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Can India afford the luxury of wasteful expenditure on healthcare?

Dr. R.Kumar  

Sr Eye Specialist and President Society for Promotion of Ethical and Affordable health Care

Expenditure on medical treatment is growing at an unsustainable rate, and policy makers are increasingly concerned to seek ways to reduce wasteful spending. Rushing to the doctors/hospitals for minor complaints arising out of unhealthy lifestyle such as sitting for too long on the desk, sleeplessness, dehydration, substance abuse, headaches due to excess screen time, minor sprains and spasms, malnutrition etc invites the label of becoming a ‘patient’.  Then routinely ordering diagnostic tests on such ‘patients’ are unnecessary and wasteful. It is followed by administering pills that are costly and possibly harmful.  In some other cases going in for surgical interventions that may be avoidable, risky and unproductive, constitute wasteful spending.  It may also include spending on services that lack evidence of producing better health outcomes, as compared to less-expensive alternatives or just counseling. When two approaches offer identical benefits but have very different costs, the case for steering patients to the less costly alternative may be clear--for example, using good generics instead of brand-name drugs. It is further complicated by inefficiencies in the provision of health care goods and services; and costs incurred while treating medical errors, such as preventable infections in hospitals. Aggressive interventions at ‘end of life’ situations in the face of impending death also fall in the same category. There is a great need for evaluating waste, implementing waste-reduction strategies, and reducing the burden of patient care spending.  Wasteful spending may constitute nearly one-half of all spending on treatment of the sick.  Can India afford the luxury of wasteful healthcare? Can schemes like Ayushman Bharat succeed in the face of wastage of or unethical exploitation of scarce national resources?

Failed Model

Compared to India that spends about 1% of GDP on health care, US spends 18%, but is still unable to cope with the Medicare demands due to wasteful spending!  Some estimates show a wastage of $992 billion or 37% of the approximately $2.6 trillion annual total spending on patient care in US. The wasteful spending is also due to overtreatment to guard against malpractice lawsuits. Then there is a case of using potent medicines when none is required e g antibiotics in cases of viral fevers or ordinary coughs and colds. Such abuse of antibiotics or other medicines is not only is un-necessary, but also enhances the cost and jeopardizes the health! Another example is continued chemotherapy treatments for patients having advanced cancers. These treatments can cost lacs of rupees but may extend a patient's life by only a few weeks. The life extended is neither bearable nor productive. It calls for a bold decision to quit. It entails freeing the patient from the tyranny of a technologic and bureaucratic torture to keep alive at all costs. It also means freeing the society from the burden and expense of caring for a growing multitude of extravagantly demanding moribund persons?

Patient dictates

Many patients, who consult their doctor, present with physical symptoms that are not explained by any disease.  The underlying cause may be depression, anxiety, financial loss or marital discord. Nevertheless, these patients often demand and receive extensive investigation and treatment, which is usually attributed to pressure from patients to ‘do something’ via medicinal route. Ideally only explaining and counseling could suffice in most of such cases.  This is not due to doctors’ unethical greed.  It is the penchant in the community to run to the hospitals for every little complaint, which may be self-limiting or require only lifestyle measures.  They forget that hospitals are monuments of disease and not health resorts. There is a need to reduce the role of hospitals and doctors by 70-to 80%, which is possible by health education. Setting-up of a large number of new AIIMS at huge costs but poor infrastructure and shortage of trained manpower will not only be wasteful but also counter-productive. Making the community aware about the hazards of over- treatment and teaching medical students and doctors about the importance of delivery of high-quality, but low-cost care can go a long way to reduce wasteful spending. Fee for service model and greed of earning high profits by hospitals, pharmaceutical houses, medical device suppliers and other stake-holders in sick-care chain is burdensome. Pressure groups trying to extract huge pound of flesh from Ayushman Bharat packages are a living example of working for profit rather than service!  Besides health education vigorous efforts to pursue the reduction of waste in health care are clearly warranted.

Wasteful spending

 Massive wasteful spending on health packages as advertised or gobbling a set of pills everyday with the mis-belief that it is necessary to remain healthy, is the testimony of wasteful spending. Patient requiring elective procedures, who otherwise are Healthy, are subjected to comprehensive lab work before each intervention. Doctors routinely order annual electrocardiograms and other heart tests for people who don't need them. Some women get annual cervical cancer testing even when it is  recommended 3-5 years.  The never ending queues at various laboratories and hospitals are the proof of such wasteful approach. Unfortunately, medical system is plagued by a payment system that gives cash incentives for doing tests and procedures and nothing for not doing. Patients often insist that a medical provider must "do something," like write a prescription or perform a test and not just lecture on health education. That mindset has contributed to abuse of scarce medical resources. Given our limited resources, and growing population, this mindset needs a paradigm shift.

Once you are labeled as ‘patient’ it is difficult to shed the label unless a good doctor tries to convert you from patient to non-patient. India has to raise a workforce of such good doctors, since we cannot afford wasteful spending on avoidable medical treatment. 

 

 The Tribune 28th February 2019

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