Healing the Health­care Di­vide

FICCI Business Digest - - Contents -

An­nounce­ment of the flag­ship Ayush­man Bharat – Prad­han Mantri Jan Ar­o­gya Yo­jana (PMJAY), on the In­de­pen­dence Day, to cover over 10 crore poor and vul­ner­a­ble fam­i­lies with a cov­er­age up to INR 5 lakhs per fam­ily per an­num for se­condary and ter­tiary care hos­pi­tal­i­sa­tion is cer­tainly a timely and much needed trig­ger to re­form health­care de­liv­ery in In­dia and to achieve the coun­try's growth as­pi­ra­tions. PMJAY was for­mally launched on 25 Septem­ber 2018.

As we move to­wards achiev­ing uni­ver­sal health cov­er­age for In­dia, we would need to tackle var­i­ous chal­lenges in­clud­ing sub­stan­tial ex­pan­sion of the coun­try's health­care in­fra­struc­ture to cover the 50 crore ex­pected ben­e­fi­cia­ries.

Sus­tain­able Pric­ing in Health­care

The pri­vate sec­tor that has been pro­vid­ing nearly 60 per cent of in- pa­tient care and has con­trib­uted to 70 per cent of bed ca­pac­ity ex­pan­sion in the last decade, will be a cru­cial part­ner in suc­cess­ful im­ple­men­ta­tion of PMJAY.

How­ever, there are ris­ing con­cerns amongst pri­vate health­care providers in terms of in­ad­e­quate pack­age rates for the pro­ce­dures cov­ered for hos­pi­tal­i­sa­tion. Con­ven­tion­ally, the ma­jor weak­nesses of pub­lic health in­sur­ance schemes, whether Rashtriya Swasthya Bima Yo­jna (RSBY) or CGHS (Cen­tral Gov­ern­ment Health Scheme), have been non-vi­able re­im­burse­ment rates and de­lays in pay­ments to the hos­pi­tals, af­fect­ing the fi­nan­cial sus­tain­abil­ity of such schemes with the em­pan­elled hos­pi­tals.

For the gov­ern­ment's as­pi­ra­tional mis­sion to suc­ceed in pro­vid­ing ac­cess to health­care for its most vul­ner­a­ble pop­u­la­tion, it is im­per­a­tive to de­vise a re­im­burse­ment mech­a­nism based on a sci­en­tif­i­cally de­vel­oped cost­ing frame­work. It is time to recog­nise cost­ing from the point of view of both – af­ford­abil­ity as well as vi­a­bil­ity and make con­certed ef­fort to un­der­stand the ac­tual cost associated with a med­i­cal pro­ce­dure in­clud­ing di­rect ma­te­rial (drugs and con­sum­ables) as well as indi­rect cost of man­power and in­fra­struc­ture.

For suc­cess­ful im­ple­men­ta­tion of PMJAY, it will be crit­i­cal to en­sure that pack­age rates for pro­ce­dures cov­ered un­der the mis­sion are ad­e­quate to pro­vide qual­ity ser­vices to the ben­e­fi­cia­ries and do not ham­per the sus­tain­abil­ity of the health­care providers. Dif­fer­ent stake­hold­ers in health­care have a dif­fer­ent per­spec­tive of cost. While the price con­trollers view the cost of care mainly as cost of con­sum­ables, pa­tients see cost as what they pay out of pocket and hos­pi­tals work cost around de­part­ments. Be­cause of this dis­con­nect, the ef­forts of de­riv­ing ra­tio­nal re­im­burse­ment rates for health­care ser­vice providers have been in­ef­fec­tive in the past. The only way to bring a fun­da­men­tal re­form is to con­sider the cost within the de­liv­ery sys­tem – the cost in­curred by the provider.

