Outstanding and Receivables: A Long overdue problem faced by service providers

Doctors are not a happy fraternity today. There are several reasons for this.

• Practicing doctors live in fear of criminal prosecution or violence.
• Specialists are unhappy because of the unrealistic targets they are expected to meet.
• Corporate hospitals are unhappy because they are denied their due reimbursements in time.
• Service doctors and medical faculty are unhappy because their salaries are not at par and the new 7th Pay Commission has reduced the non- Practicing Allowance (NPA).
• MBBS doctors are unhappy because they do not have opportunities to get a postgraduate degree.

The medical profession provides services to Central Government Health Scheme (CGHS), Employees Health Scheme (EHS), Public Sector Units (PSUs), Ex-servicemen Contributory Health Scheme (ECHS) and similar organizations at highly subsidized rates. Yet the due reimbursement is delayed for months together and is given without any interest.

This was among the several issues that I had touched upon in my Presidential address. Therein I had said, “The constitutional right “equal pay for equal work” should be implemented in medical profession. All service doctors and resident doctors should get full 7th Pay Commission, obligatory research grants, uniform age of retirement and uniform nationwide pay scales, legitimate leaves, and working hours and conditions.”

Then again, “Uniform service conditions for doctors and faculty” and “Reimbursement of emergency services for private sector” were a part our major demands in the Dilli Chalo movement.

Let’s review here the problems faced by service providers.

• Service providers empanelled with the above organizations are in a very vulnerable position. Providers cannot deny services to these patients as the number of beneficiaries is large and ceasing services will cause a public disaster.
• With services being continued, the government has gone into a state of inertia and apathy.
• The service providers are struggling with operations and continuation of service due to the following main challenges:

o    Delayed reimbursements: The current situation of outstanding is alarming with payments worth hundreds of crores pending. For example, the outstanding amount from CGHS includes up to 75 crores of Max Healthcare, over 20 crores of empanelled hospitals of Fortis in the north, in Bangalore and Maharashtra and about 5 crores of Dr Lal’s Path Labs.

This excessive delay is affecting the very sustainability of the operations for the service providers. As a cascading effect, lab providers face delay in other payments from hospitals as they do not have enough funds to pay the labs because of delay in receiving reimbursements. While the service agreement provides for 70% of payment within 5 days, payments are delayed by months. An intervention from the Finance Ministry is also required to rectify the current problem as delays are also caused due to misalignment between Ministry of Finance, Ministry of Health & Family Welfare and the payment partner- UTI

o    Wrongful Deductions: - Even though service providers are deliver services as per rates given by the Government, illogical deductions are made from the claims with no intimation to the service providers. The quality of service and costs involved are judged by inadequately qualified persons during claim processing.

o    Reconciliation Issues: Several gaps exist in the current system of dispute resolution and arbitration for such cases. There is a need of validation of the system by an independent body, maybe FICCI Indian Council of Arbitration (ICA). Grievance redressal for service providers should be relooked into and streamlined

o    Contract Renewal and Extensions: The agreement, which is valid for 2 years, has been extended up to 4 years by the Government, without citing any rationale for the extension. The current contract due to expire in October 2016 was extended up to end of June 2017 and still there is no sign of new agreement.

o    Terms of Agreement: Agreements should be restructured before upcoming renewals to account for the following:

- Organizations like CGHS should have a mechanism to accommodate inflation like in case of the Pharma Industry where price hike of up to 10% every year is allowed.

- The Andhra Pradesh state Government order has been linked to Consumer Price Index (CPI), these organizations should also have similar considerations.

- The rates of organizations like CGHS should be based on a scientific rationale.

- Experts from the private healthcare sector should also be a part of the rate fixing exercise.

- A unilateral scheme with all specifications in favor of the government is not acceptable to the industry

(Source: FICCI Health meeting held on 13^th June chaired by Dr Girdhar Gyani)

IMA Resolutions on Doctor’s Day

Doctor’s Day, as we all know, is the day dedicated to the memory of Dr BC Roy. The day marks his birthday and it is also the day when his physical body left us. But his soul is still alive in our minds. This day also reminds us of our purpose with which we chose medicine as our profession and our responsibilities towards the community.

Hence, in a befitting tribute to this legend of medicine, on Doctor’s Day this year, the Indian Medical Association (IMA) took some resolutions.

• Our theme for “Doctor’s Day” for the year 2017 will be “My Family Doctor”.

