Revisiting Healthcare in 2019

Revisiting Healthcare in 2019

Dr KK Aggarwal

President CMAAO , HCFI and Past National President IMA

The year 2019 saw a lot on new health promises. Let us review some of the important ones.

Disease Outbreaks

1.               As per Who list https://www.who.int/csr/don/archive/year/2019/en/ No major health outbreak in India in 2019.

2.               No case of Polio was noted.

3.               In June 2019, an outbreak of acute encephalitis syndrome occurred in Muzaffarpur and the adjoining districts in Bihar state of India, amidst the second-longest heatwave in the region, resulting in deaths of more than 100 children, mainly due to hypoglycemia.

4.               The index case of Nipah in Koci in June was contained the disease was controlled before it took off

5.               Congo fever: 17 cases were reported in Gujarat and three tested positive in Rajasthan.

6.               More than 67,000 people across India have been diagnosed with dengue so far this year, reports by the National Vector Borne Disease Control Programme (NVBDCP) show. By mid-October, reports show, the disease had claimed 48 lives.

7.               The number of HIV-infected people who go on to develop Tuberculosis (TB) is increasing in India, according to the India TB Report 2019, which was released by the government on September 25, 2019.Nearly 25 per cent of all deaths among PLHIV are estimated to be due to TB. The highest percentage of patients who tested positive for TB and were also infected with HIV came from Nagaland (15.6 per cent), followed by Karnataka (10 per cent), Chandigarh (9.1 per cent) and Manipur (8.9 per cent).

Major Concerns of the year

1.               Pollution in North India

2.               Rising AMR

Parliament Bills

1.               The parliament passed the National Medical Commission (NMC) Bill. The bill provided for setting up a National Medical Commission (NMC) in place of the MCI to develop and regulate all aspects of medical education, profession and institutions in India.

2.               The government in November referred a bill, which seeks to ban commercial surrogacy in India, to a 23-member select committee of Rajya Sabha.

3.               The government passed Prohibition of Electronic Cigarettes (Production, Manufacture, Import, Export, Transport, Sale, Distribution, Storage and Advertisement

4.               The draft bill Healthcare Service Personnel and Clinical Establishments (Prohibition of violence and damage to property) Bill, 2019 is pending to be passed

5.               The Allied and Healthcare Professions Bill, 2018 was introduced in Rajya Sabha by the Minister of Health and Family Welfare, Mr. J P Nadda on December 31, 2018. The Bill seeks to regulate and standardise the education and practice of allied and healthcare professionals. Jan 02, 2019 referred to standing committee

6.               The Occupational Safety, Health and Working Conditions Code, 2019 pending

Delhi

1.               Delhi health bill, which will replace Delhi Nursing Home act

2.               The Delhi Government will shift serious patient to private ICU. The payment will be done by DG if no bed is available with them

Major Courts Decisions

1.               Delhi high court on ‘courts in its own motion’ has asked the CDSCO to release a list of over the counter drugs

2.               Delhi high court on ‘courts in its own motion’ has asked the Railways to have emergency medical services at all major stations

Strikes

On 11 June 2019, following the assault of two junior doctors at Nil Ratan Sircar Medical College and Hospital (NRSMCH) the previous night, junior doctors in Kolkata began protesting and demanded the Chief Minister of West Bengal, Mamata Banerjee to intervene and provide adequate security to medical professionals, culminating into the collapse of healthcare facilities in the state. Despite attempts at mediation, protests continued through 13 June, finally resulting in the Chief Minister issuing an ultimatum to the protesting doctors, which was eventually defied by the protesting doctors who wanted the government to meet their demands for security and a public apology from the Chief Minister.

Life expectancy and Vital Statistics

1.               Life expectancy in India has increased from 49.7 years in 1970-75 to 68.7 years in 2012-16, as per the National Health Profile 2019. For the same period, the life expectancy for females is 70.2 years and 67.4 years for males.