The goal of Uni­ver­sal Health Cov­er­age can be ac­com­plished only with clear cri­te­ria for cost­ing as well as ad­e­quate and timely re­im­burse­ment. There­fore, it is im­per­a­tive to de­velop a proper cost­ing ap­proach to de­rive re­im­burse­ment rates that are aligned with ser­vice de­liv­ery costs at dif­fer­ent lev­els of care, lo­ca­tions and vol­umes. In­ter­na­tional stud­ies sug­gest the cost

cri­sis in health­care can be fun­da­men­tally solved with ac­cu­rate mea­sure­ment of costs and their fair com­par­i­son with out­comes. With this as the ge­n­e­sis, FICCI un­der­took a study on cost­ing of Health­care in In­dia, to de­rive the costs associated with de­liv­ery of se­lect med­i­cal pro­ce­dures across se­lect pub­lic and pri­vate hos­pi­tals from around the coun­try. The method­ol­ogy and find­ings of the study were re­leased in a pa­per ti­tled ‘De­mys­ti­fy­ing Health­care Costs: A Sci­en­tific Ap­proach’, by Dr VK Paul – Mem­ber (Health), NITI Aayog, dur­ing the con­fer­ence.

San­gita Reddy, Vice Pres­i­dent, FICCI and Joint MD, Apollo Hos­pi­tals En­ter­prise Ltd. feels, 'In­dian health­care is no longer at cross­roads with the an­nounce­ment of Ayush­man Bharat. Health­care has en­tered the Uni­ver­sal Col­lec­tive Su­per-high­way. It is a fact that there are sig­nif­i­cant gaps in health­care ac­cess, but we also have the where­withal to de­liver the high­est qual­ity of care avail­able any­where in the world at one-tenth of the prices. We want to make use of tech­nol­ogy to make health­care avail­able to ev­ery­body. '

The health­care cost­ing is com­plex due to the na­ture of de­liv­ery of ser­vices. There are sev­eral prac­ti­cal is­sues in cap­tur­ing util­i­sa­tion of re­sources by the ac­tiv­i­ties within the de­liv­ery sys­tem. The health­care ser­vices re­quire re­sources at mul­ti­ple points of de­liv­ery within the sys­tem, with vary­ing in­ten­sity of con­sump­tion of re­sources. FICCI, as a change agent, has been work­ing to­wards de­vel­op­ing a ra­tio­nal cost­ing tem­plate since 2013, un­der the aegis of Min­istry of Health and Fam­ily Wel­fare, Gov­ern­ment of In­dia, and was the nodal agency for the de­vel­op­ment of Na­tional Cost­ing Guidelines.

HEAL: Fo­cus on Bal­anced Health­care

Given that health­care in In­dia is poised to wit­ness a tec­tonic shift, FICCI or­gan­ised the 12th edi­tion of its an­nual health­care event – FICCI HEAL in New Delhi on 30-31 Au­gust 2018 on the theme 'Health­care at Cross­roads', sup­ported by NITI Aayog. Shar­ing his views at the in­au­gu­ral of event, Union Health & Fam­ily Wel­fare Min­is­ter JP Nadda said that 'Ayush­man Bharat is a his­toric pro­gram which looks at health holis­ti­cally with twin pil­lars of Health and Well­ness Cen­tres (HWCs) for com­pre­hen­sive pri­mary health­care and fi­nan­cial pro­tec­tion for se­condary and ter­tiary care hos­pi­tal­i­sa­tion, through PMJAY. Un­der Ayush­man Bharat 1.5 lakh sub-cen­tres and PHCs will be con­verted into Health and Well­ness Cen­tres. All sup­port should be given to HWCs to en­sure pro­mo­tive and pre­ven­tive care, for which we are go­ing for uni­ver­sal health screen­ing at the age of 30. This is a par­a­digm shift as far as health­care is con­cerned and this is again an area where the pri­vate sec­tor can come in.'

Nadda opined, 'The Gov­ern­ment of In­dia is keen to for­malise a mul­ti­stake­holder fo­rum to ar­rive at pol­icy de­ci­sions and for­mu­late im­ple­mentable strate­gies to make health­care af­ford­able and ac­ces­si­ble to all. At present, there is no for­mal struc­ture for pol­icy in­ter­ac­tion and such syn­er­gies would be im­por­tant to achieve a hep­ati­tis-free In­dia by 2030.'

