If we dont self-regulate, then the govt. will

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There has always been a dispute whether healthcare is a commercial business or a social business. The first step in regulation of the medical profession was taken when the medical profession was brought under the Consumer Protection Act (CPA). Consequently, any medical service provided to the patient in the form of consultation, diagnosis and treatment came to be under the ambit of ‘service’ as defined in the CPA.

In several of its judgements, the Hon’ble Supreme Court of India has stated that costs/charges in the medical profession must be reasonable. In the matter of Samira Kohli vs Dr. Prabha Manchanda & Anr on 16 January, 2008, the Apex Court said, “28. But unfortunately not all doctors in government hospitals are paragons of service, nor fortunately, all private hospitals/doctors are commercial minded. There are many a doctor in government hospitals who do not care about patients and unscrupulously insist upon unofficial payment for free treatment or insist upon private consultations. On the other hand, many private hospitals and Doctors give the best of treatment without exploitation, at a reasonable cost, charging a fee, which is reasonable recompense for the service rendered. Of course, some doctors, both in private practice or in government service, look at patients not as persons who should be relieved from pain and suffering by prompt and proper treatment at an affordable cost, but as potential income-providers/ customers who can be exploited by prolonged or radical diagnostic and treatment procedures. It is this minority who bring a bad name to the entire profession.”

The word to be taken note of here is “exploitation”. You cannot charge more in an emergency. If you do, this may mean that you are exploiting the patient.

Earning a profit is required for sustenance. But should this justify profiteering? A very fine line separates the two, which must never be crossed.

The word “reasonable” needs to be defined. The govt. always wanted to cap pricing in the medical profession. Towards this end, the govt. introduced the Clinical Establishments Act (CEA) to regulate prices in health care, which was opposed by the IMA.

The govt. is now trying to control prices via TPA, CGHS, state government health scheme and now through the newly launched “National Health Protection Scheme” under the Ayushman Bharat initiative announced in the Budget on Feb.1, 2018. The National Health Protection Scheme will provide coverage of Rs 5 lakh rupees per family per year for secondary and tertiary hospitalization, but only under the ‘general ward’ category to about 50 crore beneficiaries. This scheme may be taken advantage of or exploited.

This means that the govt. may cap the prices for each procedure as it did under the Rashtriya Swasthya Bima Yojana (RSBY), a health insurance scheme for the Below Poverty line (BPL) families, which provided a coverage of Rs 30, 000/- per annum to beneficiaries on a family floater basis. Under this scheme, the govt. has framed indicative package rates for several interventions or procedures.

The only way health sector can be controlled is by way of re-imbursement.   Just as the HMOs have controlled healthcare costs in the US, insurance companies in India too may control pricing in India.

Two types of costs may be worked out; one, a reasonable’ cost, one which could be covered under the ‘general ward’ category as directed by the govt. and the other a ‘private’ cost, which is not capped and allows charging as per the paying capacity of the patient.

If we don’t self-regulate, then the govt. will. Then we may have no choice but to comply with the price cap that has been put by the govt.

Dr KK Aggarwal

Padma Shri Awardee Vice President CMAAO Group Editor-in-chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Medical profession does not need any regulators: IMA

Health Care, Medicine, Social Health Community Comments Off

Doctors are considered next to God and require no regulators

New Delhi, 27 December 2017: The Union Cabinet recently rendered another blow to the medical profession with the approval of the draft National Medical Commission Bill, 2017. The NMC will “cripple” the functioning of the medical profession by making it completely answerable to the bureaucracy and non-medical administrators. Devoid of federal character, this non-representative half non-medical body will be a poor substitute for the MCI. NMC will not represent the medical profession of India in any manner.

Delivering affordable health care to India’s billion plus people presents enormous challenges and opportunities for the medical fraternity. Political ideologies play a distinctive role in determining the health policies of our country. The profession is fighting to ensure that further escalation of healthcare costs can be avoided. This, again, is only for the greater good of the community. This and other points were discussed at the Annual Central Council Meeting of the IMA held in Mumbai.

