Outstanding and Receivables: A Long overdue problem faced by service providers

Outstanding and Receivables: A Long overdue problem faced by service providers Doctors are not a happy fraternity today. There are several reasons for this. • Practicing doctors live in fear of criminal prosecution or violence. • Specialists are unhappy because of the unrealistic targets they are expected to meet. • Corporate hospitals are unhappy because they are denied their due reimbursements in time. • Service doctors and medical faculty are unhappy because their salaries are not at par and the new 7th Pay Commission has reduced the non- Practicing Allowance (NPA). • MBBS doctors are unhappy because they do not have opportunities to get a postgraduate degree. The medical profession provides services to Central Government Health Scheme (CGHS), Employees Health Scheme (EHS), Public Sector Units (PSUs), Ex-servicemen Contributory Health Scheme (ECHS) and similar organizations at highly subsidized rates. Yet the due reimbursement is delayed for months together and is given without any interest. This was among the several issues that I had touched upon in my Presidential address. Therein I had said, “The constitutional right “equal pay for equal work” should be implemented in medical profession. All service doctors and resident doctors should get full 7th Pay Commission, obligatory research grants, uniform age of retirement and uniform nationwide pay scales, legitimate leaves, and working hours and conditions.” Then again, “Uniform service conditions for doctors and faculty” and “Reimbursement of emergency services for private sector” were a part our major demands in the Dilli Chalo movement. Let’s review here the problems faced by service providers. • Service providers empanelled with the above organizations are in a very vulnerable position. Providers cannot deny services to these patients as the number of beneficiaries is large and ceasing services will cause a public disaster. • With services being continued, the government has gone into a state of inertia and apathy. • The service providers are struggling with operations and continuation of service due to the following main challenges: o Delayed reimbursements: The current situation of outstanding is alarming with payments worth hundreds of crores pending. For example, the outstanding amount from CGHS includes up to 75 crores of Max Healthcare, over 20 crores of empanelled hospitals of Fortis in the north, in Bangalore and Maharashtra and about 5 crores of Dr Lal’s Path Labs. This excessive delay is affecting the very sustainability of the operations for the service providers. As a cascading effect, lab providers face delay in other payments from hospitals as they do not have enough funds to pay the labs because of delay in receiving reimbursements. While the service agreement provides for 70% of payment within 5 days, payments are delayed by months. An intervention from the Finance Ministry is also required to rectify the current problem as delays are also caused due to misalignment between Ministry of Finance, Ministry of Health & Family Welfare and the payment partner- UTI o Wrongful Deductions: - Even though service providers are deliver services as per rates given by the Government, illogical deductions are made from the claims with no intimation to the service providers. The quality of service and costs involved are judged by inadequately qualified persons during claim processing. o Reconciliation Issues: Several gaps exist in the current system of dispute resolution and arbitration for such cases. There is a need of validation of the system by an independent body, maybe FICCI Indian Council of Arbitration (ICA). Grievance redressal for service providers should be relooked into and streamlined o Contract Renewal and Extensions: The agreement, which is valid for 2 years, has been extended up to 4 years by the Government, without citing any rationale for the extension. The current contract due to expire in October 2016 was extended up to end of June 2017 and still there is no sign of new agreement. o Terms of Agreement: Agreements should be restructured before upcoming renewals to account for the following: - Organizations like CGHS should have a mechanism to accommodate inflation like in case of the Pharma Industry where price hike of up to 10% every year is allowed. - The Andhra Pradesh state Government order has been linked to Consumer Price Index (CPI), these organizations should also have similar considerations. - The rates of organizations like CGHS should be based on a scientific rationale. - Experts from the private healthcare sector should also be a part of the rate fixing exercise. - A unilateral scheme with all specifications in favor of the government is not acceptable to the industry (Source: FICCI Health meeting held on 13th June chaired by Dr Girdhar Gyani) Dr KK Aggarwal National President IMA & HCFI Recipient of Padma Shri, Dr BC Roy National Award,Vishwa Hindi Samman, National Science Communication Award & FICCI Health Care Personality of the Year Award Vice President Confederation of Medical Associations of Asia and Oceania (CMAAO) Past Honorary Secretary General IMA Past Senior National Vice President IMA President Heart Care Foundation of India Gold Medallist Nagpur University Limca Book of Record Holder in CPR 10 Honorary Professor of Bioethics SRM Medical College Hospital & Research Centre Sr. Consultant Medicine & Cardiology, Dean Board of Medical Education, Moolchand Editor in Chief IJCP Group of Publications & eMedinewS Member Ethics Committee Medical Council of India (2013-14) Chairman Ethics Committee Delhi Medical Council (2009-15) Elected Member Delhi Medical Council (2004-2009) Chairman IMSA Delhi Chapter (March 10- March 13) Director IMA AKN Sinha Institute (08-09) Finance Secretary IMA (07-08) Chairman IMAAMS (06-07) President Delhi Medical Association (05-06)