2.               HIV virus now can be made untraceable undetectable and an HIV positive person will be able to live a normal married life on daily uninterrupted treatment

Major Campaigns

1.               Fit India Movement by Ministry of Sports GOI

2.               Perfect Health Mela by Heart Care Foundation of India

Economics

1.               The downfall in the economy was a major issue in 2019.

2.               In 2019, Fortis Healthcare announced that it has completed the acquisition of RHT Health Trust (RHT) assets for an enterprise value of Rs 4,650 crores.

3.               Rs 5,800 cr Medanta-Manipal deal falls through as sides disagree over valuation

Medical  Update

1.               For patients with heart failure and low heart pumping function with persistent symptoms and an elevated serum natriuretic peptide level on optimal pharmacologic and device therapy a new ray of hope came for better due to availability  of  a new drug dapagliflozin

2.               In patients with type 2 diabetes with kidney involvement (urine albumin excretion >300 mg per day and eGFR >30) the incorporation of an SGLT-2 inhibitor into the patient's glucose-lowering regimen has been shown to improve the diabetics complications.

3.               We expect in 2020 all patients with an LDL-C >100 mg/dL and a greater than 10 percent risk of a cardiovascular disease event within 10 years, will be put on statins. Also, All patients with  cardiovascular disease independent of the baseline low density lipoprotein cholesterol (LDL-C) level they will be put on lifelong high-intensity statin therapy (atorvastatin 40 to 80 mg or rosuvastatin 20 to 40 mg) rather than moderate intensity statin or no LDL-C lowering therapy.

Ayushman Bharat

As on 2^nd December 19590 hospitals empanelled, 6800774 patients benefitted via admissions and  11.46.69,820 cards issued

IMA

Dr Rajan Sharma took over as the National President 

New Drugs introduced in India in 2019

1.     Fenspiride hydrochloride film coated extended release tablet 80 mg and Fenspiride hydrochloride bulk for allergic asthma

2.     Bilastine tablets 20 mg and Bilastine Bulk for urticaria

3.     Iguratimod film coated tablets 25mg and Iguratimod Bulk for rheumatoid arthritis

4.     Fingolimod Capsules 0.5mg and Fingolimod hydrochloridebulk for multiple sclerosis

5.     Remogliflozin etabonate bulk and Remogliflozin etabonate film coated tablets 100 mg for diabetes

6.     Concentrate of Proteolytic enzyme enriched in Bromelain topical gel for eschar

7.     Menotrophin injection 600 IU/ml, 1 ml & 2 ml multi dose vial (Highly purified) for infertility

8.     Rifapentine 150mg film coated tablet for TB

9.     FDC of Bictegravir, Emtricitabine and Tenofovir alafenamide 50mg/200mg/25mg tablets for HIV

10.  Levomilnacipran ER capsules 20mg/40mg/80mg/120mg for depression

11.  Bosutinib bulk and Bosutinib tablets 100mg, 400mg, 5600 mg for cancer

12.  Algard HWS-256 (didecyl dimethyl ammonium chloride 10.14% w/w + n-Alkyl dimethyl benzyl ammonium chloride 6.76% w/w as disinfectant

13.  Algard - R-82 (octyldecyl dimethyl ammonium chloride 6.510 w/w + Dioctyl dimethyl ammonium chloride 2.604% w/w + Didecyl dimethyl ammonium chloride 3.906% w/w + Alkyl dimethyl benzyl ammonium chloride 8.680% w/w as disinfectant

14.  Safinamide methane sulphonate bulk drug and Safinamide tablets 50, 100mg for Parkinson disease for Parkinson disease

15.  Droxidopa bulk drug and Droxidopa capsules 200mg/300mg for postural hypotension

16.  Acalabrutinib 100mg capsules for multiple myeloma

17.  Abemaciclib 50mg, 100mg, 150mg and 200mg film coated tablets for breast cancer

18.  Ripasudil hydrochloride hydrate bulk drug and Ripasudil Eye drops 0.4% w/v for glaucome

19.  Diperoxochloric acid concentrate and Diperoxochloric acid topical solution for diabetic neuropathy ulcers

The high costs of healthcare: Necessary vis-à-vis unnecessary costs

An elderly patient with loss of consciousness was admitted in a corporate hospital in NCR. The patient’s hospital stay was for less than 48 hours and the total bill amounted to more than one lakh.