“Medical profession is regarded as a noble profession and no other profession has been given a similar high status. ‘Doctors treat, but God heals’ is a well-known saying. Doctors are considered next to Gods and hence require no regulators. They need to self-regulate themselves,” said Dr KK Aggarwal National President IMA during the Annual Central Council meeting.

Addressing the Central Council meeting, Dr KK Aggarwal and Dr Ravi Wankhedkar Incoming National President IMA, in a joint statement, said, “Dharma of a doctor is to treat and save the life of a person at any cost. It is time that the community supports us as we support them. We speak the loudest when we speak with one voice. Now, all corporate houses shall have to follow the MCI ethics and will help the profession provide affordable healthcare.”

Honorary Secretary General IMA Dr R N Tandon said, “Today, IMA is the largest medical professional body and is committed to affordable health care.”

The IMA has added the following in the last one year.

  • New medical emblem for doctors to differentiate MBBS doctors from non-MBBS doctors
  • IMA self-regulation code
  • A one-day educational event on TB with over 1000 doctors in March 2018
  • IMA policy on preventing antibiotic resistance
  • IMA restoration guidelines
  • IMA declaration of pollution as public health emergency\
  • IMA policy on writing NLEM drugs and capping the prices of non-NLEM items
  • New guidelines on criminal prosecution of doctors
  • IMA no incentive policy (no cuts, no commissions, no referral fee without service)
  • IMA accreditation of clinics, less than 50 bedded medical establishments and educational programmes
  • Aao School Chalen on the 5th of every month
  • IMA One drug-One price-One company policy

Straight from the Heart: Will the powers-that-be sit up and take notice?

Health Care Comments Off

The Union Cabinet recently rendered another blow to the medical profession with the approval of the draft National Medical Commission Bill, 2017. The NMC will “cripple” the democratic functioning of the medical profession by making it completely answerable to the bureaucracy.

It is time that the powers-that-be took urgent notice of this crisis and acted accordingly. The medical profession is currently facing the darkest hour. Not only are patients slowly losing faith in doctors and the profession as such, but are also becoming violent against doctors with the slightest provocation. This bill is only an addition to these existing woes and will exacerbate the situation for the medical fraternity and the students of medicine.

The structure of the NMC

The federal character of MCI is not found in the NMC. All the state governments have representation in MCI. Only five states in rotation will have representation in NMC as a result of which it will take two decades for a state to re-enter NMC. The Cabinet has cleared NMC Bill with a 25-member commission appointed by the central government. Of these members, 20 will be appointed by the search committee chaired by cabinet Secretary. Nomination will be done for 12 ex-officio and 6 part-time members. Three of these will be from disciplines such as management, law, medical ethics, health research, consumer or patient rights advocacy, science and technology, and economics. Only five will be elected by the registered medical practitioners from amongst themselves from such regional constituencies.

In effect, it would resemble a situation where the whole parliament is getting dissolved in favor of 25 nominated ministers by the President of India with only five elected members of parliament, one from each zone of the country with no powers to be re-elected.

The chairperson, secretary, and members shall hold office for a term not exceeding four years and shall not be eligible for any extension or reappointment and will retire by age 70. This will lead to a possible backdoor entry of bureaucrats after retirement.

In the MEDICAL ADVISORY COUNCIL, the Chairperson of the Commission shall be the ex-officio Chairperson of the Council and hence will have no autonomy. Every member of the Commission shall also be the ex-officio members of the Council. Each Board shall be an autonomous body and shall consist of a President and two Members, all nominated by the search committee. The commission will be more of an appellant body for aggrieved decision of an Autonomous Board within sixty days.

The four autonomous boards

The bill provides for the constitution of four autonomous boards entrusted with conducting undergraduate and postgraduate education, assessment and accreditation of medical institutions and registration of practitioners under the NMC.

UGME and PGME boards The UGME Board will grant recognition to a medical qualification at the undergraduate level and PGME Board shall grant recognition to the medical qualification at the postgraduate and super-specialty levels. Both boards may seek directions from, the Commission, as necessary. Any recommendations for UG and PG courses shall be made by the three-member committee under the control of the central government.

