Losing the golden hour

What does it say about health care if even celebrities don’t get critical first aid?

Dr KK Aggarwal

Reproduced from: https://indianexpress.com/article/opinion/columns/losing-the-golden-hour-timely-healthcare-india-5873843/ (Give hyperlink here when posting)

Will we get timely healthcare when we need it is a question often asked by people in India. The answer, unfortunately, is no. Cardiac arrest revival needs to be done within four minutes, angioplasty in a heart attack needs to conducted within 90 minutes and a road traffic accident victim needs to be provided on the spot first aid within 10 minutes and the victim’s vital parameters should stabilise in an hour. Advanced ambulance care needs to reach the victim within four minutes. But even in Delhi, a patient cannot get such care.

The right to health and right to timely medical care is a fundamental right under Article 21 of the Constitution. But are we getting timely medical care? The December 16, 2012 rape victim, for example, was transferred from Munirka to Safdarjung Hospital — a distance of 6.2 km allegedly covered in 45 minutes — without any help.

The then NDMC chairman, Imtiaz Khan, died on April 23, 1998, at his office in the building which housed the health department. Were advanced resuscitation measures administered to him?

Congress leader, Rajesh Pilot died in 2000 in a car accident in Dausa less than 100 km from Jaipur. He was in a coma when he was admitted to the Sawai Man Singh Hospital, Jaipur. The situation could have been different if he was carried in an advanced ACLS ambulance? The golden hour was lost.

Former president, Giani Zail Singh, died in Chandigarh on December 25, 1994 after receiving multiple injuries in an accident on November 29 that year. The accident happened near Kiratpur Sahib in Ropar district. He was shifted to Chandigarh, 45-km away. Was he shifted in ACLS ambulance or provided a golden hour first aid in Ropar?

Former Delhi chief minister, Sahib Singh Varma, died on June 30, 2007, when his car collided with a truck on the Jaipur-Delhi highway (NH-8). He was taken to the Shahjanpur Civil Hospital, 13 km away from the accident site. Obviously no ACLS care was available for so short a distance.

Gopinath Munde, then the Union Minister for Rural Development, met with an accident at Prithviraj Road-Tughlak Road roundabout in Delhi at 6 am on June 3, 2014. He was brought to the AIIMS by his driver and assistant. The doctors said that Munde was not breathing when he was brought. Why was he shifted to the hospital? The ambulance should have come to him. Did the ACLS ambulance reach the spot?

One report of the death of former president A P J Abdul Kalam quotes his secretary, Srijan Pal Singh. Singh apparently heard a long pause from the former president when he was two minutes into his speech at IIM-Shillong. Singh’s account is a class description of an impending heart attack. Kalam’s eyes were three-quarters closed as he collapsed, according to his former secretary. When there was a doctor at the site, why did the former president’s secretary attempt to revive him?

Singh’s recollection that Kalam’s hands were clenched, his face was still and his eyes motionless, is a classic representation of cardiac arrest caused by ventricular fibrillation. As per Singh’s statement, he was brought to the nearest hospital within five minutes of the cardiac arrest. There are three phases of cardiac arrest. The electrical phase comprises the first four to five minutes and requires immediate defibrillation. The hemodynamic phase lasts about four to 10 minutes following a sudden cardiac arrest (SCA). Patients in the hemodynamic phase benefit from excellent chest compressions to generate adequate cerebral and coronary perfusion and immediate defibrillation. The metabolic phase occurs following approximately 10 minutes of loss of pulse. Few patients who reach this phase survive.

In the first 10 minutes, there are high chances of revival using hands only CPR followed with DC electric shock.

A study in The Lancet has shown that about 15 per cent of patients who survived needed at least 30 minutes of resuscitation. Why was not advanced CPR given to Kalam for the full period?

Former minister of state for external affairs, E Ahamed died on February 1, 2017. He suffered a cardiac problem while the President was addressing Parliament. There were over 30 doctors amongst the MPs at that time. No one was approached. He was shifted to Ram Manohar Lohia hospital, where he died. Why can’t the President’s speech be stopped for such emergencies?

Former Delhi CM, Sheila Dikshit, died on July 20, 2019 at the Escorts Heart Institute. She experienced breathlessness at her home in Nizamuddin and was shifted to Escorts in Sarita Vihar in a car — a distance of six km, which takes up to 24 minutes as per the Google map. She had a cardiac arrest on the way. Why was she not provided an ACLS ambulance at her home?