• IMA will have “Zero Tolerance” for unethical practices by medical professionals and or medical establishments.  These include Referral Fee, Cuts, Commissions received without involving any services. Offenders can get their names removed from the primary membership of IMA.

• IMA will not tolerate any targets given to medical specialists who join hospitals.  IMA will soon come out with a standard appointment contract between consultant and corporate hospitals.

• IMA supports a “uniform code of medical ethics” for medical establishments, industry and doctors.

• IMA does not support criminal prosecution of doctors in clinical practice.  

• Medical or surgical consent should include not only the competency of the doctor or establishment to handle a procedure, but also competency of facilities available to handle complications. 

• IMA Awards announced on “Doctor’s Day” will be presented during Centenary Celebrations of Medical Conferences in India on 23rd & 24th September, 2017 at New Delhi.

• IMA will intensify its public image through “IMA Thank You” & “Public Health Awareness Campaigns” using various advertisement modules.

• IMA Accreditation and Academic Council will be operational from 15^th July 2017.  Dr KK Kalra Ex CEO NABH has joined IMA as CEO of the Council.

• IMA opposes reduction of Non Practicing Allowance (NPA) and delinking it to basic pay in the 7th Pay Commission.

Dr KK Aggarwal

National President IMA & HCFI

IMA announces awards and action points on the occasion of Doctor's Day

Importance should be accorded to family physicians and the nobility of the profession should be restored

New Delhi, 03 July 2017: With this year's theme as 'My Family Doctor', the IMA celebrated Doctor's Day on 1 July 2017. Among other activities held on this day, the IMA announced awards under various categories, which would be presented during Centenary Celebrations of Medical Conferences in India on 23rd and 24th September 2017 at New Delhi.

The Association announced Zero Tolerance to unethical practices by medical professionals and or medical establishments. These include Referral Fee, Cuts, and Commission received without involving any services.  Offenders can get their names removed from the primary membership of IMA. There will be no tolerance for targets given to medical specialists joining hospitals. The IMA will soon come out with a standard appointment contract between consultant and corporate hospitals.

Speaking about this, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said, "This doctor's day is about celebrating and honoring the tradition of the family physician. Family physicians looked after all the health needs of a family, even many generations of a family, regardless of their specialization. They treated and provided preventive health care to a family as a whole because they were aware of the family history and served as a link between the patient and the specialist. The society should be educated on the benefits of getting treatment through a family doctor. Apart from this, IMA has also announced many other measures as part of this day."

There should be a uniform code of medical ethics for medical establishments and doctors. The Association re-defines medical or surgical consent and that should include not only doctors or establishment’s competency to handle procedures but also the competency to handle complications how so ever rare they are.

Adding further, Dr Aggarwal, said, "The IMA does not support criminal prosecution of doctors in clinical practice. It should be understood that doctors are not healing angels. The situation today is that doctors now are being prosecuted in various special acts for non-professional activities like not wearing apron, not displaying a defined board or not keeping a copy of PC PNDT Act.  Doctors are also being prosecuted for minor violations of privacy, confidentiality of patient information and data and violations of minor clauses in surrogacy, IVF and HIV_AIDS acts. This is not acceptable to the medical profession."

The Association opposes reduction of NPA in the 7thPay Commission. IMA will also intensify its public image through 'IMA Thank You' and 'Public Health Awareness Campaigns' using various advertisement modules. Apart from this, the IMA Accreditation and Academic Council will be operational from 15th July 2017.  Dr K KKalra, ex CEO NABH, has joined IMA as CEO of the Council.

The recipients of the IMA awards are as follows: Women Empowerment Award - Dr Jayshree B. Mehta and Dr Soumya Swaminathan (2016), Dr Rishma Pai (2017): Doctor of the Decade Award - Dr A Marthanda Pillai and Dr Shashank Joshi (2016), Dr Randeep Guleria (2017); Life Time Achievement Award - Dr Vinay Aggarwal (2016), Dr Ved Prakash Mishra (2017); Doctor of the Year Award - Dr R N Tandon, Dr Girish Tyagi, Dr R V Asokan, Dr Hrishikesh D Pai, and Dr K K Kalra (2016), Dr Shiv Kumar Mishra, Dr Bhupender Ahuja, Dr Saumitra Rawat, Dr H P Saraf, and Dr Mona Desai (2017), Dr Bharti Kashyap; Medical Eminent Teacher Award - Dr Georgi Abraham, Dr C G Bahuleyan, Dr M C Mishra, and Dr J A Jayalal (2016); and IMA Eminent Nurse Award - Ms Anita Deodhar  and Ms Evelyn P Kannan

