Hospitals: India
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Hospitals and the law
Consent forms
Pre-printed forms an unfair practice
Dipak Dash, ’Pre-printed consent form unfair practice’, July 9, 2020: The Times of India
The apex consumer commission, NCDRC, has called the fixed format for consent or undertaking form for medical procedures an “unfair trade practice”, saying the pre-printed form fits in for any procedure, doctor or patient and thus is a case of “administrative arbitrariness”. The order of the National Consumer Disputes Redressal Commission (NCDRC) came on Monday while hearing a medical negligence case involving RG Stone Urology and Leprosy Hospital in Delhi. While dismissing the complaint of any medical negligence or deficiency in service by the hospital terming it as “frivolous, bereft of merit and ill-conceived”, a two-member bench of the commission comprising Dr S M Kantikar and Dinesh Singh took note of the peculiarity of the ‘informed consent’ form.
Directing the hospital to deposit Rs 10 lakh in the Consumer Legal Aid Fund of the commission within a month, the NCDRC said, “We note that a pre-printed and fixed ‘informed consent cum undertaking’ form, with blank spaces for limited select handwritten entries and for the signatures has been used. The main body of the form is pre-printed and fixed. It can fit into any procedure, any doctor, and any patient, after filling up the blank spaces for the limited select handwritten entries and getting / affixing the signatures. We note this to be administrative arbitrariness and onesided high handedness, and to be unfair and deceptive, on the part of hospital, for which, though, the complainant has not been prejudiced in this particular case.” The order is likely to have wider ramifications considering that several hospitals follow the pre-printed and fixed ‘informed consentcum-undertaking’ form for carrying out any procedure.
A former NCDRC member said in several cases, insurance firms win cases as they claim that the conditions are written in detail and they take the consent of the consumer. Even in medical negligence complaints, hospitals maintain that they personally make the patient or the attendant understand the medical procedures.
The cheats
2019
Ishita Mishra, August 28, 2019: The Times of India
It has been just about a year since the Ayushman Bharat scheme — the Union government’s ambitious programme for providing health protection to around 10 crore vulnerable families — was initiated, but already a long list of scams has surfaced involving hospitals that have exploited provisions of the scheme to make a quick buck.
Many of these scams have been unearthed in the tiny Himalayan state of Uttarakhand where private hospitals have been accused of siphoning almost Rs 1.20 crore of public funds in just a few months. And they seem to have done it in bizarre ways — from showing surgeries being conducted on patients who had actually been discharged days ago, to dialysis shown as having been performed in a facility where there was no kidney specialist.
In fact, quite a few hospitals in the hill state showed patients to be afflicted with deadly diseases while they were later found to have been suffering from common cold. Some hospitals showed operations done on patients whose surgeries had already been completed elsewhere. Yet others claimed money by submitting records of surgeries done on patients who were perfectly healthy. Sample the case of a Dehradun-based patient. When a team of the National Health Authority (NHA), which visited Uttarakhand in May to do a physical verification of beneficiaries, met the patient, they were in for a surprise. The man was listed in their records as someone who needed emergency hip replacement surgery but he was found to be merrily driving around on a scooty.
“How can a person who needs emergency hip replacement drive a two-wheeler? The hospital had claimed Rs 90,000 for his surgery which was declined by us,” said Abhishek Tripathi, director, Atal Ayushman Yojana (Uttarakhand). The team further found that the patient was a dealer of medical instruments used in hip transplants, which raised more suspicions regarding the authenticity of his case.
Vinod Ortho Clinic in Dehradun, the medical facility which had recommended the surgery, was also found involved in another dubious case – of a patient who had undergone surgery in a government hospital. The patient whose limbs had already been amputated was shown as having undergone a similar surgery in the clinic even though it was later found he had been admitted there only after a minor infection in one of his amputated legs. The clinic has now been de-empanelled from the scheme. When TOI spoke to the clinic’s owner, Dr Prasoon Maheshwari, he claimed that he hadn’t done anything wrong. “I am planning to move court to challenge the action taken by Atal Ayushman authorities in the state,” he said and added that he was targeted since “many renowned doctors were having a problem with the fact that patients had started coming to me instead of them as I was charging less and delivering better results.”
Uttarakhand currently has over 150 hospitals empanelled under the scheme. Although it started out last year in September as Ayushman Bharat covering around 5.37 lakh beneficiaries, its scope was extended by the BJP government to bring more people under its umbrella. On December 25, 2018, chief minister Trivendra Singh Rawat to mark the birth anniversary of former PM Atal Bihari Vajpayee renamed the scheme Atal Ayushman Yojana and said the scheme would cover around 18 lakh more beneficiaries besides the ones identified earlier under the central plan. The state is footing the bill for the additional beneficiaries, each of whom is entitled to medical cover of Rs 5 lakh.
