.
Sudhir Sarnobat, Co-founder and Director of Medimanage Insurance Broking Ltd gives insights into the way hospitals go about overcharging an insured patient,
No Choice of Room: All hospitals have separate standards for rooms viz of rooms like common, twin-sharing, deluxe and super deluxe. A patient should get to choose his /her room based on their budget and acceptability of comfort required during hospitalization.
Many of the hospitals deny the common and twin sharing class to members who have insurance under the pretext that it’s their policy. Even if the patient is not availing cashless facility, the doctors ask the patients whether they have insurance (and all patients without understanding the implication, nod in affirmative) and then direct them to a room category that is more expensive.
Different rate cards: Some small and medium hospitals maintain different tariffs which are mainly classified in three categories viz. Self-Paying, Insurance (Reimbursement) and Insurance (Cashless). The tariff is lowest for the self-paying patient and is called as base tariff. It’s loaded by 10-15% for Reimbursement Patients and then loaded by another 10-15% for cashless patients. Some big hospitals do have similar practices but they do it in a subtle manner.
Doctor’s Consultation charges: Small hospitals have visiting surgeons whose fees are mostly never published in standard tariff. Some of these hospitals inflate the doctor’s fees based on the patient’s status i.e. charge higher fees for those patients with health insurance. There are two management modalities followed in India, one is Full Time Consultant model where the doctors who are attached at one hospital cannot work for any other hospital. The doctor’s fees are generally fixed in such models. Second model is visiting consultants who are attached to multiple hospitals and admit their patients based on patient’s capacity to pay. Big hospitals have visiting surgeons who do not have fixed fees and hence doctors themselves decide the fees to charge.
Unnecessary Hospitalization: Some hospitals also push an insured patient for admission in the hospital (as only then insurance pays for treatment) where the same may not be needed. This is another form of exploitation of insured patients.
Unnecessary medical tests: Some hospitals go for excessive investigations when the patient is insured. They also make patient get involved in investigation chasing (due to structure of Human body, some or other parameters are going to be up or down based on various conditions). This is normally acceptable so long there is no major complaint from the patient. But in cases where doctors find insured patient’s parameters little excessive, they ask for further investigation and go for treating these parameters through medications and interventions.
With all the kind of malpractices rampant with the hospital bills, it is the insurance companies who are facing enormous losses due to both high claims ratio and fraudulent claims.
What do the TPAs say?
Third Party Administrators are given the responsibility of accepting the claims and settling the valid ones by the Insurance Companies hence we asked, Mr. Madhavan, COO of Mediassist one of the leading TPAs about this problem. Mr. Madhavan said “there is some discrepancy in the charges between the bill of insured and uninsured but only in some hospitals. Initially there was a lot of discrepancy in the charges but after the intervention of the TPAs we find that mostly only Tier 2 Hospitals indulge in it than the Tier 1 companies.” He believes that once the industry observed the trend and presented the hospitals with the data about the inconsistency, the hospitals agreed to follow a tariff and TPA with their consolidated data have a control over the costs.
On where does the discrepancy creep in, Mr. Madhavan believes that it is more in cashless claims where it is a kind of emergency and there is very little time frame in passing the claims, in reimbursement claims the patient pays the bills from his pocket so he negotiates with the hospital and the additional time frame gives a good chance for the TPA to review the case.
Effect of this trend
This trend of overcharging patients with health insurance coverage will affect the customer both in the long term and short term. In the short term, if he is charged for a disease for example for cataract for about Rs. 50,000 then he is left only with Rs.50, 000 cover if he has taken a 1 lakh cover. Thus an overcharged bill has a negative impact on your cover amount especially if it is a family floater or if the sum assured is less.
Sudhir Sarnobat explains the long term effect of extorting money from the insurance cases, he says that the higher cost of treatments of insured patient means that the claims are higher; this he feels will either force the insurance company to limit the benefits or increase the premium. Both of these conditions will affect the penetration or viability of health insurance to people. He says, “The important element of success of insurance is to have the maximum population insured but that gets defeated when insurance becomes unattractive to buy. That further leads to only needy buying the insurance because they only see the benefit in buying costly and restrictive cover, who in turn go for claim which further increases claims.”
What are the TPAs/Insurance companies doing to tackle this problem?
Mr. Madhavan says “We are constantly in talks with the hospitals which are in our network; they share the tariff card with us so we know about their standard charges.” About the Doctor’s consultation fees, he says, “when we make package deals with the hospitals in our network, we not only negotiate the tariff but also fix the rate of consultation charges.”
About the further measures to be taken, he says, “there is lot that can be done to tackle this problem, TPA can convince more hospitals especially the commercial hospitals to give discounts and other measures to reduce the prices.”