MAR board This Board shall grant permission for establishment of a new medical institution, carry out inspections of medical institutions for assessing and rating. It can also hire and authorize any other third-party agency or persons for carrying out inspections of medical institutions and for assessing and rating them, as required. It also has the power to impose monetary penalty (first time, second time, and third time in ascending order) against a medical institution for failure to maintain the minimum essential standards specified by the UGME Board or the PGME Board. All the three monetary penalties imposed shall not be less than one-half, and not more than ten times, the total amount charged. Such variation of 50% to 10 times will be the root cause of future corruption. It can also be used as a political action to favor or destroy someone. It will also become necessary to seek prior permission of the MAR Board to establish a new medical college.

EMR board This board shall maintain a National Register and regulate professional conduct and promote medical ethics. The EMR Board or State Medical Council shall also give an opportunity of hearing to the medical practitioner or professional concerned before taking any action, including imposition of any monetary penalty against such person. There will also be a separate National Register for licensed AYUSH practitioner who qualifies the bridge course (Homeopathy or a practitioner of Indian medicine).

Plight of medical students

It has been proposed to conduct UG-NEET in English or other languages with common counselling. There will also be a uniform National Licentiate Examination operational within three years with no PG NEET and with common counselling. This makes it seem like there will be one common licentiate exam. The addition of another exam indicates the height of insensitivity to the plight of medical students who even otherwise undergo a long and tortuous academic career replete with highly competitive exams.

The NMC allows private medical colleges to charge at free will nullifying whatever solace NEET brought. The government can fix fee for only 40% of the seats in private medical colleges. No medical college will survive if there is state central dispute in the fee structure. Up to 40% will give a wide margin for corruption.

Determining who is a qualified medical professional

As per the bill, any person who qualifies the National Licentiate Examination shall have his name and qualifications enrolled in the National Register or a State Register, as the case may be (prospective). Foreign medical graduates shall also have to qualify the National Licentiate Examination only. The Commission, however, may permit a medical professional to perform surgery or practice medicine without qualifying the National Licentiate Examination, in such circumstances and for such period as may be specified by regulations. It also indicates that a foreign citizen who is enrolled in his country as a medical practitioner in accordance with the law regulating the registration of medical practitioners in that country may be permitted temporary registration in India for such period and in such manner as may be specified by regulations. Any person who contravenes any of the provisions of this section shall be punished with fine which shall not be less than one lakh rupees, but which may extend to five lakh rupees. The Central Government can approve the grants of such sums of money as it may think fit.  This will be credited to a fund called the “National Medical Commission Fund” which shall form part of the public account of India.

The course structure

One a year, there will be a joint sitting of the Commission, the Central Council of Homoeopathy and the Central Council of Indian Medicine. This will decide on the approval of specific educational modules or programs that may be introduced in the UG and PG courses across medical systems. This discussion will also entail developing bridges across the various systems of medicine and promote medical pluralism.

Handing over power to administrators

The central government has the power to dissolve the commission if it has persistently defaulted in complying with any direction issued by them. The central government may, by notification, supersede the commission for such period, not exceeding six months, as may be specified in the notification. Anywhere else in the world, the medical profession is bestowed with reasonable autonomy with patient care and safety as the main benefits of such autonomy. Regulators need to have autonomy and be independent of the administrators. The NMC will be a regulator appointed by the administrators under their direct control.

In conclusion

It is not the first time that the government has made such a move. In 2005, the then Union health minister, Dr Anbumani Ramadoss, tried unsuccessfully to bring about a legislation to dissolve the MCI and set up another council under the control of the Health Ministry, which was rejected. That scenario is repeating itself today, with the difference that the union cabinet has given its approval to the draft NMC. The Parliament has a larger role to play in protecting the interest of the medical profession of the country. It is time to act.

Dr KK Aggarwal

National President IMA, Padma Shri Awardee

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