Policy shift ?! How to save small hospitals and the save the public health from corporatization of health care ?

  The Legislative policy preferring Major Policy shift ?!

Dear friends, the world has been transforming at lightning speed. so, our profession. But the tragedy is that the health care is in the hands of such people who have no knowledge of public health, modern medicine and human values.

This series of blog posts are  just not waves of our emotional outbursts but  decisive and incisive articles. 

 

In this post, i am high-lighting the first and fore most issue that has been plaguing not only the health cate but also doctor-patient relationship i.e. corporatization & commercialization of health care in various perspectives and the remedies the govt should take to reduce the commercialization and save the small hospitals and ensure affordable quality care to the people.

1. corporatization of health care. -that leads to slow killing of family doctors and small hospitals and monopoly of health care market in the tight commercial hands of corporate giants and insurance hawks.

How it started in INDIA?

There has been organized interaction of industry with the government since the 1990s to promote healthcare services as a big business opportunity, wherein provision of health services through hospitals is projected as a major profit-generating activity, having the following features:

 • Healthcare becoming an active component of services sector in the economy

• Emergence of corporate hospitals

• Promotion of medical tourism

• Emergence of an organized healthcare industry.

What is meant by corporatisation of healthcare? 

In the context of health systems, corporatisation refers to:

 • the process of establishing hospitals as corporations or companies

 • private companies investing in health care for increasing profits and dividends to shareholders;

• entry of publicly listed companies in setting up of hospitals or listing of hospitals on stock exchanges .

Such adoption of corporate structure is accompanied by several behavioural changes within the organisation, in order to maximise revenues and profit. These changes are not limited to setting up of corporate hospitals; rather this ‘corporate culture’ also influences functioning of other kinds of private hospitals.

In India there has been a process of corporatisation of the private health sector over the past two decades, and a penetration into the entire health sector of the corporate economy, management practices and culture.

 

Why the service sector has been often termed as industry? 

The term healthcare industry is an umbrella term used to refer to hospitals, diagnostic centers, pharmaceutical-medical equipment and devices, and the insurance industries. The hospitals sector is reported to be the major segment among all these, and hence the term healthcare industry is commonly used in India to refer to corporate and other big private hospitals.

The spread and scale of corporate investments in healthcare in India is mind boggling.

set up as private and public limited companies,the hospital industry in India was estimated to be worth   9 trillion $ in 2022.

The business rating and business intelligence institutions (such as CRISIL and CMIE) were reporting attractive returns in the healthcare industry and an increase in sales of healthcare sector companies since one decade. 

Business reports show that healthcare in India has become an attractive sector for private equity (PE) investments, with international companies and investors making major investments in hospitals in India.

Either emulate or exit! - Nursing homes and smaller hospitals are either closing down or emulating corporate practices   .

According to one survey, “Out of the 10000-odd nursing homes registered in the state ,about 25%  have shut down”. Doctors who owned small hospitals pointed to the lack of level playing field. They are not able to offer a range of exotic, luxurious facilities as corporate hospitals can”. According to a small hospital owner, ‘big hospitals put up big hoardings, whereas if I published an advertisement in the newspaper I will be questioned, I will be given a suspension and a show-cause notice.

New segments and newer developments  in private health sector.

 Dedicated hospital management companies have been set up, such as Radiant Lifecare Private Ltd, Vitalife, Hosmac which provide a range of services to hospitals, including contracted management of healthcare facilities. Hospital management is an important source of revenue in the hospital industry. Most big corporate hospital chains such as Apollo, Narayana, Fortis, etc. beside running their own hospitals, also manage other hospitals. Companies and chains of companies are also emerging in the diagnostics sector, in pathology and imaging, such as Thyrocare, NM Medical, Medinova, Metropolis. Franchising of small diagnostic centers, specialty clinics and pharmaceutical stores is also increasing notably. Certain specialized companies provide short stay surgery such as Apollo Spectra and Nova. Companies such as Portea exclusively provide home-based medical care, including doctor consultations. Online platforms like Practo have come up, which are being widely used by doctors to increase their visibility. 

What are the Implications of corporatization for doctors, medical practice and patients ?

Corporate hospitals- a double-edged sword for doctors.The emergence of corporate hospitals seems to have created several opportunities and advantages for doctors. However, it has also thrown up various challenges for them. Several respondents pointed out that, ‘doctors go to a corporate hospital because they will get good salary, they get access to a lot of advanced equipment, and they have much better infrastructure and personnel compared to small set ups’.

Some doctors find it better to work with corporate hospitals as doctors need not make their own investments, need not worry about administrative aspects like staff, renewal of a license, etc. All this is taken care of by the hospital, and the doctor can focus on medical practice and get their income.

According to a pathologist, ‘Corporates have a good legal team with them that handles all these things, but solo practitioners have to manage everything single-handed. That does make a difference’. Being attached to big corporate hospitals also conferred status, prestige, credibility and according to some, it also provided security against violence from patients, as compared to small-medium sized hospitals.