On the other hand, Sudhir Sarnobat feels that the problem can be tackled through the education of the insured so that they know what are the limits to the expense for a particular disease for example, if the patient informs the hospitals that the limit on the cataract treatment in his policy is Rs. 20,000, the hospital either has to charge reasonably or the patient shifts to other hospital. The other solution that he provides is that there should be a regulatory board for hospitals like IRDA in insurance that will control the hospitals and bring some transparency in its operations.
With no near end of this problem of overcharging insured patients, the Insurance companies and the TPAs have to do their best to reduce the claims, whatever they do, it is the insured who faces the brunt.
Many people would give an arm and a leg to achieve good health without having to exercise, eat right, sleep right and so on… In fact now-a-days, everyone wants that 'one' exlusive short cut to good health! So, we at Medimanage.com decided to go ahead and do just that on this ‘WORLD HEALTH DAY’.
We went ahead and simplified the puzzle that is good health for you by asking 8 top, leading health experts from around India about the one health tip they would give you on World Health Day, which would set you on the path towards a healthier you!
Dr. Panda, Vice Chairman and Cardio Vascular Thoracic Surgeon, Asian Heart Institute.
Walk your way to good health! Regular exercise helps improve immunity & gives a sense of wellbeing. Endomorphin- a mood enhancer is secreted with regular exercise. When you go up, your blood pressure goes down… so climb the stairs for a healthier heart!
Dr. Anjali Mukerjee, M.D. (A.M) Nutritionist, Researcher, Columnist, Author and Founder, Director - Health Total
Staying healthy is a journey, not a destination. Looking young and beautiful begins with good health and can be achieved by minor corrections in our eating and living habits. A daily glass of raw vegetable juice like carrot, amla, mixed vegetables is rich in anti-oxidants, enzymes and removes toxins, and digests food better. Control stress as it suppresses the immune system and our mind which is the biggest contributor to diseases.
Mickey Mehta, India’s leading Holistic Health and Fitness Guru
I hope everyone gets responsible towards their self health and the health of our mother earth. A vibrant health condition will certainly bring about love peace and harmony. Wish you all a very happy World Health Day.
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I attended a very interesting conference on Medical Ethics over the weekend where I was invited to give a presentation on the ethical aspects of IVF. My talk was on IVF - the good, the bad and the ugly, and I will be uploading this soon.What I found very interesting was a talk by one of the organisers, Dr Sunil Pandya. He posed a very provocative question - Are conferences on medical ethics of any use? He was lamenting the fact that inspite of organising many such conferences, the standard of medical ethics seemed to be going progressively downhill in India. Medicine is perceived to be a money making business rather than a profession; and doctors are seen to be greedy individuals, out to maximise their income, rather than act as healers.Is this a sign of the changing times we are living in? Are we fighting a losing battle? Can we do anything to improve the situation? Can ethics be taught? And are doctors willing to learn?Most medical students become doctors because they are idealistic. They want to become healers because they like helping patients and want to help them to get better. Unfortunately, medical college seems to kill their ideals and dreams. They often become cynical and uncaring. There are few good role models they can emulate, and in fact they often end up learning bad habits from their seniors – for example, how to be rude to patients so they can complete their duties and find time to catch up on their sleep.
Things are even worse when they start practice. Sadly, no one encourages a young doctor to be ethical. In fact, there is a lot of pressure on the doctor who has just hung out his shingle to be unethical, because the only way a new doctor seems to be able to get patients today is by providing cuts and kickbacks to the referring family physician. Woe betide the junior doctor who does not toe the line – he is likely to be forced to sit in an empty clinic, twiddling his thumbs! Please remember that young doctors just starting practice are very vulnerable. They are under a lot of financial pressure, as they have loans to payback and families to feed, so they find it quite easy to justify these payments to their own conscience. They are easily tempted to take shortcuts - after all, everyone does it – so why shouldn’t I? And I’ll only do it in the beginning – I’ll stop once I am well off. Unfortunately, this is a steep slippery slope and once doctors start going downhill, it’s practically impossible to stop and get off! In order to pay the cuts, they are forced to accept part of their fees in cash, and then the next easy step is to under-report their income and cheat on their taxes.The presence of pharmaceutical companies with their billion dollar marketing budgets is another potent force in causing doctors to lose their ideals. These companies are easily
