Wednesday, 11 March 2015

The story of Merging HealthCare, Insurance Industry and Quality in Emerging Economies: When…… it’s OK ….IS NOT OK!


From the Desk of Sagar Galwankar, MD
I often look at Economies in Transition, where healthcare is considered an emerging market and wonder whether the speed at which consumer demand grows for materials ever aligns with the demand for more healthcare.

When we say …we need something…that means we don’t have the thing and we need it…..or we have something but we want it more or we want better.

When we put healthcare into the same perspective …….an increased demand or what the capitalist calls “Emerging Market” means the market is so ill that it is extremely thirsty for health care solutions.

To the world an Emerging HealthCare Market definitely gives a different picture when you say Health of the Nation is Wealth of the Nation.

 When speaking of nations some nations have universal healthcare while some emerging nations have a two forked system of health care…one funded by the government and one funded by private money.

The Government Funded is considered or utilized maximum by the “Less Affording/ resource limited patients” as well as mandated government employees and the Private Funded is utilized by insured and self-paying patients.

I don’t deny that there is a miniscule overlap and cross over.

Now we come to a scenario where there is rising economy and employers are mandated to insure their employees as well as people realizing that they need insurance …thanks to advertising, sensitization, and mass realization, we now have a rising number of insured citizens.

Based on the few facts namely:  1. Rising Population 2. Rising number of insured 3. Increase burden of illness and 4. Growing economy .....the phenomenon “Emerging HealthCare Market” is born.

This phenomenon leads to a radical tsunami of investor enthusiasm and promotor confidence.  Everyone dreams of becoming a Billionaire, this is again based on the fundamental that there are many affording ill people to support the industry of patient care.

These investors who have names like Venture Capitalist, Equity Players, Private Funders etc. now start pouring money into healthcare.

How do they pour this money into healthcare?

They do this via four mechanisms:

1.    Support Big Players in the HealthCare like big chain of hospitals to diversify and create day care centers, lab networks etc. and grow further

2.    Support Small hospitals to become big by opening more branches

3.    Buy stocks in health sector in the stock exchange

4.    Buy shares and invest via funds who again invest directly or indirectly into health care markets, hospitals etc.

When Investors put their money they want their money back.

They want margins and profits.

Hospitals start looking like hotels and healthcare equates to hospitality.

The difference is that ….in Hotels clients come with happiness and to hospitals patients come with pain.

It’s a different set of situations but for investors it is the same when it comes to ….money in and money out.

So now the Invested HealthCare system has to generate revenue instantly to prove growth and reinforce investor confidence.

What do the promotors do: Hire Marketing Teams, Get Advertising to the door of every primary care doctor, reach out to every potential patient, Offer different products like Health Check Ups, Create inquisitiveness to hunt out some disease so that some cure can be offered at their hospital. Skin, Anxiety, Breast Exam etc.  Run Banners and hoardings showing a patient holding his chest with a tag line # “Chest Pain….it could be a heart attack…call ……”

E-Marketing….That’s another gateway to publicize.

Marketing more than Medicine is a reality.

Advertising Firms, Door to Door Agents…you name it and the strategies exist. Facebook, Twitter, Social Media, Events …..There is no end.

Revenue is the Key …..Patient Flow which Pays is the answer.

Health of the patients becomes the business of the promotors.

The maximum importance is giving to marketing and advertising in order to increase paying patient flow….this is the truth about new as well as established hospitals and healthcare facilities.

The administrator/ CEO/ Managing Director is rarely a Physician, this is because Supply Chain, Maintenance, Instrumentations, Security, Food and Beverage, Billing, Human Resource, Finances, Strategies are major areas in a heavily invested healthcare system.

The Physician and the patient on whose shoulder the system is fundamentally existing suddenly becoming a miniscule part of the whole picture.

It’s definitely an Oxymoron from my perspective.

Now comes the aspect of QUALITY: Where does this aspect exist in this whole story of GROWTH

Imagine…..You have borrowed Millions, Set up a big hospital which looks like a Hotel, spent tons on marketing and advertising …..What is left for Human Resource and Quality ?

Instruments, Equipment, Approvals, Staff all cost money. Administrators, Advertisers, Managers, Marketers all cost money. So does Maintaining Quality….but is there enough left after so much consumed by the earlier?

Quality HealthCare in the real sense means practice of Evidence Based Medicine.

Example: When a Patient of Chest Pain Comes: The Emergency Physician rules out all causes of Chest Pain from Myocardial Infarction to Pulmonary Embolism to an Aortic Dissection and many more.

In nations where Troponin Test is the most expensive test and is priced 100 times the Retail Price, it’s impossible to practice Quality Care. Where EKG continues to be used to triage chest pain then Quality is always a Question. Where CT Scan is a medium to extrapolate profit, quality is always a challenge.

In Emerging Markets Insurance Companies mandate that a 24 Hour Admission is required at the least to claim for healthcare benefits from the policy. Well that results in increase rates of admission.

When a simple fever costs thousands then insurance cost goes up. The hospital wants to recover the cost it has invested in the system so it bills thousands.

 Just Talking about Quality is of no use when there is demonstration of lack of practice of Evidence Based Medicine.

In any HealthCare system the Emergency Department Care reflects the overall quality of care given by a HealthCare System.

Until every physician in the Emergency Department is duly qualified by a Single Accredited National Agency governing a Uniform Set Training Model, it’s impossible to establish quality care.

Till the time every physician practices the same evidence based guidelines and does not use his own guidelines based on the science of “In My Experience” things will always be the same.

The perception that Insurance Companies will continue to insure people and people will continue to feel that they have access to health care......will break very soon.

Insurers will crack down on healthcare facilities, charges/payments will be questioned, quality will be accessed and care decisions will be challenged. They too like others have to make money...they also have investors to answer to !

Insurers will question: Admission Criteria to High Billing Critical Units, Criteria for keeping patient longer in hospital, payments for hospital acquired infections, payments for patients who come back to the hospital within few days, justification for multiple consultations, number of outpatient visits, number of investigations….it’s just a matter of time.

It took a decade in the developed world for this Insurance Industry crack down, it will happen faster in Emerging Markets.

Where the mantra is “If you have a fever and the malaria parasite test is negative still don’t do blood cultures but treat for malaria, typhoid and admit in ICU for observation” “It’s OK to do that…”

It will soon be “Not OK”

Investors are banking on paying patients who will either pay from their pocket or insurance will pay for them.

In the times to come it will be the Insurer who will decide the fate of investors.

Quality will become the leading question very soon.

“It’s OK ……..will soon be ……it’s not OK!”

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