Understanding the cost of healthcare

Interviewed by,

Mahima Kumari,

Second year MBBS student, PJMCH, Dumka, Jharkhand

Divya Samat

Intern, MBBS, KJ Somaiya Medical College, Mumbai.

To learn more about the cost of healthcare, we interviewed Dr. Sushant Shinde, MD Medicine, Founder of  Quest.

  1. Share with us a little about your journey as a medico and the defining moment that made you realize the “cost” of healthcare?

I am MD Medicine, a practicing physician with an interest in rheumatology. My MBBS was from Krishna Institute of Medical Sciences and I did my post-graduation in medicine from AIIMS Delhi. Right now I am a private physician in Mumbai as well as an educator. During MBBS, we observe patients as snapshots, only able to see them at a particular time and we put more focus on the costs of investigations. It is only as senior residents that we get to follow up on patients, see their progress longitudinally is when we can truly see how much healthcare costs. I became sensitive to it during my internship but started understanding it in my later time as a senior resident when I could see patients over years, and I have learned more on the topic in my time as a consultant.

For example for cases like chronic kidney disease, regular meetings with doctors, dialysis,ongoing medicines have to happen which over time can get costly and affect the whole family. In India, it is often the families that pay as they are not covered by insurance, which leads to a continuous burden on the family and affects each and every one of them. 2) Do you think it’s possible to attain an optimum balance between the corporate hospitals, the insurance industries, and the doctors to ensure that quality care is provided to the patient?

When we think of the cost and health care, there is a field that is emerging called Health Economics. The simple idea is we need to study multiple aspects of healthcare, including who’s paying. This can be the patient himself, the patient’s extended family, it could be parents, or in the case of elderly people, their children. Beyond that, there can be insurance, charitable organizations, or the government in the form of government-aided or municipal corporation-run hospitals. So payments can come from a variety of sources. It would not be correct to say insurance is the only model that exists. If I look at insurance from that perspective, the question of can insurance and a balance with corporate hospitals ensure quality health care? The answer is no because that’s not what is happening for most people. Insurance, as well as corporations, are eventually for profit organizations. Whenever it is for profit, there will be certain inclusion and exclusion criteria that are guided not by the need of the patient, but by the ability to reflect well on the balance sheet. The best interest remains of the stakeholders of the corporations and the stakeholders of the insurances which is not always aligned with the best interest of the patient. Now, this does offer a lot of benefit for big-ticket questions like if someone has to undergo an angioplasty, a knee replacement surgery, or a transplant. Here, corporations and insurances can offer state of the art care, which governments might not always be in a situation to do. The investments are going to be very heavy and the volumes are not always going to justify the investments by governmental organizations.

Insurance and corporations have a role but this role needs to be better defined. We need to evaluate what is the role better suited for and what do you do about those aspects which stay out of that, for example, primary health care. I don’t need insurance to take care of something like a common cold, diarrhea, or minor wounds which require a suture, and yet they are a significant burden of costs on the patient’s health. So, who fills in this gap? For today, the answer is the patient is paying for it but I think there can be models which can evolve over here.

We just need to see the countries which have a higher amount of insurance than we have. Does this really sort out their problems? Also, does it paradoxically increase the health care cost? Because if the purpose of the whole discussion is to reduce the cost, insurances have, at least in the US markets done pretty much the exact opposite of it, they’ve pushed up the cost of health care, rather than bringing the cost of it down. So we need to innovate on that. We need to have better models and I would say we need to have ingenious models developed for countries like us, which have unique healthcare situations. We need to take into consideration the population we have, the diseases we have, the accessibility questions like reaching out to a small village, a tribal zone, or even flood-affected areas which are very frequent in developing countries. These are questions where insurances will simply fall flat on their face, they will have no answers to these questions.

3) Do you think that it would be possible to implement a universal health care program like in the UK in a country like India with the resources we have?

I think the answer is yes. If you look at the health care system that the UK has today, you will find there are certain limitations like if you want to meet a specialist, you would have to wait for weeks simply because the GP has to refer and the specialist has to see a certain number of patients and so on. On the other hand, in India, if you want to meet a specialist, you’re waiting for two days or three. We need to see that as something positive for India. If the Indian Universal Insurance if we label it that way is to develop, it has to develop while accommodating all these positive features of our healthcare. We need to take care of the cost but the cost shouldn’t come at the cost of efficiency that our healthcare has. We need to be ingenious again, is what I would say. I think we have the ability to do it, whether we have the will to do it is a question which I very often ask myself. The answer to that is not always a yes in my mind. But if that is to be turned into a yes, I don’t think we really lack the capacity to do so.

