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Editor: Nagaraja.M.R.. Vol.17....Issue. 20...........16/05/2021
FIR against 4 hospitals in
Andhra Pradesh for irregularities in Covid treatment
The hospitals started admitting patients on the
condition that no bills would be given to them. This is apart from the
irregularities of excessive charging and misappropriation of Remdesivir vials,
Director General, Andhra Pradesh Vigilance and Enforcement Department KV
Rajendranath Reddy said.
An FIR was filed against four private hospitals in
Andhra Pradesh on Friday after the Flying squads of the state Vigilance and
Enforcement Department found irregularities and malpractices on their part in
providing Covid treatment.
The hospitals started admitting patients on the
condition that no bills would be given to them. This is apart from the
irregularities of excessive charging and misappropriation of Remdesivir vials,
Director General, Andhra Pradesh Vigilance and Enforcement Department KV
Rajendranath Reddy said.
FIR has been
registered against these hospitals under Disaster Management Act, KV
Rajendranath Reddy said. (ANI file photo. Representative image)
An FIR was filed against four private hospitals in Andhra
Pradesh on Friday after the Flying squads of the state Vigilance and
Enforcement Department found irregularities and malpractices on their part in
providing Covid treatment.
"The flying squads have continued inspections
of hospitals on Friday. The teams have inspected 15 hospitals so far and found
irregularities in four hospitals and booked criminal cases against the
management of all the hospitals involved," Director General, Andhra
Pradesh Vigilance and Enforcement Department KV Rajendranath Reddy said.
Hospitals started admitting patients on the
condition that no bills would be given to them. This is apart from the
irregularities of excessive charging and misappropriation of Remdesivir vials,
he added.
"Narayana Hospital, Guntur was charging exorbitant
prices beyond prescribed rates and no bills were given for payment made. Sai
Rathna Hospital in Anantapur and Jangareddygudem hospital in West Godavari
district were also charging excessively, discouraging admission of patients
under the ArogyaSri welfare scheme, and misappropriation of Remdesivir. Kumar
Hospitals, Arilova in Visakhapatnam was not giving bills. FIR has been
registered against these hospitals under Disaster Management Act," Reddy
said.
Limitations and Distortions of
Profit-Based Health Systems
in Book Review — by Bharat
Dogra
In
the course of facing the ongoing challenge of the pandemic, a sad reality that
has manifested itself time and again is
that profit-driven health systems are unable to respond effectively to such
crisis situations. There are several disturbing anecdotes of how the profit driven systems and the
individuals running them behaved in a selfish and callous way towards patients.
These anecdotes get talked about and disturb us a lot, but in reality these are
only the more obvious manifestation of more widely pervasive and deeper
problems which may be causing a lot of problems and distortions even in normal
times without attracting much criticism because these distortions have been
‘normalized’ in the system. It is very important to recognize this as a systems
problem and not just as sporadic manifestations, as without such recognition
and understanding it is not possible to bring the necessary reforms.
Another important aspect of this problem is that if
such a distorted system exists in a very rich country, some of its ill-effects
can be checked because a lot of funds are available. However when some poorer
countries try to copy parts of this system, or else pressures are exerted on
them to do so, then these countries are unlikely to have the funds to check
these ill effects. Hence much more harmful impacts may result. Hence it is even
more important in these countries to recognize and understand these distortions and to avoid
them. It is in this wider context that careful study and documentation of profit-driven
health systems has a very important role.
The USA health system is regarded as a very important example of a profit-driven
health system and some important and useful studies of the distortions that
exist here have emerged in recent years. However the book being discussed here
has a very special relevance in this literature. This book titled Doctored – The Disillusionment of an American
Physician’ has been written by Dr. Sandeep Jauhar and published by Farrar,
Straus and Giroux, New York. Dr. Jauhar has been the Director of the Heart
Failure Program at a leading US hospital and has also written regularly for the
New York Times.