able to seduce doctors into prescribing their expensive drugs, even when they are not in the patient’s best interests, and it’s hard to resist the temptation. Diagnostic centers and laboratories which provide a “referral fee” just add to the vicious cycle, which means that it’s becoming easier day by day to count the number of ethical doctors on your fingertips.No one likes being unethical. I believe that most people are upright, and would rather earn an honest living, so they can sleep well at night. Most doctors who are well off would rather earn a comfortable income ethically, rather than sell their soul for a few extra rupees. If a doctor has an adequate income, most will refuse to be unethical for an additional measly 20%. However, if he stands to lose over 50% of his income by sticking to his high moral principles, then most doctors, like most ordinary citizens, will crumble. It’s not fair to subject doctors’ morals to such an unfair stress test! The present system practically forces young doctors to become unethical! Unfortunately, self-regulation by the medical profession has failed miserably. Similarly, policing by the government is a very ineffective solution, which actually creates even more unethical behaviour, as doctors learn to game the system.We need to change the ecosystem in which doctors practice. I feel the major reason for the sad state of affairs today is the presence of middlemen between the doctor and patient. This middleman could be the family physician who refers patients to specialists; or the HMO , who decides which doctors are going to be on their panel. If we can cut out the middleman who demands his cut, and ensure that the doctor-patient relationship becomes a simple and direct one, I think doctors will have much more incentive to remain ethical and practice honestly. Under these conditions, I believe most doctors will prefer to practice ethically ! Is this a pipedream? No ! I’d like to offer a simple practical solution which I feel can help to improve the situation and we are trying out the following experiment, to see if it works. HELP is offering grants to provide free websites for doctors. Millions of patients are already online, looking for good doctors – and we need to ensure that good doctors have an online presence, so it’s easy for patients to find them. We hope these websites will help good doctors to showcase their talent, and will allow them to grow their practice ethically. This will help patients as well, who will become aware of what services ethical doctors provide, and what medical facilities are available in India. The transparency which the web imposes will:
These websites will also improve the doctor-patient relationship, by allowing much more open communication between doctor and patient, by cutting out the middleman. Interacting with patients online will also help doctors to become more patient-centric and empathetic. Information Therapy - the right information at the right time for the right person - can be powerful medicine and can help to heal a sick healthcare system! Ideally, every doctor and clinic should have an online patient education resource center – and it’s becoming extremely easy and inexpensive to make sure that they do.
Why were most doctors ethical in the "good old days"? I don’t think they were more principled or had higher moral standards! I feel this was simply because there used to be only one or two doctors in a community and patients quickly learned through word of mouth, who was good and who was bad. This ensured that doctors treated all their patients well, because they were completely dependent upon their patient’s goodwill. Rude doctors or incompetent doctors were soon booted out because patients refused to go to them !Why do bad doctors flourish today? This is primarily because patients are clueless. It’s hard for them to get reliable feedback about a doctor from other patients. They cannot differentiate between a good doctor and a bad one because they have limited medical knowledge. However, once good doctors start educating their patients online, the balance of power will change quickly. Patients will be able to learn about their medical problems and treatment options; and will be able to quickly screen through multiple doctors online, from the convenience of their homes, so they can select the one they feel is best for them. Once patients have this knowledge and power, doctors will have to improve their bedside manners, if they want to continue to attract patients !I feel there is no point in complaining about declining ethical standards or waxing lyrical about the good old days. Good doctors do not need to be taught ethics and bad doctors will never learn! Will my solution solve all problems? Sadly, no. There will always be greedy doctors who would rather eat cake, and it is true that many bad doctors will also have their own websites. However, over time, thanks to the negative feedback which expert well-informed empowered patients will provide online about these bad doctors, they will be forced to improve! Meanwhile, good doctors will flourish, thanks to the positive feedback their patients will provide about them. We hope that once all doctors have an online presence, this will create a win-win situation for patients and doctors, and will allow doctors to practice medicine ethically once again !
“I have a cold, I should see a doctor”, “My left leg aches during the night, I should see a doctor”, “My left eye’s vision is blurred, I should see a doctor”….. the occasions might be different, but every time we feel we are going down with some or the other illness, it’s the Doctor we run to see!
But who’s seeing to the doctors?!
In a study conducted by the IMA’s(Indian Medical Association)Pune Chapter, it was found that the Indian doctors life span is only 55-59 years of age! An astounding 10 years less than the average life span of the general population in India! So what’s killing our doctors?
A sedentary lifestyle, lack of exercise, work pressure and stress are the culprits! Doctors, these days are found working long hours often juggling their own clinics along with their duties at hospitals. These balancing acts is creating stress and putting them under pressure, add a sedentary lifestyle to the mix and what you have is a potent recipe for disaster! A sedentary lifestyle is responsible for obesity and heart ailments amongst other things, a fact verified by statistics which single out cardiac arrest as the number one factor for causing deaths amongst Indian doctors.
Lack of activity compounded by a lack of exercise is leading to an alarming rise in the number of Indian doctors found suffering from various ailments. So the next time you visit your doctor for a health check up, ask him to get one for himself too!
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