Perhaps it is this blanket extension of the scope of the scheme, although well-intended, that has led to it being open to fraud. During screening of the claims that started in March this year, officials came across case after case of alleged swindling. It led to seven hospitals being de-empanelled for forgery, FIRs were filed against four and 12 others were issued show-cause notices for "gross irregularities".
A member of the investigation team said, “A 30-bed hospital in Kashipur in Udham Singh Nagar claimed to have 24x7 emergency facility. But it was found to be manned by just one doctor who was also the owner. It turned out that this doctor was also serving in a government-run hospital in Kashipur itself. The hospital had made medical claims of Rs 2,72,600 which were cancelled after scrutiny.” In two other cases, in Kashipur and Haridwar, government doctors associated clandestinely with private hospitals had prepared claims worth several lakhs through the scheme.
In a primary health centre in Udham Singh Nagar’s Kelakhera, a pharmacist was found referring patients to three private nursing homes in the town. One of the nursing homes had employed an Ayurvedic doctor and showed him as an MBBS degree-holder by forging documents. The nursing home was also found showing common fever patients as suffering from fatal diseases to avail compensation under the scheme.
Investigators found that hospitals had devised another method to get more money. A hospital in Haridwar, for instance, filed a claim for performing 38 cataract surgeries in 45 days, all of which were done after 9:30pm and classified as "emergency". The probe team rejected the claim since cataract is not an emergency surgery.
Another Haridwar-based hospital had forged patients’ medical history in 152 cases. The hospital, officials said, had got empanelled in the Atal Ayushman scheme by showing itself as a medical college but failed to provide accreditation of Medical Council of India. The hospital showed patients with common diseases like enteric fever, recurrent vomiting and dehydration and gastroenteritis as suffering from serious illnesses.
“They fraudulently converted general diseases into fatal ones and siphoned over Rs 10 lakh. The hospital also discharged 12 patients directly from the ICU which is not possible because patients have to be kept under observation after shifting from ICU. This hospital also filed claims of 12 surgeries done in 14 hours which were all attributed to the same doctor which again is not possible,” Tripathi said.
Although TOI contacted all the hospitals whose cases are mentioned in this report, no response was forthcoming. One of the hospitals that responded said that speaking to media will be "violation of the MoU signed under the scheme". Elaborating, Dr Santosh Srivastava of MP Memorial Hospital, Kashipur, under the scanner for performing dialysis on over 1000 patients in six months without any nephrologist, said the MoU signed between Atal Ayushman Society and the hospital has a clause that states no party can speak to the media unless the process of de-empanellment is done.
“If the Atal Ayushman authorities are speaking to the media and disclosing the names of hospitals to whom notices were served, this is a gross violation of the MoU,” he alleged.
SCAMMERS AT WORK
1. Man listed in records as patient needing emergency hip replacement surgery
Fraud
He was found driving around on a scooty. The hospital had claimed Rs 90,000 for the surgery, which was declined
2. Doctors discharged 12 patients directly from ICU, claim 12 surgeries in 14 hours
Fraud
Patients can't be discharged directly from ICU, have to be kept under observation. All the 12 surgeries in 14 hours attributed to one doctor
3. A 30-bed hospital claimed to have 24x7 emergency facility
Fraud
It had just one doctor, who was also the owner. Moreover, he was serving at another hospital
4. Hospital in Haridwar claimed to have performed 38 'emergency cataract surgeries' in 45 days, all after 9.30pm.
Fraud
Cataract is not an emergency surgery
UTTARAKHAND IS NOT ALONE
In Uttarakhand, 154 hospitals are empanelled, seven are de-empanelled, while notices have been served to 12 hospitals. Claims amounting to Rs 20 crore have been sanctioned to various hospitals under the Ayushman scheme. In UP, where 1,843 hospitals are empanelled, show-cause notices have been served to 27 hospitals, while four have been de-empanelled. In Saharanpur, a gang making fake Ayushman cards was busted recently. Over 200 service centres in Agra and three in Pilibhit issuing health cards to non-eligible beneficiaries were deactivated. In Bihar, 684 hospitals are empanelled. Action has been taken against one hospital although officials say others are being probed for malpractice
HEALTH SCHEME FOR THE POOR
Launched in September 2018 (in pic), Ayushman Bharat or Pradhan Mantri Jan Arogya Yojana (PMJAY) covers 10 crore families, who will be given up to Rs 5 lakh cover per year
Entitlement based on deprivation criteria in Socio-Economic Caste Census (SECC) database for rural families. For urban areas, occupational category of urban workers' families to determine entitlement
Cashless and paperless access to services for beneficiary at the point of service
Eligible people can avail benefits in government and listed private hospitals
Valid ID (Aadhaar not mandatory) required, Ayushman Bharat helpline number: 14555
Rates, charges, fees
Charges in all private hospitals can’t be same: HC
Nov 12, 2019: The Times of India
Delhi high court has refused to direct authorities to fix uniform rates to be charged by private nursing homes and hospitals as the amount would depend upon the nature and type of disease as well as the quality of treatment provided.