(Hony) Brig. Dr Arvind Lal, Chair, FICCI Health Ser­vices Com­mit­tee and CMD, Dr Lal PathLabs said 'It is im­por­tant to de­rive ra­tio­nal and sus­tain­able pack­age rates for In­dian health­care is no longer at cross­roads with the an­nounce­ment of Ayush­man Bharat. Health­care has en­tered the Uni­ver­sal Col­lec­tive Su­per­high­way. It is a fact that there are sig­nif­i­cant gaps in health­care ac­cess, but we also have the where­withal to de­liver the high­est qual­ity of care avail­able any­where in the world at one-tenth of the prices. We want to make use of tech­nol­ogy to make health­care avail­able to ev­ery­body.

pro­ce­dures cov­ered un­der the Prad­han Mantri Jan Ar­o­gya Yo­jana, to en­sure qual­ity care can be pro­vided and the costs in­curred within the health­care de­liv­ery sys­tem are cov­ered. For this, there is a strong need to un­der­stand costs from the per­spec­tive of all rel­e­vant stake­hold­ers – the gov­ern­ment, the providers and the con­sumer.'

Even after 70 years of in­de­pen­dence, pub­lic pro­vi­sions for health­care re­main largely in­ad­e­quate and In­dia's health­care model is shaped mostly by pri­vate health­care. Glob­ally, In­dia has been recog­nised for avail­abil­ity of high qual­ity se­condary and ter­tiary care at the frac­tion of price as com­pared to de­vel­oped coun­tries. But it fails to pro­vide even ba­sic health­care be­yond the ur­ban lim­its, putting about 70 per cent of its pop­u­la­tion dwelling in the ru­ral ar­eas at risk of suf­fer­ing from pre­ventable and cur­able dis­eases and con­di­tions.

Dr VK Paul, Mem­ber (Health), NITI Aayog, Gov­ern­ment of In­dia, said that as course cor­rec­tion in health­care takes place, qual­ity and ethics will be the guid­ing force. He urged the pri­vate sec­tor to en­gage

It is im­por­tant to de­rive ra­tio­nal and sus­tain­able pack­age rates for pro­ce­dures cov­ered un­der the Prad­han Mantri Jan Ar­o­gya Yo­jana, to en­sure qual­ity care can be pro­vided and the costs in­curred within the health­care de­liv­ery sys­tem are cov­ered. For this, there is a strong need to un­der­stand costs from the per­spec­tive of all rel­e­vant stake­hold­ers – the gov­ern­ment, the providers and the con­sumer. (Hony) Brig. Dr Arvind Lal, Chair, FICCI Health Ser­vices Com­mit­tee and CMD, Dr Lal PathLabs

with the gov­ern­ment in pro­vid­ing qual­ity care at rea­son­able rates, mon­i­tored by the gov­ern­ment. He said, 'PMJAY is not pos­si­ble with­out the en­gage­ment of the pri­vate sec­tor. We also need to cre­ate a pipe­line of spe­cial­ists and pri­vate sec­tor can help in fill­ing that gap.'

Dr Alok Roy, Co-chair, FICCI Health Ser­vices Com­mit­tee and Chair­man, Med­ica Group of Hos­pi­tals, high­lighted, 'De­vel­op­ing and main­tain­ing hos­pi­tals is a cap­i­tal-in­ten­sive af­fair and there­fore, man­ag­ing costs, achiev­ing prof­itabil­ity and jus­ti­fi­able growth are very im­por­tant for any hos­pi­tal ven­ture to be suc­cess­ful. Hos­pi­tals face num­ber of chal­lenges as they are ex­posed to greater risk as com­pared to other in­dus­tries, ow­ing to com­plex­ity of op­er­a­tions, en­sur­ing ap­pro­pri­ate qual­ity of care and hu­man­i­tar­ian and eth­i­cal is­sues in pro­vid­ing health­care.'

Varun Khanna, Co-chair, FICCI Health Ser­vices Com­mit­tee and Ex­ec­u­tive VP, For­tis Health­care, feels, 'We have less than 1 bed to a 1000 peo­ple as op­posed to global av­er­age of 6 beds to 1000. And what we fun­da­men­tally need in this coun­try is cap­i­tal for health­care.'

Shar­ing his ex­pe­ri­ences from prac­tic­ing in UK, Prof (Dr) Di­nesh Bhugra, CBE, Pres­i­dent, Bri­tish Med­i­cal As­so­ci­a­tion, rec­om­mended, 'There is a need to shift the fo­cus from se­condary health­care and hos­pi­tals to pri­mary care. There is also a need to change the way we train the next gen­er­a­tion of doc­tors and med­i­cal stu­dents.’

