If we don’t self-regulate, then the govt. will

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