Amitabh Bachchan was saved because of timely local first aid. On August 2, 1982, on the sets of the film Coolie, he had a near-fatal accident and was shifted to nearby hospital. He was shifted to Mumbai later. The early treatment helped in saving his life.

We have a fundamental right to receive point of care advanced first aid within four minutes. But people in need don’t always get it

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Price discrimination in Health Care

Dr KK Aggarwal and Professor Nitin Aggarwal

Price discrimination is a microeconomic pricing strategy where identical or largely similar goods or services are transacted at different prices by the same provider in different markets.

It is not same as product differentiation.

Price differentiation essentially relies on the variation in the customers' willingness to pay and in the elasticity of their demand.

The term differential pricing is also used to describe the practice of charging different prices to different buyers for the same quality and quantity of a product

•                    Personalized pricing (or first-degree price differentiation) : is selling to each customer at a different price or one-to-one marketing. It maximizes the price that each customer is willing to pay. It is usually done for selling devices to a hospital and from a hospital to the patient

•                    Product versioning (or second-degree price differentiation) is offering a product line by creating slightly different products for the purpose of price differentiation. Examples are strategies of shifting NLEM drugs to Non NLEM, selling a drug with new release technology etc.

•                    Group pricing (or third-degree price differentiation): dividing the market into segments and charging a different price to each segment (but the same price to each member of that segment). Typical examples include student discounts, seniors' discounts, rural discounts, institutional discounts, health days discounts.  

Ethical: if it is transparent and the benefit gores to the customer.

Unethical ?:  No benefit to the customer. Example, trade generic and brand generic where the MRP is same but the price to the retailer is markedly different.

Capping of costs of health care is not far off

There has been lot of talk about capping of costs of health care. And, sooner or later, this will become a reality.

There is going to be a capping of medical costs to provide affordable and also accessible health care. The govt. will bring out a policy to cap the treatment costs including hospitalization costs.

The only way the govt. can do this is by bringing the entire health services under the gambit of the Essential Commodities Act as ‘essential medical services’. The prices of any commodity can be controlled only under this Act by making them ‘essential’ so that they are available to the consumers at fair prices.

Declaring health as an ‘essential’ service will ultimately benefit all in the long run. The costs of drug will reduce, there will be no strikes…the net result would be better and more cost-effective care for all.

Currently, only the prices of those drugs or devices are fixed, which are included in the National List of Medicines (NLEM). This has been done under the provisions of the Drug (Price Control) Order 2013 framed under Section 3 of the Essential Commodities Act to fix the ceiling prices for drugs. The drugs and devices in the National List of Medicines (NLEM) are included under Schedule 1 of the DPCO 2013.

DPCO allows the National Pharmaceutical Pricing Authority (NPPA) to revise the list of essential medicines based on need and bring it under govt. price control. But, not all drugs brought under price control are essential medicines. The ceiling prices of even non-scheduled drugs and/or devices can be fixed under certain circumstances as defined in Para 19 of DPCO 2013: “Notwithstanding anything contained in this order, the Government may, in case of extra-ordinary circumstances, if it considers necessary so to do in public interest, fix the ceiling price or retail price of any Drug for such period, as it may deem fit and where the ceiling price or retail price of the drug is already fixed and notified, the Government may allow an increase or decrease in the ceiling price or the retail price, as the case may be, irrespective of annual wholesale price index for that year.” The govt. cited para 19 of DPCO to cap the high costs of knee implants.

If the drug or medical device is not already listed under schedule I, the said drug or device is first included in Schedule 1 as ‘essential’ and then their ceiling price is fixed. This is what happened when the govt. capped the prices of cardiac stents.

Health care in the United States is governed by Medicare and HMOs. Medicare is the national health insurance program run by the govt. Its counterpart in India can be said to be the ‘Ayushman Bharat National Health Protection Scheme’ or ‘Modicare’. But unlike Medicare, Ayushman Bharat does not cover senior citizens. Eventually, it will have to cover senior citizens also. HMOs or Health Maintenance Organizations can be likened to TPAs or Third Party Administrators. HMOs provide or arrange managed care for health insurance, individuals acting as a liaison with health care providers (hospitals, doctors) on a prepaid basis (Wikipedia).