FICCI Health­care Ex­cel­lence Awards: 16 Health­care Pro­fes­sion­als & In­sti­tu­tions Fe­lic­i­tated

The Lieu­tenant Gov­er­nor of Delhi, Anil Bai­jal, along with the Min­is­ter of State for Health and Fam­ily Wel­fare, Anupriya Pa­tel and Chair­per­son, Kok­i­l­aben Dhirub­hai Am­bani Hos­pi­tal & Med­i­cal Re­search In­sti­tute, Mum­bai, Tina Am­bani,

gave away the 10th FICCI Health­care Ex­cel­lence Awards to 16 health­care pro­fes­sion­als and in­sti­tu­tions in New Delhi on 30 Au­gust 2018.

Speak­ing on the occasion, Bai­jal urged to re­move para­dox­i­cal sit­u­a­tions present on the ground in pro­vid­ing qual­ity health­care to all. He said, 'De­vel­op­ment of a coun­try is pre­dicted on the ba­sis of the health­care sit­u­a­tion in the coun­try. We need right pol­icy and reg­u­la­tory frame­work to achieve re­mark­able growth.' Em­pha­sis­ing on the im­por­tance of start-ups, he said that they are re­defin­ing the health­care sec­tor and urged the pri­vate sec­tor to come for­ward and work in col­lab­o­ra­tion with the gov­ern­ment to take health­care to the next level.

Min­is­ter of State, Anupriya Pa­tel re­it­er­ated the ben­e­fits of Ayush­man Bharat and said that gov­ern­ment is work­ing to­wards strength­en­ing Pub­lic Pri­vate Part­ner­ship (PPP) and creat­ing work­able and vi­able PPP model which can be im­ple­mented in next two-three years.

Tina Am­bani men­tioned the five 'As' are im­por­tant for the health­care sec­tor and em­pha­sized, 'Ac­ces­si­bil­ity, af­ford­abil­ity, aware­ness, as­pi­ra­tion and as­so­ci­a­tion are the five pil­lars that will help to bridge the gap in pro­vid­ing qual­ity health­care to the com­mon man.'

Code of Ethics for Health Ser­vices In­dus­try

Recog­nis­ing the need for trans­parency and ac­count­abil­ity in the func­tion­ing of all health­care es­tab­lish­ments, FICCI de­vel­oped the Code of Ethics for Health Ser­vices In­dus­try through ex­ten­sive con­sul­ta­tion with stake­hold­ers from the Gov­ern­ment as well as the pri­vate sec­tor.

The code, which is ap­pli­ca­ble to health­care pro­fes­sion­als, health­care providers, di­ag­nos­tic cen­tres and other health­care in­sti­tu­tions op­er­at­ing in In­dia, covers sev­eral as­pects of eth­i­cal con­duct in­clud­ing pa­tient cen­tric­ity, pri­vacy and con­fi­den­tial­ity, fair trade prac­tices and griev­ance re­dres­sal.

Al­ready 7 other as­so­ci­a­tions, with more than 30,000 in­sti­tu­tional and in­di­vid­ual mem­bers; and more than 15 health­care or­gan­i­sa­tions from across In­dia, have en­dorsed the code. How­ever, this is just the begin­ning of a jour­ney to prop­a­gate the code to a large num­ber of health­care ser­vice providers across the coun­try.

This vol­un­tary code can be used as a yard­stick by the health ser­vice providers for their day to day con­duct and in­ter­ac­tions with pa­tients as well as within the health­care com­mu­nity.

Union Health & Fam­ily Wel­fare Min­is­ter JP Nadda with in­dus­try lead­ers.

L to R: Chair­per­son, Kok­i­l­aben Dhirub­hai Am­bani Hos­pi­tal & Med­i­cal Re­search In­sti­tute, Mum­bai, Tina Am­bani; Min­is­ter of State for Health and Fam­ily Wel­fare, Anupriya Pa­tel and Lieu­tenant Gov­er­nor of Delhi, Anil Bai­jal, at the 10th FICCI Health­care Ex­cel­lence Awards.

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