Healthcare Delivery Experiences in Bombay
Below are excerpts from personal experience less than 12 months ago from 3 of the top hospitals in India. This is meant for non-Indians wanting to go to India to receive medical treatment. This is also meant for those in India to realize the potential for what could be done about these situations and understand why some of these issues are important equation in a developing a country. So here goes . . . . 1. Doctors are considered next to God. It’s a cultural thing. You cannot question them, look at them in the eye or ask for anything more than they tell you.
2. Physician training is not as comparable as you might see in Europe, US or Canada. The concept of a ‘residency’ program after your med school is a grey area. You might often see a 26 yr old doctor seeing patients.
3. There is no concept of a relicensing or maintaining annual (like the CME in the US). You’re a doc once and that’s that. You may be completely removed from what the current care standards are but still practice.
4. There are no medical record systems (inpatient or outpatient) – not even in the top hospitals (like Breach Candy, Jaslok, Bombay Hospital, etc). No one has a history or knowledge about you unless you tell them. Thus, things like drug-drug interactions, drug-allergy interactions, immunizations, etc are mostly unknown. There are many known cases of complications arising due to this fact. The expectation of an integrated model does not exist.
5. There is no concept of medical malpractice (or if it is – it’s very rare). If the doc screws up – you just have to accept it in most situations.
6. Medications are prescribed more than what you might see in developed countries and in a very free form way (including Schedule II drugs). You will see fairly healthy 40 yr olds taking a dozen meds because the “doctor said so”. Patient’s do not know, understand or question why they are on certain medications. There is a direct financial incentive for the physician from pharma companies to prescribe you medications. There is no concept of conflict of interest or ethics in most cases. Even with the most respected top tier physicians and surgeons in the country.
7. If you are admitted in a hospital and are told that the doctor will see you at a certain time, most probably he/she will not show up until a few hours after (if at all). There is no concept of care protocols, physician accountability or ‘customer service’ in general in healthcare. If by a miracle, the doctor shows up – they will swing by for 2 mins, mumble something incomprehensible and leave. Some may clarify their gibberish if you are diligent enough to ask them what they said.
8. Meds and procedures (X-Rays, blood tests, etc) are fee for service and some cost 10x what you may pay in the US. There is no benefits management model. You might have had an x-ray yesterday but just because it was done by your GP, the specialist will order it again at the facility where he is affiliated with (to receive a referral fee).
9. Managed care is available to the top 2% of the population and is rarely found. Thus, >90% of care delivery models are fee for service in all settings (inpatient and outpatient). Even with insurance, some hospitals may not accept it or cover 100% of your costs. The physicians have a direct financial incentive to keep you in the hospital for as long as they want and for any minor issue. The most common words used “lets admit you” – will leave you in bewilderment! The longer you stay sick and in the hospital – the more money everyone makes. There is no concept of length of stay protocols or trying to keep you away from the bedside. There is no one to question them.
10. The insurance company will not reimburse you immediately or as you are incurring costs. Private and even most state run hospital will not admit you until you pay thousands of rupees upfront (yes, you could die in front of them and they would not care). Once you are in the hospital, the counter starts and you need to pay everything upfront in cash if you want to be discharged. If you don’t have the money to pay – you continue to rack up bills and stay at the hospital with interest being charged to your account. If you have insurance, there will be a long drawn-out investigative process (2-6 months) that may potentially pay some or all of your bills incurred. The funniest thing – you will not be discharged on a Sunday. So if you are all set ready to go by Saturday afternoon – that’s your problem as until Monday – no one will be able to discharge you.
11. Nurses are nowhere close to the training, sophistication in handling patients and the knowledge compared to developed countries. These ‘nurses’ are glorified helpers of sorts. They will do as they are told by the head nurse (who may be comparable in private hospitals). They have no knowledge about meds, procedures, patient history or anything. You REALLY need to be on top of them and monitor what they are giving you or your loved one.
12. Hygiene in the top tier hospitals is fair compared to what you might see in developed countries. I would not rate it good even compared to the community hospitals in rural US. They do a decent job but there are no standards or a common body to measure and certify these facilities.
13. Hospitals are run like hotels. You have several tiers of service and rooms and the kind of food you can order. The more you pay – the better service you get and a better room.
14. There is still a lot of onus on interventional procedures. Even the most minor problem or even the remotest suspect of something results in cutting up the patient involving months of rehab and thousands of rupees irrespective of the efficacy or potential outcome from such an intervention. This is far fetched from some progressive treatment protocols you see in the US.
15. Patients are generally treated like second citizens. Its not about the patient – it’s about the doctor. Strange but true. You the patient come last in what you have to say and how you want to receive care. Once you are “admitted” – they got you!
I can only think of one thing – in crises come opportunities. I mean think about it – can you imagine the market potential for Healthcare IT, Operations and Compliance related companies? This market is a mammoth – bigger than what US will ever be.
Also understand that several of my uncles, aunts, etc are some of the top tier practicing physicians and COO of major hospitals in Bombay. And they concur to this write up!
I should also say that Indian doctors are one of the best in the world and the most sought after individuals in any country. Most of them are very good at what they do. But after getting a 1st hand experience, I am not sure I have faith in the whole “healthcare tourism’ market as India’s core practice and care management model is several decades behind from where US & Europe are today. If I want a knee replacement; yes, I can get it cheaper in Bombay but I’d rather go to MGH or Brigham.
The above are just some pitfalls you need to be aware of before receiving care in Bombay (or India for that matter).
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posted by Janak Joshi @ 7/02/2009 10:59:00 AM
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