Affordability or quality of service? Choose both

Health Care No Comments

Every citizen in the country has a right to receive safe and quality medical treatment. Achieving universal health coverage is a target (3.8) under the Sustainable Development Goal (SDG 3). All member states of the UN including India have committed to try to provide universal health coverage to all their citizens by the year 2030. Universal health coverage means good quality health care that is Available, Accessible, Affordable and Accountable.

The Institute of Medicine, USA (IOM, 1990) has defined quality in health care as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”. The American Medical Association (AMA, 1991) has defined quality as “the degree to which care services influence the probability of optimal patient outcome”.

When a patient seeks health care, he/she looks for availability, quality and affordability. Safety, desired outcome of treatment and respect are becoming more and more important to the patients today.

It’s not just clinical care based on best practices alone that decides quality of care. Several other factors also constitute patients’ perception of quality of care such as cleanliness, reliability, responsiveness, communication, empathy, patient-centered with patient as an equal partner is decision making.

But, quality always comes at a price. Quality treatment is costlier but in the long-term, it is economical as it is associated with fewer hospital-acquired infections, complications, adverse drug reactions, re-hospitalization, as well as fewer system failures.

Quality is always preferred but it may not always be feasible because quality care may increase the cost of treatment.

So, should we focus on affordability or should we focus on quality?

Every hospital or health care establishment must try to improve and maximize quality within the resources that are available to them and with the best use of those resources. Poor quality service indicates poor utilization of resources.

Both quality and affordability need to be balanced, especially in a country like ours, which has one of the highest out of expenditures on health in the world.

Disclaimer: The views expressed in this write up are entirely my own

Govt. move to fix ceiling prices of knee implants: The need of the hour

Health Care No Comments

Dr KK Aggarwal

Early this week, the National Pharmaceutical Pricing Authority (NPPA) fixed and notified the ceiling prices (inclusive of trade margins) of orthopedic implants used in knee surgeries, both primary knee replacement surgery as well as revision surgery, under para 19 of Drugs (prices control) order (DPCO 2013) with immediate effect.

In 2005, orthopaedic implants were notified as ‘drugs’ by the Ministry of Health and Family Welfare vide its S.O. 1468 dated 6th October 2005. Consequent to this, Drug (Prices Control) Order
(DPCO) 2013 became applicable to these implants, which also came under the purview of the NPPA, which is mandated to monitor the prices of all notified drugs including notified devices.

An estimated 1.5 to 2 crores patients require arthroplasty; however, out of these which only about 1 lakh plus well off patients are in a position to pay for it every year because of the very high cost of orthopedic implants (NPPA Notification, August 16, 2017).

As per WHO estimates, osteoarthritis will be the fourth leading cause of disability by the year 2020.

The ceiling price of different materials and components used in the implant in primary knee replacement system has been fixed between Rs. 4,090/- to Rs 38,740/-. Similarly, the ceiling price of different materials and components used in the implant in revision knee replacement system has been fixed between Rs. 4,090/- to Rs 62,770/-.

As per the notification, “All manufacturers/marketers of knee implants having MRP lower than the ceiling price specified plus goods and services tax as applicable, if any, shall continue to maintain the existing MRP in accordance with paragraph 13 (2) of the DPCO, 2013”.

The earlier average MRP of cobalt chromium, the most commonly used knee implant has reduced by an average of 65%. The MRP has been capped at Rs. 54,720/- now Wfrom the earlier 1,58,324/-Knee implants made up of special metals like titanium and oxidised Zirconium has been capped at Rs 76,600/- with price reduction by 69%. The price of high flexibility implants have been capped at Rs. 56,490/-, again with a price reduction by 69% (Press Information Bureau, August 16, 2017).

All hospitals/nursing homes/clinics performing orthopedic surgical procedures using knee implants are now required to comply with the ceiling prices notified. The patients cannot be charged any additional charge over and above the ceiling price notified “except applicable goods and services tax, if any, paid or payable”.

The Indian Medical Association (IMA) welcomes this move of the govt. to fix the ceiling price of knee implants as now these implants have become more affordable and within reach of the common people. Many more patients will now be able to undergo the procedure, which earlier they could not because of the very high costs of the implants.

