Recently there has been quite a flurry of opinions, accusations and threats around the issue of regulation of private medical establishments in Karnataka.
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Although the Karnataka Private Medical Establishments (KPME) Act has been around since 2007, concerns over the last few years, around patient rights, have brought in the need for Amendments to the Act. Following a prolonged period of discussion under the Justice Vikramjit Sen Committee, the health minister put forward the Amendments to the KPME in the Karnataka Assembly on 20th June 2017.
The response to this has been contradictory and volatile. A majority of private hospital doctors immediately took out a protest opposing the Amendments. Citizen groups and civil society has largely supported the Amendments and have asked for a few more inclusions.
In view of the different positions, the Bill has now been referred to a Joint select committee of the house which will give its own recommendations by the end of July 2017. It is important for more people in Karnataka to engage in and actively contribute to the discussions as health is a state subject and issues around healthcare affect everyone in one way or the other, some more adversely than others.
The Private Hospitals and Nursing Homes Association (PHANA), the Indian Medical Association (IMA), the Federation of Hospital Association of Karnataka (FHA-K), the Karnataka Private Medical Establishment Association (KPMEA), The Association of Healthcare providers of India (AHPI) and other organisations have issued a set of demands with regard to the Amendments. These are:
- To bring in government establishments and private establishments under the same regulations and to change the nomenclature to Karnataka Medical Establishment Act (dropping the word ‘Private’).
To drop the proposal for an independent adjudicating authority at the state and district level, for grievance redressal.
To constitute a multi stakeholder committee to categorise establishments with regard to facilities and costs without any power to government to fix charges.
It is important for people accessing healthcare to understand the implication of each of these demands.
The discussion on whether the private health sector and government health system should come under the same regulatory umbrella has been discussed by several groups with good media coverage as well.
The argument for keeping private establishments under a separate regulatory system is that the private sector functions on a market logic, selling services to those who can afford to pay while the government, on the other hand, has been available to all citizens irrespective of paying ability.
Secondly, the government already has checks and balances and systems in place to ensure accountability, although the implementation has undoubtedly been poor. Owing to complete lack of regulation in the private healthcare industry till date, patients have been charged at will, data of diseases of public health importance has not been disclosed by the private sector to the government and patients have had no clear and reliable forum for grievance redressal if they felt unnecessary and wrong procedures had been performed or if they had been overcharged.
The need for a separate grievance redressal body at the state and district level is important for patients and others to be able to take up issues they feel amount to negligence, denial or care, mismanagement or malpractice. If a hospital has overcharged a patient, conducted unnecessary tests and procedures, refused care or refused to issue documents, then the patient has a right to take it up to a forum for redressal.
The recent cases of rampant hysterectomies by private hospitals in Karnataka has thrown light on huge gaps in grievance redressal even for obvious cases of malpractice. These grievance redressal bodies also offer space for doctors to complain confidentially about establishments that set targets, induces with cuts and commissions and other such exploitative practices.
The Amendments to the Bill provides for setting up of an expert committee with representation from private medical establishments, including small and medium sized hospitals, to fix rates for investigations, bed charges, consultation, surgeries, procedures, OT, intensive care, ventilation, implants, devices etc. The government will not unilaterally arrive at an upper limit and should also ensure that Tier 2 and Tier 3 hospitals are also part of this group so that standards and costs do not get skewed only in favour of large corporate hospitals.
One of the Amendments is that hospitals cannot insist on payments prior to treating a patient who comes in an emergency situation. All private hospitals should provide first aid emergency care to patients in case of accidents, criminal assaults, burns, poisoning, heart attacks etc. If a patient comes with burns, the patient should be stabilised with first aid, IV line and once stable, patient is informed about the choices with regard to costs.
If patient/attenders says it is not affordable then they are asked to settle the bills and transferred to another hospital. The referral process should ideally be patient friendly with the hospital having details of different hospitals in their vicinity and refer patient appropriately. There is currently a nexus of profiteering around the issue of emergency care. Often auto drivers, general practitioners and ambulances are given commissions to take patients requiring emergency care to far off hospitals even if there are well-equipped hospitals along the way. With this Amendment, saving the life of the patient becomes the absolute primary concern of any hospital at fairly standardised rates of treatment.
Apart from the existing amendments, a few more additions would help making the private sector further accountable as well as offering better patient care.
All private hospitals should compulsorily submit data to the government on key public health related indicators such as the number of cases of HIV, dengue, tuberculosis and other disease that have been diagnosed, treated and referred by them. Information should also be provided on whether the treatment given for these was rational and keeping with standard treatment guidelines.
The increasing antibiotic resistance and multi-drug resistant diseases can be attributed to inappropriate treatment, specifically by private hospitals. Private hospitals should also submit data on Caesarian sections, hysterectomies, cardiac surgeries, etc. so that monitoring can be done for unnecessary procedures. In the recent case of unwarranted hysterectomies in Karnataka, it was found that a majority of the women did not in fact require surgeries.
Another Amendment that should be introduced is that a health care establishment should not provide a health service for experimental, bio-medical or clinical research purposes without informed consent of patient. Patients often do not realise that they are actually a part of a clinical trial, either being exposed to a newer treatment options whose negative consequences are still uncertain, or being denied well known options. It would be important that these boundaries are clearly established and done with patients’ full understanding and written consent.
The decision to put a patient in an Intensive Care Unit and/or ventilators should be done after due process of documentation by a senior doctor about the necessity of the same. Horror stories abound about brain dead patients being put on ventilators for days and patients who are ambulatory and stable being admitted into the ICU. That these actions are intended to generate income for the establishment rather than being of any real benefit for the patient has been a growing concern and must be regulated.
The idea of visiting consultants has created a group of doctors who are not located in any one hospital but ‘on call’. One needs to consider the geographic location and rationale for these consultancies, so that patients receive the best possible care.
So for example, a neurosurgeon has sick patients in three different hospitals, would he be able to provide adequate care to all of them? Should there be a geographical limit and/or number of hospitals that one is a consultant for? Medical establishments have to ensure systems in place that patients receive seamless care in the absence of one or the other visiting consultant.
Lastly, the issue of sexual harassment and abuse is of concern in hospitals because of the nature of relationship of the medical profession with patients. Although there are different laws and Acts to address the issue, it is important that medical establishments ensure that patients are aware of their rights and that steps are in place to ensure these rights.
For eg. Women patients have a right to a female attender when they are being examined by a male doctor. All medical establishments should ensure this as a standard protocol and also display the information clearly. Children under 14 should be examined in the presence of a parent or guardian. Cases have also been disclosed of transgender persons being asked to show their genitalia when they have gone for completely unrelated medical conditions.
There have been instances of patients being completely naked in the operation theatre while the staff stand around joking or making offensive comments about the patient. The boundaries between sexual abuse, sexual harassment, abuse of power and medical management can sometimes be hazy and it is important that establishments have clear guidelines for this and ensure that patients dignity is upheld at all times.
These recommendations are not comprehensive and may need modifications to ensure that doctors and establishments are not unnecessarily penalised. Citizen groups could share their opinions and other recommendations on https://kpmeyake.wordpress.com/ which also provides more information on the KPME. The suggestions could then be handed over to the Joint Committee to keep in mind while they are finalising the Amendments.