The govt. is now trying to control prices via TPA, CGHS, state government health schemes and the Ayushman Bharat National Health Protection Scheme.

Just as the HMOs have controlled healthcare costs in the US, insurance companies in India too may control pricing in India.

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

On this Doctor’s Day, let’s pledge to change with the changing times

Patients are the most important part of the delivery of health care. They form the epicenter of the healthcare team and there is no stakeholder bigger than them in this relationship between patients, doctors and the healthcare team.

Today patients are more aware about their illnesses courtesy the Internet. Even this group of aware patients can be categorized into four based on their levels of awareness: Ignorant, Informed, Empowered and Enlightened.

·         Ignorant patients do not participate in decision making and depend on the doctor to make their decisions, with no questions asked.

·         Informed patients have questions for the doctor, but only few. These patients then usually agree to the line of treatment adopted by the doctor.

·         Empowered patients have many more questions, they cross check facts and are an equal partner in decision making regarding their treatment.

·         Enlightened patients seek the opinions of many are only then convinced about the proposed line of treatment. Convincing these patients involves several counseling sessions.

There has been rapid shift in from patients who are ignorant to patients who are enlightened. But, there has been no corresponding change in the attitudes and behaviors of doctors.

Miscommunication leading to mistrust is at the root of many doctor-patient disputes. This occurs when the level of awareness of the doctor and the patient do not match.

So, there can also be three types of doctors.

·         Doctors who expect patients to accept what they say.

·         Doctors give choices to patients and ask them to choose.

·         Doctors who give choices to their patients, but help them to choose the best option.

Enlightened patients are more legal-savvy. They are more aware of their rights. The obvious outcome is the rising numbers of medical malpractice claims against doctors.

Four judgements have created a paradigm shift in medical practice today.

Compensations amounting to more than one crore were awarded by the Supreme Court of India and National Consumer Disputes Redressal Commission (NCDRC) in three judgements.

·         In Nizam Institute of Medical Sciences vs Prasanth S Dhananka and Ors SC / 4119 of 1999 and 3126 of 2000, the Apex Court directed Nizam’s Institute to pay Rs.1 crore as compensation in lieu of medical negligence.

·         In Balram Prasad vs Kunal Saha & Ors on 24 October, 2013, the Supreme Court awarded a compensation of Rs. 6.08 crores to Dr Kunal Saha and this figure reached a staggering Rs. 11 crores after addition of interest.

·         Then, in the case of Dr. (Mrs.) Indu Sharma vs Indraprastha Apollo Hospital, April 2015, the NCDRC again awarded a compensation of Rs 1 crore to the parents of the child who was born with 95% disability.

Judgements of the Supreme Court of Pennsylvania in Shinal vs Toms and the United Kingdom (UK) Supreme Court in Montgomery v Lanarkshire Health Board and Dr Bawa Garba v General Medical Council have revolutionized the way we practice. These judgements were not delivered by any court of law in India, but the day is not far off when these would be considered relevant and become applicable in Indian settings also.

Shinal vs Toms said the consent is non-delegable and is the sole duty of the treating physician.

Montgomery v Lanarkshire Health Board negated Bolam’s law and has made it mandatory for UK doctors to inform patients of all possible risks, even though rare and benefits of the planned treatment including risks and benefits associated with the alternative treatment options and let the patient take a decision.

In Dr Hadiza Bawa-Garba vs GMC, the UK Supreme Court sentenced Dr Bawa-Garba to two years imprisonment after she was found guilty of manslaughter and convicted for gross negligence. The aftermath to this judgement is that to err is human is no longer a defense now in the UK.

The answer to all this lies in diligent informed consent to be taken at the time of the first consultation itself. Give detailed information to the patient. All material facts, which will help the patient to reach to an appropriate decision such as diagnosis, proposed treatment, risks and benefits of the treatment, alternative treatments along with their associated risks and benefits and also the risks of refusal should be disclosed. Some questions such as should the consultation be video/audio recorded by the doctor and the patient, can the patient call the doctor at any time of the day and can a junior doctor delegate by the doctor treat the patient in his absence? Also, limit your compensation beforehand.