A bench of Chief Justice D N Patel and Justice C Hari Shankar recently dismissed a PIL seeking directions to Delhi government to issue a notification on bringing uniformity in charges levied by private nursing homes and hospitals in the capital.
The court pointed out that charges levied by a private nursing home or hospital would also depend upon the facilities available with them and there can’t be a direction to make this uniform across the board.
“Looking to the prayers made in this writ petition, there cannot be uniformity in charging of rates by private nursing homes and hospitals from the patients falling under general category. All private nursing homes and hospitals cannot be equated with respect to the charges required to be paid by the patients. It depends upon the nature of disease/diagnosis of the patients and the type of treatment given by the private homes/hospitals. Even otherwise, the charges to be paid by the patients as levied by the private nursing homes and hospitals depend upon the facilities available with them. Hence, we see no reason to entertain this writ petition,” the court noted.
Declining to issue directions on a PIL by an NGO, the bench also noted in its judgment that the charges depend upon a variety of factors, including number of facilities being provided by the private nursing homes and hospitals, the promptness in providing of services, efficiency of the staff and quality of services provided.
NGO Legal Forum for Women Empowerment had not only sought uniformity in charges of private nursing homes and hospitals, but also a mechanism to help public lodge complaints or raise grievances against any malpractice by such entities.
Most caring hospitals in India
From the archives of India Today , June 10, 2009
Damayanti Datta
India's most caring hospitals
How many of our hospitals would fulfil that very human need to feel cared for when we are at our most vulnerable? Check out the writing on the wall. And that, too, from those who are usually at the receiving end—patients. A survey commissioned by the Ministry of Consumer Affairs, Government of India brought out what patients value the most when living under neon lights and in the shadow of disease.
Conducted by the consumer body, VOICE (Voluntary Organisation in the Interest of Consumer Education) on 4,000 patients in six metros, it is reportedly one of the first-ever surveys to tally patient satisfaction with quality of hospital service in India—a country not known for bestowing power to the patient.
“The view of the patient as a consumer is the need of the hour,” says Bijon Mishra of VOICE, who mentored the project. “Although the healthcare market is booming— from Rs 927 billion in 2001 it’s slated to touch Rs 2,088 billion by 2012—the number of complaints against hospitals has zoomed up.” The world of hospital caring is changing fast for the consumer. A maddening tooth-ache on a Sunday morning had forced Sandhya Negi of Patparganj in Delhi to step into the snazzy neighbourhood hospital. She wasn’t destined to burn a hole in her pocket. The doctor couldn’t be traced. The hospital apologised, but it was the phone call later in the day that took her breath away. “I’m doctor X,” crooned a voice, “Sorry for not being there. Hope you won’t hold it against us.”