Consent Revisited: Inability to manage complications leads to violence

Consent, as we know, is the authorization or grant of permission by the patient for treatment or any diagnostic, surgical or therapeutic procedure to be carried out by the doctor. A doctor has to take consent from the patient before proceeding with his treatment. It is ethical and in today’s scenario, a legal requirement. Any act done without permission is “battery” or physical assault and is liable for punishment.

A valid consent has three components: Disclosure, Capacity and Voluntariness i.e. provision of relevant information by the doctor, capacity of the patient to understand the information given and take a decision based on the adequate information without force or coercion. This is informed consent. Any permission given under any unfair or undue pressure makes the consent invalid.

The Hon’ble Supreme Court of India has defined ‘adequate information’ in the landmark case of Samira Kohli vs Dr Prabha Manchanda. This includes “(a) nature and procedure of the treatment and its purpose, benefits and effect (b) alternatives if any available (c) an outline of the substantial risks and (d) adverse consequences of refusing treatment.”

No doctor practices medicine without taking informed consent. Yet we read and hear of incidents of violence against doctors from all parts of the country. So, are we going wrong somewhere? Are we doing something wrong somewhere?

“Medicine is an art based on science”, said Dr. William Osler. Complications, adverse events or untoward incidents may occur at any time during the treatment. What is important here, how competent, we are, as doctors, or how competent is the hospital or the clinical establishment, in managing these complications or untoward incidents in a non-emergent situation.

Not being able to manage complications leads to violence.

The patient should be informed of every possible complication that may occur during this treatment, however rare they might be; even a complication rate as low as 0.1% might be 100% for that particular patient. No surgery can be called as a ‘minor’ surgery.

Mistakes are made, but we believe that nothing will happen either to us or the patient. As I wrote few days back, it’s the case of "Kya pharak padta hai" to "bahut pharak padta hai". If nothing goes wrong, then "chalta hai". But, if something does go wrong or an unanticipated event occurs, then this becomes unacceptable “chalta nahi hai”.

The key word here is ‘anticipation’.

Anticipate what all can happen in the course of a treatment and be prepared to handle them or keep your patient informed. For example, you may need to shift the patient in an emergency to a higher care center and your establishment does not have an ambulance. Outsourcing an ambulance will delay patient transportation, and in an emergency situation, the longer the delay, more agitated are the patients or family members and may become violent.

Let’s take another example. You might need the services of a specialist, say a urologist, neurosurgeon, or a nephrologist. If your hospital does not have these specialty doctors on its staff, then subsequent delays in procuring their services will increase risk of violence.

Should you have these services and other such facilities as standby? Yes, everything must be on standby. The standby fee is 25%, while presence fee is 100%.

This may increase the cost of treatment. The time has come when the patient must know that safety comes at a price in bigger hospitals.

Inform the patient and the family members beforehand, let the patient choose and accordingly the consent should be taken. Safety of the patient is very important and should be our primary objective.

A small set-up may not have all facilities as their bigger and better equipped counterparts. These smaller set-ups should keep the patient and/or family members informed about this lack of facilities and take consent.

Good communication can reduce the rapidly increasing problem of violent attacks on doctors and healthcare establishments.

‘Adequate information’ for consent should include not only the competency of the doctor to treat the case, but also include the competency of the doctor and/or the hospital to manage any emergencies or untoward incident in a non-emergent situation. Any breach in this duty is negligence.

This, I believe, is an area which we need to work on. It is the inability to manage complications that leads to violence.

As doctors we SERVE our patients and the community and provide

·  Service which we have professionally trained for, which is

·  Excellent i.e. anticipated

·  Responsible, give our 100% to the patients and take responsibility

·  Value – Group; each member of the group knows the duties of another, so no gap in service may result

·  Enthusiasm: A positive happy atmosphere

This is how we can avoid incidents of assault and violent attacks on doctors from happening.