The special relevance of this book is that the
author is not at all ideologically or otherwise a critic of the system to start
with. In fact he is very eager to succeed in this system and to serve it well
and he is willing to work very hard for this. One may say that he is very keen
to succeed within the system as it is, he is obviously a talented and bright
professional and he is willing to give his best to make the system work and to
succeed. But he is also basically a very honest person at heart and he is
troubled when he sees wrongdoing.
He has a strong sense of ethics and would like to go
by it , even though he is also keen to be a success. If in the process of his
routine work or on the road to success, he sees a violation of ethics which
will obviously harm someone sooner or
later, directly or indirectly, he is troubled and tries to avoid violation
of ethics if he can. What happens then?
This is useful to learn from the book. As he sees these problems around him, he
also studies and finds out some wider problems, or data relating to this, which
he shares with readers. So as he goes by understanding the system he has joined
with high hopes, he shares his feelings with the reader and the reader joins in
his discovery and understanding of the less pleasant realities of the generally
brightly portrayed heath system of the
richest country in the world.
In this book Dr. Jauhar has portrayed a highly
commercialized system in which doctors who want to be honest to their
profession feel very helpless and hence are exposed to high levels of
depression. In a survey of 12,000 physicians, only 6 per cent described their
morale as positive! The majority of them said they did not have enough time to
spend with their patients because of paperwork. In the USA, among professions,
physicians have the highest suicide rate. One American doctor kills himself (or
herself) every day.
One doctor said on Sermo, the online community of
more than 1,25,000 physicians, “Working up patients in the ER these days
involves shortgunning multiple unnecessary tests (everybody gets a CT!) despite
the fact that we know they don’t need them, and becoming aware of the
wastefulness of it all really sucks the love out of what you do. I feel like a
pawn in a money-making game for hospital administrators.”
Another doctor quoted in this book says, “You’re
doing things, and you’re doing them because you’ve got to be doing them, but
you’ve thinking, why the hell am I doing this?”
One doctor regrets, “We allowed the insurance
companies to come between us and our patients.”
Dr. Jauhar says, “Year after year, health care
spending grew faster than the economy as a whole. Premiums for insurers like
Blue Cross, whose reimbursement rates were determined by doctors, increased 25
to 50 per cent annually. Meanwhile reports of waste and fraud were rampant.”
A Congressional investigation found that surgeons
performed 2.4 million unnecessary operations resulting in nearly 12,000 deaths.
The Institute of Medicine estimated that wasteful
health spreading (that does not improve health outcomes) costs $750 billion in
the USA every year.
A study published in the England Journal of Medicine
found that one in five Medicare patients discharged from the hospital was
readmitted within a month. One in three was readmitted within three months.
Dr. Donald Berwick and Dr. Allan Detsky wrote in the
Journal of American Medical Association that inpatient care at teaching
hospitals has become a relay race for physicians and consultants, and patients
are the batons.
Researchers have found that a doctor who owns a
nuclear scanner is seven times as likely as other doctors to call for a scan.
Between 1987 and 2006 the exposure of Americans to radiation increased by seven
times, primarily because of CT scans. The number of CT scans in the USA in one
year is around 70 million.
Patients are overexposed to a battery of
specialists, several of whom they do not need, while the doctor who knows a
patient best is often not involved in her or his care at the time of
hospitalization. Dr. Jauhar gives one example, “A fifty-year old patient of
Oni’s was admitted to the hospital with shortness of breath. During his month-long
stay, which probably cost upward of $200,000, he was seen by a hematologist; an
endocrinologist; a kidney specialist; a podiatrist; two cardiologists, a
cardiac electrophysiologist; an infectious-diseases specialist; a
pulmonologist; an ear, nose and throat specialist; a urologist; a
gastroenterologist; a neurologist, a nutritionist; a general surgeon; a
thoracic surgeon; and a pain specialist. The man underwent twelve procedures,
including cardiac catheterization, a pacemaker implant, and a bone marrow
biopsy (to work up mild chronic anemia). … When he was discharged (with only
minimal improvement in his shortness of breath), follow-up visits were
scheduled for him with seven specialists.”