A far cry from her trip to a wellknown government hospital some years back. She still remembers the agonisingly long wait and patients swarming around a harassed doctor. Would she go back to that hospital now that she has more choice? That line of patient-thinking is reflected in the survey in hand: the top reason for choosing a superspeciality or tertiary hospital is good reputation and image, followed by referral from a doctor and recommendation by close friends and family. “The new-age consumer—more sensitive about matters concerning health, more willing to spend on the best possible service and more keen to get value for money, is asserting his choice,” says Dr Naresh Trehan, the man who had set up the Escorts Heart Institute & Research Centre in Delhi on his return to India from the US two decades back. Not surprisingly, “referred by doctor” is the top reason in districts, among the less educated and economically weaker. “There is persuasive evidence that quality of care influences hospital demand,” write two US economists, Dana Goldman and John Radley, in their December 2008 study, ‘Hospitals as hotels: the role of patient amenities in hospital demand’. While a one-standard-deviation increase in amenities (“such as good food, attentive staff, and pleasant surroundings”) raised a hospital’s demand by 38.4 per cent on average, the demand was substantially less responsive to clinical quality. In the survey in hand, too, hospitals that topped in “overall satisfaction” were those that offered more amenities. From cleanliness to parking, clear signage to wheelchairs— Apollo, Chennai, and Wockhardt, Bangalore, met most of the standards. At Manipal Hospital, Bangalore, a greater proportion of respondents had used the emergency; Wockhardt, Bangalore won top ratings for easy accessibility, round the clock service, equipment, and helpful nurses. Escorts Hospital, Delhi, and Apollo, Chennai, scored on registration—counter and form, efficient staff, sitting arrangement to time taken. Manipal, Apollo, Chennai, and Care Banjara, Hyderabad, fared best in nursing staff—courtesy, flexibility and attitude. Going by the same logic, the All India Institute of Medical Sciences, Delhi (AIIMS), despite its reputation, did not fare well. Staggering under patient overload, the average time taken to get registered here works out to 74 minutes, while the average in superspeciality and tertiary hospitals is 22.4 minutes. Ask Dr K.S. Reddy, who has been with AIIMS since 1974, first as a student and finally as the head of cardiology. The experience of people “queuing up from 6 a.m. for an OPD at 2 p.m.” has been routine for him. “The idea of ‘medical care’ is benchmarked partly by peers in the profession and partly by the patient,” he says. “Treatment quality forms a key component. At AIIMS, you may have to wait long to access a doctor, but you end up getting the best possible treatment.” But the human interface with a hospital in India often lacks sensitivity and compassion, he adds. “A study like this sends out a crucial signal that a hospital must not only be care-giving, but a caring facility which is hospitable.” The lounge in front of Trehan’s chamber fills up with patients recovering from surgery at a certain point during the day. And it’s always a poignant moment. As the doctor moves about, asking a question here and checking a dressing there, the fragile men and women on wheel chairs reach out—touching, stroking, kissing his hands—looking wonderingly up at his face. In medicine, the patient’s trust in a doctor’s “superior power” is an important part of the therapeutic effectiveness. And more than pristine degrees, the doctor’s attention span and willingness to listen to patients matter. In the VOICE study, patients expressed satisfaction with doctors not so much in clinical terms but more for their “courtesy” and for “listening, explaining and visiting when required”. Surprisingly, the same doctors that patients approved of scored lowest when “communicating the expected charges” to patients (for instance, Apollo, Chennai and Manipal, Bangalore). Wockhardt Superspeciality on Cunningham Road in Bangalore, surpassed on several counts: it’s most referred by other doctors, top in overall trust in diagnostics, second in “trust on doctors”, one of the top five in overall patient satisfaction, to name a few. What’s their secret of success?
Methodology
The survey was conducted at 45 primary and secondary hospitals, 17 tertiary and superspecialities, covering 4,000 consumers from six metros and nine districts over 2007-08 and submitted to the Government in November 2008.
Quality of health has different meaning for providers and recipients of healthcare. For the former, it’s clinical (affiliation, technology, mortality, discharge, treatment, surgical procedures etc). For patients, it’s more subjective. This study was done purely from their perspective.
A Key Performance Indicators model was adopted. A Situation Appraisal Analysis was then conducted to identify factors that impact quality of service. Secondary studies and interaction with stake-holders suggested 110 factors and an Importance-Influence Matrix was drawn up to identify those—safety, security, services, food, cleanliness, availability of medicine, quietness, staff behaviour, communication, speed of service, waiting facilities, location, signage, fees, etc. The choice of hospitals was based on a tele-pilot survey of VOICE subscribers about facilities they frequented most in the last six months. Field workers had faced problems of accessibility in some (e.g. Jaslok, Asian Heart and Hinduja hospitals in Mumbai).
Honour roll: Top 5
Overall satisfaction
1. Escorts Heart Institute & Research Centre, Delhi
2. Care Banjara, Hyderabad
3. Apollo Hospital, Chennai
4. Manipal Hospital, Bangalore
5. Wockhardt Superspeciality, Cunningham Road, Bangalore
Word of mouth leaders
1. Manipal Hospital, Bangalore
2. Indraprastha Apollo, Delhi
3. Escorts Heart Institute , Delhi
4. All India Institute of Medical Sciences, Delhi
5. Peerless Hospital and BK Roy Research Centre, Kolkata
Most chosen for good image
1. Escorts Heart Institute, Delhi
2. Batra Hospital, Delhi
3. Sir Gangaram Hospital, Delhi
4. Max Superspeciality, Delhi
5. Indraprastha Apollo, Delhi
—Report on Study of Client Satisfaction with Quality of Hospital Services, 2008