Dr KK Aggarwal

National President IMA & HCFI

Majority of doctors fear violence and are stressed out, reveals IMA study

The all-India survey highlights the unsatisfactory nature of the job and the urgent need to create awareness

New Delhi, 01 July 2017: A landmark all-India survey released by the Indian Medical Association (IMA) on the occasion of Doctors Day has found that about 82.7% of doctors in India feel stressed out in their profession. While fear of violence is the main stressor in many doctors (46.3%) followed by fear of being sued (24.2%) and fear of criminal prosecution (13.7%). The findings come in the light of the many atrocities faced by the medical fraternity today, the most disturbing of which include violence against doctors and their criminal prosecution. The anxiety of doctors over the issues plaguing the profession is evident by the fact that about 56% of them do not get a comfortable 7-hour sleep most days of the week.

Conducted online over a period of 15 days, the survey received responses from 1681 doctors including general practitioners, physicians, surgeons, gynecologists and super specialists working in private OPDs, nursing homes, corporate hospitals or government hospitals. It is an eye-opener on the extent to which doctors have been affected. About 62.8% of the doctors surveyed are unable to see their patients without any fear of violence and 57.7% have thought of hiring security in their premises.

Speaking about the survey, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said, "The medical profession is undergoing some of the toughest times today with its nobility and integrity at stake. Today medicine is just another profession, and doctors have become like everybody else: insecure, discontented and anxious about the future. This survey was aimed at analysing how happy and satisfied doctors are with their profession. The results prove the fact that doctors are not very happy with what they are doing and a large part of it is due to lack of patient trust in them. The emotional, mental, and physical attacks on doctors are at an all-time high. More than half of the doctors surveyed indicate that they suffer from increasing anxiety.  A sizeable chunk does not want their children or grandchildren to take up this profession. Most doctors are of the opinion that while they chose medicine because it was worthwhile and noble, the profession has been reduced to nothing but a charade today."

It is pertinent to note that a large number of doctors suffer from blood pressure and diabetes. Another notable factor is that about 76.3% also get anxiety quite often. As per a nationwide study conducted by IMA earlier, doctors face maximum violence while providing emergency services, with as many as 48.8% of such incidents reported from intensive care units (ICUs) or after a patient undergoes surgery. The main reason reported behind such violence is unnecessary investigations or delay in attending to a patient.

Adding further, Dr Aggarwal, said, "On this Doctor's Day, it is important to make people aware that this growing discontent and anxiety among doctors can have serious consequences for patients. Unhappy doctors will make for unhappy patients. The fear of lawsuits; runaway malpractice liability premiums; and last but not the least, loss of professional autonomy has led to many physicians looking at themselves as mere pawns. This survey is a definite proof of that."

The 'Doctor–Patient' relationship is a sacred one and this survey points to the fact that the dignity of the profession should be maintained. Doctors are also human beings and not healing angels. Victimizing the medical practitioner if the patient does not respond to treatment is unacceptable as are other atrocities against doctors.

Another study conducted by the Indian Medical Association (IMA) highlighted the significance of soft skills for doctors. The survey showed that patients expect their doctors to be courteous; almost 90% of patients wanted their doctors to introduce themselves to patients, acknowledge the patient, give every patient a patient listening, impart complete information about the diagnosis, investigations, and treatment and revise and review what the patient has understood. About 40% of the patients said that the doctor should also thank them for giving an opportunity to treat. So, stay ALERT: Acknowledge and Ask, Listen, Explain, Revise and Review, and say Thank you to the patient.

Doctor as a Giver

Today is Doctors’ Day and on this occasion, I take this opportunity to revisit the role of a doctor.

Chapter 10, shloka 21 of the Bhagawad Gita gives the definition of God, when Krishna reveals himself to Arjuna by saying, “Adityanam ahaṁ viṣhṇur jyotiṣhaṁ ravir anśhuman, marichir marutam asmi nakṣhatraṇam ahaṁ śhaśhi”, which translates as “Of the twelve Adityas, I am Vishnu, of all luminaries, the radiant sun, of the seven Maruts, I am Marichi and of the constellations, I am the moon.” All these phenomena are the manifestations of Krishna.

All the forms that Krishna used to define himself, give something. Moon gives peace of mind, sun gives light etc. Devta is someone who gives. Anybody who gives can be said to be like a devta. But this giving has to be unconditional and loving.

A common man’s perspective of God is of a force that can do and undo anything, for whom nothing is impossible, who is the final decision maker, whose decision cannot be challenged, who can give an instantaneous relief, who can punish and reward and he who overcomes miseries. He can also answer the unknown as he is supposed to know everything.

