Need to curb malpractices

THIRUVANANTHAPURAM: The government and powerful private health sector are on a collision course over Kerala Clinical Establishment (Registration and Regulation) 2017 Bill. The proposed law, which governs the functioning of clinical establishments, including hospitals, is now before the Subject Committee. While the government is hopeful of cleansing the system with the new law, the private sector that accounts for 70 per cent of health care delivery in the state fears the imposition of license raj. There are a large number of authorised and unauthorised centres and clinical establishments across the state. Though occasional raids by civic bodies and health department had resulted in the temporary closure of some of these institutions, many had got away with even serious violations.

The lack of diagnostic facilities like CT, MRI scan and advanced diagnostic laboratories in government hospitals has compounded the problem. Even premier institutions like the Medical College Thiruvananthapuram are under huge pressure. With the lone MRI unit not able to meet the demand, patients particularly the poor, have to wait for five to six months for their turn.  The pressure on MRI and CT scan attached to most medical college hospitals and government hospitals is huge with patients from medicine, surgery, gynaecologic, cardiology, neurology, nephrology, paediatric surgery, paediatric neurology and surgical gastro being referred in big numbers. It is in this context that the government believes the Bill is important to ensure proper accreditation/certification, trained staff besides checking the exorbitant charges for various diagnostic tests. The state council, proposed in the Bill with health secretary as chairman, would be quite effective in monitoring registration, accreditation and regulation of prices. Similar monitoring committees would be set up at the district-level under respective collectors.

Under the new law, clinical establishments would be classified into various categories based on their existing facilities.  The Bill proposes to give permanent registration to clinical institutions that have received National Accreditation Board for Hospitals (NABH) or the National Accreditation Board for Laboratories (NABL) accreditation. Each establishment would be liable to put up existing rates besides details of diagnostic facilities available in Malayalam and English at a vantage point. Even poor patients are forced to shell out a huge amount to get the procedure at private centres where the cost ranges from Rs 6,000 to 10,000. And for BPL patients for whom the procedure is free in government sector, there are just two options- not to have it at all or wait for five months. Experts say the Bill is significant since raids carried out at private diagnostic centres had failed to yield desired results. As the registration for such centres is now being given under Panchayat Raj and Municipality Acts, there is not much that the health department can do in regulating unauthorised establishments.

Moreover, provisions of existing Public Health Act under which raids are carried out do not prescribe stringent punishment or heavy fine for those violating rules.  Most of these offenders used to get away with small fines. Another handicap is the existing Public Health Act which is a combination of erstwhile Madras Public Health Act and Travancore Public Health Act. It is in this backdrop that the Kerala Clinical Establishment Bill is seen as a strong measure to curb the malpractices in this field. In the absence of standardised rates, the laboratories across the state are charging at will. It is no secret that many of the Government and private doctors have close links with private diagnostic centres and a portion of the exorbitant fee collected from the patients is allegedly given to them as cut.  The variation in charges is mainly in advanced diagnostic tests including CT scan, spiral CT scan and MRI. Besides, rates of even most common tests like routine blood examination, glucose and ultra sound scans vary considerably form laboratory to laboratory. 

However, the IMA and Hospital Board of India believe that the present approach of the bill was one of licensing. The Government has the mandate and option of considering the accreditation process as an alternative. Inspection and Licensing should be replaced with accreditation and certification. For instance, KASH or NABH entry-level accreditation. The private sector feels that power to delicense is likely to be misused especially in situations when there is public pressure. Such developments would demoralise doctors and other heath care staff. As such this power is a disincentive for new entrepreneurs. Another concern is regarding a single authority for the entire state is a much more friendly way of regulation. Single empowered council at the state will be much more efficient. The State Government could be the appellate authority.

Major concerns of private sector 

Government prescribing treatment protocols will straitjacket patient care and may even impact patient safety adversely. Government may issue guidelines during epidemics.  Protocols should be left to the profession. Institutional protocols will be acceptable.
The viability of small and medium hospitals is at a vulnerable stage now. The Act may end in pushing them into extinction.
The stabilisation clause is impractical and at least the same should be defined as mandatory primary first aid and appropriate referral.
Fixing of charges and rates may actually end up in increased charges and rates to the people.
With more than 50 plus laws and regulations in place, hospitals are overregulated. Is there a possibility of good governance with fewer laws?
Promotional clauses like ‘aided hospitals’, retainership of GPs and fact-finding missions like line listing and professional costing of services may have soothing effect on the profession.
Having a single authority for the entire state is a much more friendly way of regulation. Single empowered council at the state will be much more efficient. The State Government could be the appellate authority.

Categorisation of pvt hospitals a tough task

Ahead of implementing the Clinical Establishment Act, most major institutions in the private heath sector want clear categorisation of hospitals and that too after a comprehensive study about the charges levied for diagnostic, treatment procedures and patient care. Experts say prior to putting in place a standardisation plan, the categorisation of private hospitals should be done in four sections. These include hospitals with PG programme and standardised modern facilities, centres without PG programme but having standardised modern facilities, centres with few specialities and modern standard facilities and centres completely without standard modern facilities.

Facilities of each hospital will have to be studied in detail prior to categorisation. These need to be well defined. Unless such an exhaustive exercise is carried out covering all hospitals, the move would be meaningless. They believe only base charges can be fixed for procedures which are usual. But the case is different for unusual procedures like transplant programmes, involving a lot of brain storming, planning and proper execution.  Therefore fixing charges for entire procedures may not be practical.

Sources in private sector say superficial studies will not be of much help. A number of experts will have to be taken on board besides adopting scientific methods to get a proper feedback. The standardisation of rates in private sector was not an easy task. Each hospital has different types of facilities, speciality, medical experts and it would not be easy to classify them, they add. They say the government should explore possibilities of bringing in top hospitals within the purview of its health care schemes to make facilities in private hospital affordable to common man.