The times and people have changed. We might not like how this has affected the doctor-patient relationship from when the doctor was the sole decision maker and his word was literally the law, which the patient was expected to accept and follow. From a paternalistic role, doctors have now to adjust to patients becoming equal partners in decision making.

These changes are here to stay.

Let us change with the changing times and accept them as they are …

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

IMA Suggestions for Health Budget 2013-2014

A meeting on the Health Budget for the year 2013-14 was held on 21^st January, 2013 at IMA House. The following were present:-

Dr Narendra Saini, Hony Secretary General, IMA; Dr D R Rai, Sr. National Vice President, IMA; Dr K K Aggarwal, National Vice-President (Elect) IMA; Dr Atul Arora, Hony. Joint Secretary, IMA; Dr Nipun Choudhury, Apollo Hospital; Dr Atul Gandotra, Consultant Pharmaceutical; Dr S C Pandey, Central Govt. Hospital; Dr K K Kalra, NABH; Dr Chander Prakash, Sunder Lal Jain Hospital; Dr Girdhar Gyani, AHPI; Dr Vijay Aggarwal, PCH; Dr Zainab Zaidi, NABH; Dr B K Rana, NABH ; Dr Vijay Kohli, DMA; Dr R K Katharya, Hony Joint Secretary, IMA; Dr R K Gupta, Hony. Joint Secretary, IMACGP; Dr K K Kalra, NABH; Dr B K Rao, SGRM; Dr M K Singhal, IMA Rohini IMA; Dr Kalra, MS Hedgewar Hospital ; Mr Atul Gandotra; Dr Himanshu Jain, HRH and Dr M Bakshi, HRH

Basic issues

1. Food security, primary education, primary justice and primary healthcare are the minimum requirement of common man.

2. Health care needs coordinated effort of all healthcare workers.

3. The benchmark set for the standard health care: accessible, affordable and quality health care.

4. Current situation: Central Budgetary allocation of health- 0.9% of GDP; State expenditure on health- 5.5% of the budget; Central funding in the state for public health- 15%; 75-80% out of pocket expenditure; 70% of patients are managed by private sector and around 15 lakh doctors only 1.5 lakh in Govt.

IMA Recommendations

Health care Status

a. Health should be given infrastructure status and should be notified.

b. No commercial rates for electricity and water consumption for healthcare sector. It should be flat domestic rate without any slabs.

c. Upgrade districts hospitals to medical colleges or super- specialty hospitals.

d. Encourage PPP

e. Incentives for healthcare infrastructure providers: tax holidays, income tax rebates, provision of cheap medicine and instruments.

f. Easy Visa for patient who want to come for treatment from other countries.

 

Health budget allocation

a. Increase the budget for the Health to 2.5 % of GDP as envisaged in National Health Policy 2002.

b. No allocated funds for equipments, schemes, campaigns, projects should lapse. Accountability should be there.

c. Increased budgetary provisions for: drugs in govt. hospitals (at present only 15%); non communicable diseases; disease surveillance; safe drinking water; sanitation; mental health; child and maternal health; geriatric care; cancer.

d. Separate new fund provisions for reimbursements of emergency treatment given in private sector; for production of indigenous drugs, equipments and products.

e. More fund allocation for telemedicine and mobile units.

f. More fund allocation for new medical, nursing, dental and paramedical colleges.

g. Generic medicine should be available freely and their retail price should be properly monitored.

Taxes, custom Duty

a. Tax rebate on Preventive health check-up and health insurance at present is Rs.10,000 it should be increased to Rs. 25,000

b. Zero duty on medical equipments, drugs and reagents. Govt. get only Rs. 2 24 crore as duty through life saving equipment which is a meager amount.

c. Research and development should be given tax rebate. Special incentive should be provided for R & D.

d. No tax should be imposed on indigenous medicine and equipments.

e. Hospital should not be treated as “commercial venture” so property tax and land taxes should be charge as normal taxes.

f. Income tax free income for doctors willing to serve the rural areas.

g. Income tax reliefs for doctors who document 10% free service in their practice.

2. Insurance

a. Remove Service Tax on Medical Insurance.

b. Free insurance for the elderly

c. Soft loans for medical education and for opening of medical establishment.

d. Micro insurance (low premium for low income group) must be addressed.