4) Would you say you can put a price on human life as insurance companies often do? How do we assess whether a costly procedure leading to only a slight improvement in the patients condition is worthwhile?

Governments have to take a call and decide if it wants to make it available to the people at a lower cost. And if everyone can’t get the drug then let’s put a rationale on who is the most deserving candidate for it. We have to be practical about how many resources we have and how best to serve our community. However, if we take this question and put it in the domain of ethics, where we doctors come in, the answer is no, because we cannot put a price on human life. Patients have different priorities, there is a difference between losing a kidney and a joint. While patients will immediately try to save their kidney, despite being able to afford it, they might not want to save a joint, as they either can’t afford it as they feel their money best be used somewhere else or they feel it’s not worth it.

Thus it’s not only insurance but patients as well who choose to not take a treatment. Insurances have to answer to their stakeholders about how their model is profitable. If they run into losses then who would pay for the remaining patients? Thus the question of ethics is misplaced here, as I believe the question really is about health economics. We need rigorous study in health economics which compares both aspects, risk to the patient and profit/mitigating loss to a healthcare provider. That kind of scientific rigor can take the hook of ethics out and bring in the practicality of the naysayers, who say we need to be practical. The data we have right now is primarily of the companies, their stakeholders, their perspective on it, the patient’s perspective is missing. What happens when a patient does not get the therapy they need? So if the question is not ethical then is it practical?

For example, during the HIV epidemic of the ’90s, there was an HIV cutoff on who could be treated due to a shortage of drugs. India had created cheap generic medicines and increased its mass productions. Following this, WHO and India changed their policies and in today’s times there is no longer an HIV cutoff, everyone with HIV gets medicines. But at that time was the HIV cutoff ethical? No, but it was practical due to the logistics of drug availability.

Our situation is not as dire as in those times, we have better healthcare, accessibility, infrastructure, technologies. We have a vocal population now thanks to social media, in which they can assert their thoughts. We need all stakeholders to come together to study these questions because the answers are missing and we need to do this under the domain of health economics.

5) How much would you say the current government schemes help the common man? And what kind of plans should the government aspire to implement that would lead to healthcare costs being less of a burden for the common man? I think Indian governments over a period of time including the current governments leave a lot of room to be expected as far as health care goes. Honestly, I don’t know how many people were aware of how much of the GDP was really being spent on health care till COVID.

Prior to the pandemic, the present dominant administration had further reduced the portion of GDP being spent on healthcare services and there was no hue and cry about it. We stay in a democracy and so it is going to be the responsibility of the voters and taxpayers to hold our governments accountable for it. And that just does not happen in India.

One big reason why this decline would also continue today is that the vocal taxpayer does not use the healthcare services provided by the government. The depth of the problem is reflected by the fact that our taxpayers, our educated population, the population which needs health care from the government sector does not feel comfortable in availing these services. I think this is not because the healthcare in the government sector is poor at least as far as the health part is concerned. The care part however leaves a lot to be desired.

Now, what should the government do about this? I think the answer to that is that we need to triage. We need to figure out where the government’s role is best suited. I think the most important step, which is completely missed because of our lack of funds and the lack of motivation on this, is the primary healthcare or preventive services. At that point, our healthcare is damaged. This cannot be addressed just by increasing the funds for the hospitals but also requires restructuring and a strong thought on our education systems also, the way doctors are being trained. Being a general practitioner is just not glamorous enough after the corporations have come up and if you do not have an MBBS doctor serving the community, then you have that place filled up with someone else who is not an MBBS doctor. You just don’t have enough supply for the demand of primary health care. The government needs to sit and think on it, not just the cost, but also its policies need to be refined to address the question of preventive health care, versus the question of primary health care to address the question of care in healthcare. It’s not just a question of having an MRI machine, the machine needs to work and the services which are delivered are up to date.

COVID changed a lot for us. It did bring healthcare to the forefront of public debates. When I look at what happens when the political class, the media, and all the stakeholders including the public are asking for accountability, it is amazing the kind of services they have been able to deliver. You had the health in the right place, you’re delivering vaccines, you’re having these jumbo care setups, you’re having the drugs available. And you had the care aspect.

That gives me the hope, the optimism to say if this was possible when the governments decided to act, well, if the government decide to act I don’t think it can’t be replicated, maybe not to this extent, but to a significant extent. So I think there is a huge scope of what we can do and what our government can do. But it is going to be a long course that requires the population to ask for accountability the way we did during COVID.

6) The patients we encounter often feel that the more costly the service or more expensive the drug prescribed, the better the quality. How do we go about combating this notion?