However, doctors also shared their unease and discontent, and raised serious concerns about challenges such as differential terms of employment, insecurity in employment, constrained professional autonomy and pressure of performance targets, which they have been facing while working with corporate hospitals. While senior specialist and super specialist doctors are considered elite professionals, and get red carpet treatment from corporate hospitals, early career doctors struggle to get entry in corporate hospitals and often experience a tough time working with them. While reflecting about the differential approach of corporate management towards senior, mid and early career doctors, it was mentioned that, ‘Corporates are always after the big names to get more business’. On the other hand, for young doctors getting entry into the corporate setup is also quite difficult. It was told that, ‘If a senior doctor is already occupying a post of consultant in a major corporate hospital, there is no space for a junior doctor to get the slot’. Regarding payment, although it was largely agreed that pay in corporate hospitals is certainly better than small hospitals, however the situation is different for junior, mid-level doctors and for senior or established doctors. Juniors are said to be not well paid in corporate hospitals.

According to a small hospital owner, ‘A fully private corporate hospital is a place of exploitation for the doctor’. The entry of management cadre in the hospitals is also redefining the role and professional autonomy of doctors. Doctors felt that ‘Managerial staff apply the principles of some other branch of economic activity to healthcare. They do not doubt that healthcare is to be run as a business and they are quite brazen about it’.

Most of the doctors mentioned that their autonomy gets constrained in corporate hospitals. An ophthalmologist remarked that, ‘I don’t have autonomy in taking decision about patients. Sometimes I can be pressurized because of those targets. I don’t have autonomy in deciding whether I need this equipment or not, which is decided by the management’.

Regarding performance targets, most respondents expressed their concern: In corporate hospitals each and every consultant is given target to achieve that much revenue at the end of the month. - ‘Each one in corporate is given a target - from sweeper to doctor. Full timer as well consultant doctors are told to get x number of patients, depending upon specialty’.

Corporatization is promoting healthcare corruption and is affecting the doctor-patient relationship . The challenges doctors have been facing in the context of corporatization of healthcare are having wider implications for overall medical practice, as well as for the doctor-patient relationship.

 Linked with corporatization, overall medical practice is being affected in terms of prevalent malpractices and increased cost of care. Cost of care has gone up because of so much of investment into the healthcare setup; and setting targets leads to a lot of unnecessary investigations and treatment modalities. Performing unnecessary diagnostic tests and treatment bills, etc. ultimately burden the patient with the increased cost of care.

While discussing inflated cost of healthcare, one respondent expressed concern that, ‘When the small and medium-sized hospitals close down, it is the middle class, lower-middle class - the majority in this country – suffer. They are the real sufferers because they cannot afford the corporate hospitals’.

Further, it emerges that with the shift from a patient-centric model to a revenue generating model, frictions between doctor and patients have increased. Many respondents agreed that in family practice or small hospitals, doctors are much more connected with their patients and pointed to the impersonalized nature of doctor-patient interaction in corporate hospitals.

 Patient respondents pointed out that ‘earlier doctors personally used to take rounds and spend 15 to 20 minutes with each patient. These days mostly the Registrar is in touch with the patient, and the Consultant is involved only for specific matters. The doctor comes, greets and leaves’.

Conclusion and directions for change:

 The overall trajectory of the health sector in India during the last three decades has been of increased commercialisation of health care, accompanied by stagnation and weakening role of public health services.

The dominant discourse in India during 1950s to 1970s treated the healthcare sector as a set of socially embedded institutions – mostly public or charitable hospitals, along with individual private practitioners – whose primary logic consisted of responding to health care needs of the people they served.

From 1980s onwards, commercialisation of healthcare gathered momentum with rise of private nursing homes and smaller private hospitals; health care was being converted into a market based commodity, and profit making emerged as an important dynamic. This set the stage for the next phase - from the turn of the millennium, large private and corporate hospitals have emerged as significant players, whose overwhelming driving logic is maximization of profits.

Corporatisation of health care has emerged as a process which while centred on corporate hospitals, is also influencing other players in the sector in various ways - including individual practitioners, small, medium, large and charitable private hospitals.

Overall, commercialisation and corporatisation of healthcare have converted the health sector in India from its earlier mould of socially embedded institutions, to becoming an arena for aggressive maximization of profits, often at the cost of affordability, rational care and access to care for large sections of the population.

In this setting, to reinforce the character of health care as a social good and basic social right, there is need for major strengthening of public health services, along with developing a policy framework related to health care which will contain the negative impacts of commercialisation, while tackling the phenomenon of corporatisation of health care. Development of such a policy framework requires large scale discussion and consensus building among concerned stakeholders, keeping public interests paramount.

·         The state should not put the small and corporate big hospitals on single line in fixing or framing the regulations.

·         Regulation of COST & PRICING  in BIG/CORPORATE hospitals should be a critical component although considerations of quality of care would be important,

·         We must be aware that imposing overly demanding infrastructural standards would favour corporate and large private hospitals, but may be difficult to fulfill for rural and small town setups, leading to their closing down and thus favouring corporatisation of healthcare.

·         Govt should encourage small hospitals (below 50 beds) by removing all type of regulations along with  providing soft loans,tax exemptions,non-commercial billing of electricity &water.

·         Govt must play its active role in tertiary care by establishing centers of excellence in all districts thus proving good and effective competition to the corporate hospitals that could check the higher pricing in corporate hospitals and prevent the monopoly in marketing.

·         Ultimately we need to move towards a public-centred system of Universal Health Care, which would be based on robust public health systems .

Wishing that Profiteering from sickness would become a matter of the past, and healthcare would become a social good enjoyed by all as a basic right !

 

In the next post we will focus on the detrimental "Mixopathy &Crosspathy & skill shifting  in health care.