Earlier this year, the Govt. had fixed the ceiling prices of coronary stents, which also came as a relief to the general public.

Disclaimer: The views expressed in this write up are entirely my own.

Gorakhpur Tragedy: Findings of the IMA Inquiry Committee

Health Care Comments Off

Dr KK Aggarwal
National President, IMA

The Gorakhpur tragedy, where many innocent lives were lost, has shaken the nation and stirred a debate in the country.

Taking cognizance of the seriousness of the situation, Indian Medical Association (IMA) HQs constituted an Inquiry Committee comprising of Prof KP Kushwaha, Former Principal & Head, Dept of Pediatrics, Medical College Gorakhpur; Dr Ashok Agarwal, National Vice President IMA and Dr BB Gupta, President IMA Gorakhpur Branch.

The committee also asked the following doctors to appear before it to present their case.

• Prof Dr Rajiv Mishra, Principal BRD Medical College, Gorakhpur at the time of the incident
• Prof Dr Satish Kumar, Head, Dept. of Anaesthesia, Medical College, Gorakhpur
• Dr Mahima Mittal, Associate Prof, Dept. of Paediatrics, Medical College, Gorakhpur
• Dr Kafeel Khan, Asst. Prof and Nodal Officer, Encephalitis Ward, Dept. of Paediatrics, Medical College, Gorakhpur
• Dr AK Shrivastava, Superintendent in Chief, Nehru Hospital, Medical College, Gorakhpur

But, the above doctors failed to appear before the Inquiry Committee, which then decided to visit the Dept. of Pediatrics in the Medical College.

People there were hesitant to speak. The scope of the Committee was to only examine the working of the doctors as other issues such as lack of oxygen, inadequate staff and any structural deficiency were being investigated by the Chief Secy, UP Govt.

The committee also took note of the various reports published in the newspapers and other media. The following conclusions were arrived at:

• Oxygen supply was interrupted for a short time on the night of August 10, 2017.
• The liquid oxygen supplier had not been paid his dues since last 5-6 months.
• Cleanliness of hospital and ward was unsatisfactory. Presence of dogs and rats in hospitals is not acceptable by any standards in the hospital premises.
• The hospital was handling these cases and other critically ill patients much more than its capacity.
• There is no facility in Gorakhpur and nearby districts to manage encephalitis.
• There is a lack of staff – paediatricians, nurses and other paramedical staff – in PHCs/CHCs.
• ICUs in 10 districts of Poorvanchal area are not functioning because of lack of staff and other resources.
• No alert was issued by the hospital administration regarding shortage of oxygen, The traeting doctors should have been alerted seven days before the fresh oxygen supply was not received.

According to the IMA, although there is no evidence of medical clinical negligence against Dr Rajiv Mishra and Dr Kafeel Khan, prima facie it appears that a case of administrative negligence against them cannot be ruled out. Hence, administrative inquiry and action may be taken against them.

The recent movie ‘Airlift’ was based on the true story of evacuation – airlifted – of several hundreds of Indians from Kuwait during the first Gulf war and brought back to the country.

Similarly, we read about ‘green corridors’ without any traffic disruptions being set up to transport harvested organs like heart to reach another hospital, where there is a patient waiting to receive the organ. It’s an emergency where time is of utmost importance.

Why can’t the same be done in situations such as the Gorakhpur tragedy, where an epidemic of encephalitis recurs every year and, many children lose their lives every year because of the illness?

In view of this tragedy, IMA has suggested the following to avoid similar situation in the future.

• There should be a state policy to airlift such critically patients in a timely manner to nearby best facilities.
• All patients denied treatment at government hospitals should be reimbursed for the cost of treatment in the private sector at pre-defined rates.
• All hospitals should have back up of one-week supply of all essential drugs, investigations and oxygen.
• IRDA has made it mandatory for all private hospitals to get NABH accreditation. The same should be extended to all government set ups.
• Essential drugs and investigations, not non-essential drugs and tests, should constitute the bulk of the expenditure of the allocated budget to reduce the cost of treatment.
• All payments for health care services should be made either in advance or in time.
• Doctors are clinicians as well as administrators. It is important to make a distinction between clinical medical negligence and administrative negligence.
Disclaimer: The views expressed in this write up are entirely my own

Dr KK Aggarwal

« Previous Entries