Let’s take a look at just a very small part of the bill – biochemistry. Among other lab investigations (and other modalities), the patient underwent kidney profile, liver function tests, lipid profile and thyroid profile. The total cost of these tests was Rs 9780/-.

Two questions arise:

1. Is this not overpricing?

2. Were they necessary?

The charges of IPD may sometimes be even much higher than the OPD charges, especially if they are billed as express charges.

The practice of doing “profiles” needs to be deliberated. Why do lipid profile at admission when the patient may not be fasting? Why do T3 and T4 when the screening test is TSH? Why do LFT when the screening test is SGPT?

Only those investigations that are essential should be done at first, bearing in mind the clinical signs and symptoms the patient presents with. The further investigations can then proceed in a stepwise manner.

This is the rationale of the Choosing Wisely initiative, a US-based health educational campaign, which calls upon leading medical specialty societies and other organizations to identify tests or procedures commonly used in their field whose necessity should be questioned and discussed with patients. More than 70 such societies have published more than 400 recommendations of overused tests and treatments that clinicians and patients should discuss. 

It was only last year that the case of exorbitant overcharging by Gurgaon Fortis hospital for the treatment of a seven-year-old dengue patient had hit the headlines and become the talk of the nation.

Much has been spoken about the high costs of health care since then.

Yet nothing seems to have changed.

The scenario has only worsened, it has not improved.

On the other hand, the hospitals have starting saying that ICU means Rs 50,000 per day cost and with ventilator, one lakh per day.

The cost of reagents in this case may not be more than few hundred rupees but the cost of corporate culture can be exorbitant.

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

Immediate Past National President IMA

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

Healthcare for all not possible with the present budget

In his speech when presenting the budget, the Finance Minister said that health for all and education for all is his priority but the budget allocation is only Rs. 37330 crores, which is an increase of only 7.5% in the last years allocation (planned and non-planned budget together). Medical fraternity expected it to be at least 2-3% of the GDP. Even allocation to AYUSH is only 1069 crores against 1650 crores allocated to six AIIMS-like institutions. If the Government really wanted to do something for promoting healthcare, they could have allocated for six AIIMS-like AYUSH institutions whose purpose should have been prevention so that people do not require allopathic tertiary care.

There are no tax holidays or tax exemptions for doctors living in rural areas in the present budge. Also, there was no relief for making VISA easy for medical tourism.

The Rs. 110 crores allocated for disability is not sufficient. Rs. 6000 crores should have been allocated for providing free generic drugs for people coming to government hospitals. This announcement was lacking in the budget.

Rs. 150 crores have been allocated for the care of the elderly, who constitute 8% of the total population. Elderly people usually do not have insurance as insurance companies do not give them a cover. At least 8% of the total health budget should have been allocated for the elderly.

Allocations to National Health Mission (NHM) (which covers both rural and urban population budget) is only Rs. 21200 crores, which is less than the amount used last year for which rural mission. It aims to provide urban mission money from the money received from the rural mission project. Separate budget should have been allocated for the urban mission.

Rs. 4727 crores allocated for training, education and research is also inadequate as unless you patent your own equipments and drugs, you are going to be dependent on foreign market.

India Medical Association in its recent meeting with Economic Advisor, Ministry of Health, Government of India had offered that every private doctor should be incorporated for providing healthcare facilities across the country, where the Government only had to invest on the human resource.

The government can start MD in Rural Medicine with a curriculum that teaches the art of treating the patients in limited resources. After that people can choose and do their respective post graduation. This way the doctors will not feel that it is a burden on them. There will be additional degree in MD in Rural Medicine Surgery. Such doctors serving in rural areas should be given income tax-free income.