Dr. Jauhar comments, “Patients don’t always require
specialists. Patients often have “overlap syndromes” (we used to call it
aging), which cannot be compartmentalized into individual problems and are
probably best managed by a good general physician. When specialists are called
in, they are opt to view each problem through the lens of their specific organ
expertise. Patents generally end up worse- I have seen it over and over again.”
Medicare imposed a requirement that antibiotics be
administered to a pneumonia patient within 6 hours of arriving at the hospital.
Doctors often cannot diagnose pneumonia so quickly, but because of Medicare
requirement antibiotics were given despite all-too-evident dangers to patients.
Introduction of surgical report cards which rewarded
lower mortality led to a strong tendency to avoid more serious patients. As a
research report stated, “Mandatory reporting mechanism inevitably gives
providers the incentive to decline to treat more difficult and complicated
patients. …Observed mortality declined as a result of a shift in incidence of
surgeries towards healthier patients.”
In New York state 63 per cent of cardiac surgeons
acknowledged that because of report cards, they were accepting only relatively
healthy patients for heart bypass surgery. 59 per cent of cardiologists said it
had become harder to find a surgeon to operate on their most severely ill
patients.
Despite very high spending on health the USA lags
behind in health achievements. According to the Commonwealth Fund, a health
care research group, the US ranks forty-fifth in life expectancy (behind Bosnia
and Jordan). Among developed countries, it is almost at the bottom of the list
when it comes to reducing infant mortality. Similarly it is near the last place
in terms of health care quality access and efficiency.
What is more, as Dr. Jauhar tells us, “…within the
USA, regions that spend the most on health care appear to have higher mortality
rates than regions that spend the less, perhaps because of increasing
hospitalization rates that result in more life-threatening errors and infections.”
Dr. Jauhar concludes, “I am convinced of one thing;
the vast majority of doctors aren’t bad. It is the system that makes us bad,
makes us make mistakes.” He says that more doctors are willing to stay till
late and provide good care, but “they
are struggling to do so in a system that is diseased.” The most disturbing part
of what Dr. Jauhar says is that most doctors realise that the system is forcing
them into a situation in which they cannot be honest to their profession, yet
feel so trapped by the system that they can’t resist it enough to find the
honest way out.
It is these words of the system being diseased which
are most important and convey the wider grim reality. It is not a question so
much of criticizing any individual doctor’s actions but what is much more
important is that a truly honest and ethical doctor finds it so difficult to
work within the system without making compromises with which his conscience
does not really agree and which leave an uneasy feeling. To his great credit,
Dr. Jauhar is so frank with his readers that he does not hesitate to tell how
he and his own family members are also
driven to make some compromises with differing levels of willingness ( or
reluctance) and the frank discussions that take place among doctors in which
any initial reluctance to make such compromises is ridiculed and frowned upon.
We see situations in which trying to work honestly and with ethics is fraught
with difficulties while compromises which involve ethical violations make it
easy to work and join the road to career and economic gains as well. In other
words it is much easier to be dishonest ( up to a level) than to be honest in
this system. It a system in which there is more reluctance to treat patients in
more difficult conditions and more eagerness to take up relatively healthy
patients and to expose them to a number of unnecessary specialist treatments
and tests!
At this stage I would like to leave Dr. Jauhar ( as
his account was written before COVID-19) and raise a question which is relevant
to more recent times—how would such a profit-driven system respond to the new
and increased challenges of a pandemic? Will it respond in a most honest and
rational way that is needed? Isn’t honesty ( or full freedom from monetary and
financial aspects while taking a decision concerning welfare of people) related
to the rationality of the response?
All these aspects are even more relevant in poorer
and developing countries where there is a tendency to bring in aspects of the
same profit driven system, driven by same or similar narrow interests. In India
for example we see a clear trend with emphasis shifting from public to private
health care, and from basic health care for all to insurance based systems, ie
from providing health care to buying health care. Here also we see increasing
and sometimes shocking commercialization of health system, from medical
education to actual treatment, and the growing distress of the idealists who
want to serve honestly and who want to prioritize serving the poor and the neglected
people in rural areas. Clearly there is
a clear case for systems reform, here as well in the richest countries like the
USA.
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