In Bhagawad Gita and other Vedic texts, God is equated to consciousness, a network of energized information, a force which cannot be burnt by fire, wet by water, dried by air or cut by weapon; a force which is omnipotent, omnipresent and omniscient and still ever-pervading.

A trained qualified medical doctor who has his understanding based on the mind, body and soul has nearly similar characteristics. He overcome miseries as soon as he touches the patient, gives immediate relief which starts at the time he gives a healing touch to the patient.

God resides in each one of us. In his book ‘How to Know God’, Deepak Chopra has explained different levels of God. According to him a God is a person from amongst the society with one step higher level of consciousness. He describes, as per the Vedic text, seven different levels of consciousness that a person can possess.

1.       Flight & fight

2.       Reactive consciousness

3.       Restful alertness consciousness

4.       Intuitive consciousness

5.       Creative consciousness

6.       Sacred consciousness

7.       Visionary consciousness

A person who has achieved sainthood, who sees the same consciousness in everybody, treats individuals without caste, creed and religion and who overcome miseries of people irrespective of their age, status or paying capacity is God. Doctors fulfil these criteria as they have a duty to heal the sick irrespective of their caste, creed, race or financial status. Even the MCI Code of Ethics has said, “The prime object of the medical profession is to render service to humanity; reward or financial gain is a subordinate consideration (1.1.2).”  The MCI Declaration, which a doctor is required to sign at the time of registration, also says “I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient (d).”

Today with evidence-based medicine being the norm, mental and spiritual health has taken a backseat. 

This may be one reason why doctors are losing the status of God, which they were accorded since Vedic times.

But, we should remember that doctors are messengers of God to remove miseries of the sick individuals and so should always act in the best interests of the patient. “Doctors treat, but God heals” is a well-known saying. 

My best wishes to you on this Doctor’s Day … 

Dr KK Aggarwal

National President IMA & HCFI

Positive reinforcement key to help patients quit smoking

Doctors should say 'Thank you for not smoking' to patients and avoid the use of discouraging remarks

New Delhi, 30 June 2017: As part of its commitment to working closely with all National Health Programmes alongside the government, the IMA has urged individual doctors to counsel their patients who smoke about quitting smoking. It has, however, said that such counseling should be done in a manner that turns a negative situation into a more positive action. According to statistics, more than one-third (35%) of Indian adults use tobacco in some form or the other. Of these, 21% adults use only smokeless tobacco, 9% only smoke and 5% smoke as well as use smokeless tobacco. Additionally, about 52% of the adults are exposed to second-hand smoke at home.

The National Tobacco Control Programme aims at making the public aware of the harmful effects of tobacco use, controlling tobacco consumption, and minimizing related deaths. Tobacco use has many adverse health effects and is a major preventable cause of morbidity and mortality. Smoking not only increases the risk of various diseases but also reduces the quality of life, and increases health care utilization and cost.

Speaking about this, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said, "Campaigns on tobacco control convey the message 'smoking kills' with the intention of highlighting the potentially life-threatening health consequences of this habit based on the assumption that this would deter people from smoking or using tobacco products. However, many of these campaigns do not reinforce these messages in a positive manner. It is time to alter the tone of such public health campaigns from negative to positive. Quite often, we rebuke patients for failing in their efforts to quit smoking and tell them they may die if they do not quit. A statement worded in this manner can inadvertently sound discouraging to the patient."

People should know the dangers of smoking or using tobacco products. However, rather than adopting a critical approach, this message should be conveyed through positive communication for a more fruitful impact. Any violent communication should also be avoided.

Adding further, Dr Aggarwal, said, "It is best to avoid the 3Cs of violent communication - Condemn, Criticize, and Complaint. A nonviolent communication approach should be used instead to help and support patients in their efforts to quit smoking. It is important to say 'Thank you for not smoking' to the patients. Appreciate their hard work and perseverance in trying to quit this deadly habit. This way, they would know that they have your support and will in turn have trust and faith in you. Empathetic and supportive communication can increase the chances of patients adhering to lifestyle modifications."

There is a very strong relationship between a doctor's communication skills and the patient’s capacity to follow through with medical recommendations, self-manage their medical condition, and adopt preventive health behaviors. It is imperative for a doctor to adopt a positive approach to explain, listen, and empathize with the patient. This in turn can have a profound effect on the biological and functional health outcomes.