Tuesday, May 19, 2015

The corporatization of healthcare - a double-edged sword



There is a lot of distrust among the general public about doctors, hospitals and healthcare providers in general. A lot of this started after healthcare started getting 'corporatized'. It is a well-known fact that doctors get referral fees for most medical services - lab tests, pharmacy prescriptions, hospital admissions, ICU admissions etc. Many corporate hospitals also are known to set targets for their doctors for these services.

Across the world, this has led to an increased burden on the payers - whether they are insurance companies, governments or the patients. This cannot be good for anyone in the long run.

Atul Gawande (a surgeon of Indian origin in the US, author of bestsellers like Better and The Checklist Manifesto) wrote in an excellent article for The New Yorker, "An avalanche of unnecessary medical care is harming patients physically and financially."

Gawande writes, "The virtuous patient is up against long odds, however. One major problem is what economists call information asymmetry. .... Doctors generally know more about the value of a given medical treatment than patients, who have little ability to determine the quality of the advice they are getting. Doctors, therefore, are in a powerful position. We can recommend care of little or no value because it enhances our incomes, because it’s our habit, or because we genuinely but incorrectly believe in it, and patients will tend to follow our recommendations."

Another major problem, Gawande highlights, "... is the hidden harm: unnecessary care often crowds out necessary care, particularly when the necessary care is less remunerative."

The whole model of incentivising doctors for tests and procedures has just too many problems.

There are many doctors who have started resisting this model. There are some companies which are being formed that are changing the model to show that doctors can still make money (nothing wrong with that!) but by ensuring better care. The US's WellMed has a model where "if a doctor improved the quality of care, this would save on costs, and WellMed would share those savings with the doctor in the form of bonuses." This is where healthcare should be moving towards.

Doctors should be incentivised, no doubt. They should be allowed to make money. After all, they spend years learning medicine, spend lakhs of rupees getting their education. What is wrong in them trying to recover those costs and lead a comfortable life? Aren't they entitled to a good life as well? Of course! The only issue is that this should not be at the patient's expense. This should happen only if they ensure that their patients do well! Outcomes based incentives are the way to go.

Despite people cribbing about corporate hospitals, these hospitals are the ones that have brought quality healthcare to the Indian population. Walk into a government hospital today and you see the difference. Many of these hospitals are very badly run. They just do not have the infrastructure to cater to the large volume of patients. The only way patients have got access to quality is due to these corporate hospitals. There's no denying that the latest technology has been made accessible to the patients in India only due to the corporate hospitals.

Many doctors are also becoming increasingly frustrated with the system that accuses them of various unethical practices but glosses over the constraints they are operating under. This led to a doctor saying he would never advise his child to become a doctor in India.

What needs to be done is to turn the model on its head and make sure that corporate hospitals remain profitable, doctors continue to earn a decent income and yet patients don't have to undergo unnecessary procedures and tests. I'm sure the MBAs and consultants that are managing these hospitals can figure this out!

A great beginning has been made by the SLIM (Society for Less Investigative Medicine) initiative started by some Indian doctors. This society aims to reduce the number of investigations and interventions for patients. An article about the initiative says, "Doctors from across the country and non-medical professionals 'frustrated by the sheer avarice on display in the entire field of medicine' have expressed their desire to be part of the SLIM initiative."

One suggestion to SLIM - give people who are part of this initiative a certificate or a poster they can proudly display in their clinics and increase awareness about this initiative. When patients go to SLIM empanelled doctors they can be sure that they would not be subjected to unnecessary medical expenses.

Any system evolves. The Indian healthcare system must also evolve. Just like Rome, it cannot be built in a day. The good part about this is that people have started realising this and some action is already being seen. I only hope this continues and the system changes so that all can win - hospitals, doctors and most importantly, the patients.

Sunday, May 17, 2015

The perils of growing up



Summers are an interesting time for me.

I grew up with cousins around my age. We were brought up in similar circumstances. We were brought up by parents who had similar values and had similar means. We made life's decisions around the same time. Our paths diverged when I was diagnosed with kidney disease. They went on to get married and have kids, their lives being completely engulfed in the routine chores of looking after their families. The males among them made careers, the females were mostly home makers.

Summers are interesting because the cousins typically come to Hyderabad to meet their parents. They bring their kids along. I find it really intriguing to see how these kids are brought up in the age of the internet and Facebook.

I cannot help sniggering to myself when I see my cousins scolding their kids for craving colas and junk food. To me, it was just a few years back when we ourselves craved these unhealthy options. Oh, I say to myself, how the times have changed!

I have seen this happening all around me. Most of my friends are married and have kids. They all try to bring up their kids the 'right' way. Eat the right things. Study. Don't play too much. It just seems a little weird to me that our parents were saying this to us not so long ago. At least it seems not so long ago. :-)

The innocence of childhood is lost in stages. When you get married, you lose about a quarter of it. There is still three-quarters left and there is still some hope left. When you become a parent, that is it. You're done for good. You lose pretty much all of it. You don't find silly things funny. You get irritated when your kids do things even though you did them yourself.

Growing up is highly over-rated. People give and expect too much respect. Life becomes too formal, too suffocating. People are constantly on the watch. "What would the world think about me if I did this?" I generally detest Navjyot Singh Sidhu, the irritating ass who's always on a laughathon and is always hyperactive. But he did say something once that makes a lot of sense, "Duniya mein sabse bada rog, mere baare mein kya sochte hain log?!"

 Of course, there are exceptions. But the vast majority of the people are too busy trying to become successful. We need to let loose for a bit every now and then; be a child again. Life would be much more refreshing that way.

Wednesday, May 13, 2015

Postprandial hypotension in dialysis patients: feeling dizzy after a meal



For a long, long time, I have had a major problem. I feel dizzy after my breakfast. This lasts about an hour to two hours and I need to lie down to feel better. I always put this down to pulling off too much fluid during my nocturnal dialysis sessions.

This did not seem logical however. If it really was due to pulling off too much fluid, I should feel bad towards the end of the session or immediately after the session. But I feel totally fine immediately after the session. I actually have a 45-minute swim soon after. I feel totally ok during the swim. Only after I my breakfast do the symptoms start.

Many times, on work, I have to take an early morning flight. This is really horrible. I need to have my breakfast before I head to the airport. By the time I reach the airport, I am totally like a zombie. To make things worse, early mornings are the worst time to fly from Hyderabad. The Hyderabad airport check-in and security lines are really, really long and to wait in those lines with a dizzy head is just too much to take for me.

For the last few trips, I took the wheel-chair option! I was embarrassed and was worried someone would see me! "This is the guy who claims he leads a normal life despite being on dialysis and here he is - on a wheel chair!!!"

My brother Prasan, with a casual comment one morning on the way back from Govind's bandi caused an epiphany. I was feeling really dizzy after the sumptuous breakfast and he said that the body needs to do something to process all that food and that was the reason I was feeling dizzy. That may not have been an accurate description but it was the first time I realised that it was only after my breakfast that I felt dizzy.

I typed the phrase "feeling dizzy after a meal" on Google and I found what I was looking for! The condition even had a name - post-prandial hypotension and had some suggested solutions - eating light meals that are low on carbohydrates, having a glass of some fluid about 15 minutes before the meal etc. And what's more, it was a condition that was common in dialysis patients!

I tried the solutions. Some did not work. But the one that worked for me like a charm was eating a very small breakfast. These days, I have a very light breakfast and carry some breakfast to office where I have it after an hour or so of reaching. I also took the last couple of flights without any problem. I am really so happy and relieved. Thanks so much to my brother for that comment!