By default no one wants to pay a high cost, I will go where I get value for money. The government low-value needs to invest money in the health care system and think about the care it is delivering. People don’t want a low cost low value system. They would rather have a high-cost high-value system. Value is perceived by people in different ways which drive the cost up and down. Good value at low cost is what people want. All of us intrinsically value our healthcare. The value that people perceive that they get is not appropriate to the cost that they save. A lot of people assume that the value they will get in a private hospital is more., and that’s why they are willing to pay a higher cost there. If we are able to deliver good value at low cost, I don’t think people will say no to it.

7)  Regarding the prices hospitals charge for facilities, doctors don’t have a say in them. So, how can we help? What role, as future doctors, can we play?

So I think one of the roles is to question it, which I think you are doing right now. The second thing I would like to say is we need to then commit ourselves to study this question even more. One thing which we need to understand is that healthcare systems can have different roles, which control different parts of the healthcare system. For example, a doctor is going to control medical decisions. Now, for the lack of a better person in that place, the medical doctor in India is also going to talk about the economics i.e. the cost of that particular therapy. This the doctor is going to do without having any formal education in finances or counseling on finances or any form of data to back up what he’s saying.

I believe if doctors need to have a say, then we need doctors who are formally studying finances, formally studying organizations of the hospital, and formally studying the cost of healthcare. There should be opportunities for doctors and perhaps a requirement also for a lot of these doctors to study this formally in the form of added courses to healthcare, which has defined roles tomorrow in the hospital.

So imagine a situation where you have what is very often known as Doctorprenuers, that is doctors who are entrepreneurs and doctors who are able to come up with solutions which matter to their communities and they have the know-how to do that. Arvind Netralaya brought down the cost of cataract surgeries, not by changing what is going to happen in the surgery but by a number of innovative methods. Firstly, they increased the number of patients that they had by an outreach program, then by having surgeries being done in a way that one doctor was able to operate in a single OT on multiple patients, and lastly, by defining roles. This can be achieved by giving the non-doctor healthcare worker, like an Anganwadi worker the role to identify patients. This means freeing up the time of this doctor and also bringing down the cost of care because your doctor is actually earning more for your organization by doing the big chunk where the real money is going to flow into the organization. This is innovation. This innovation can only happen when you have someone who understands that the system is integrated and that kind of an understanding comes inherently to doctors who are studying the system.

So I feel the answer to that for students and for practicing doctors also remains that we need to equip ourselves with the right kind of know-how about organizations, about the procedures that we do, where does the cost really come up, how to understand the cost structure, who pays, how do they pay and how do you bring down that cost.  Then hopefully a lot of us become Doctorpreneurs that can bring down the cost of healthcare and improve the care that we deliver to our patients.

8) Do you feel that the increasing cost of healthcare in India is proportionate to the advances in technology and quality of healthcare services provided?

The quality of healthcare service providers so this is again, a difficult question to answer. I will try to answer this question in two ways. My immediate answer is no, they’re not proportionate. I will rather say that they’re not completely proportionate to the advances that we are offering and the quality of care. If we compare healthcare costs in India to the high-income Western countries, on the surface we do phenomenally. For example, COVID costs patients in the US $95,000, while in India it cost 1/3 of it. So, it’s the same advancement of drugs which benefits the world. But India is able to produce generics at a lower cost, so the Indian population gets a fantastic deal. In India, there is also ease in getting consultations from specialists, something that is difficult in Western countries and even emerging economies like South-East Asia. So, India has lower costs as well as amazing accessibility to healthcare. But when you compare the presence of insurance or supporting structures such as the ability to travel and take leave as well as the per capita income of a patient in India and the USA, then the difference becomes clear. For example, even if we get a drug for cheaper in India, that a patient will have to buy it monthly. It might cost lakhs of rupees equivalent to in the USA, but in India at 15,000 may not be seen as affordable. So, we cannot say that our patients can afford everything that has been offered under the domain of advancements of technology. The ‘90s was the decade of generics from India. Without it, the HIV pandemic in Africa was not going to be controlled. That’s something we should be proud of. But at the same time, we now are at a stage where we cannot run away from what the world is doing. We need to find solutions that are local instead of just aping the West. We need to do it as leaders in the field and we should do it on a scale where we are able to export our models of healthcare tomorrow in years to come to the Western world, an idea they would call reverse innovation. What I might call the Indian’s way of innovation. These models have to be evidence-based, based on data done in a very clear scientific manner with protocols in place. We have to prove our data through meticulous study and submit it to organizations across the world. To say look at our data come here to visit see what we are doing. And we are not picking up we are not saying that we just believe that. So that kind of rigorous work is the need of that. I think we are heading towards it. And I think the answer to your question is no because we can do it better.

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