Consent Revisited: Inability to manage complications leads to violence

Consent Revisited: Inability to manage complications leads to violence Consent, as we know, is the authorization or grant of permission by the patient for treatment or any diagnostic, surgical or therapeutic procedure to be carried out by the doctor. A doctor has to take consent from the patient before proceeding with his treatment. It is ethical and in today’s scenario, a legal requirement. Any act done without permission is “battery” or physical assault and is liable for punishment. A valid consent has three components: Disclosure, Capacity and Voluntariness i.e. provision of relevant information by the doctor, capacity of the patient to understand the information given and take a decision based on the adequate information without force or coercion. This is informed consent. Any permission given under any unfair or undue pressure makes the consent invalid. The Hon’ble Supreme Court of India has defined ‘adequate information’ in the landmark case of Samira Kohli vs Dr Prabha Manchanda. This includes “(a) nature and procedure of the treatment and its purpose, benefits and effect (b) alternatives if any available (c) an outline of the substantial risks and (d) adverse consequences of refusing treatment.” No doctor practices medicine without taking informed consent. Yet we read and hear of incidents of violence against doctors from all parts of the country. So, are we going wrong somewhere? Are we doing something wrong somewhere? “Medicine is an art based on science”, said Dr. William Osler. Complications, adverse events or untoward incidents may occur at any time during the treatment. What is important here, how competent, we are, as doctors, or how competent is the hospital or the clinical establishment, in managing these complications or untoward incidents in a non-emergent situation. Not being able to manage complications leads to violence. The patient should be informed of every possible complication that may occur during this treatment, however rare they might be; even a complication rate as low as 0.1% might be 100% for that particular patient. No surgery can be called as a ‘minor’ surgery. Mistakes are made, but we believe that nothing will happen either to us or the patient. As I wrote few days back, it’s the case of "Kya pharak padta hai" to "bahut pharak padta hai". If nothing goes wrong, then "chalta hai". But, if something does go wrong or an unanticipated event occurs, then this becomes unacceptable “chalta nahi hai”. The key word here is ‘anticipation’. Anticipate what all can happen in the course of a treatment and be prepared to handle them or keep your patient informed. For example, you may need to shift the patient in an emergency to a higher care center and your establishment does not have an ambulance. Outsourcing an ambulance will delay patient transportation, and in an emergency situation, the longer the delay, more agitated are the patients or family members and may become violent. Let’s take another example. You might need the services of a specialist, say a urologist, neurosurgeon, or a nephrologist. If your hospital does not have these specialty doctors on its staff, then subsequent delays in procuring their services will increase risk of violence. Should you have these services and other such facilities as standby? Yes, everything must be on standby. The standby fee is 25%, while presence fee is 100%. This may increase the cost of treatment. The time has come when the patient must know that safety comes at a price in bigger hospitals. Inform the patient and the family members beforehand, let the patient choose and accordingly the consent should be taken. Safety of the patient is very important and should be our primary objective. A small set-up may not have all facilities as their bigger and better equipped counterparts. These smaller set-ups should keep the patient and/or family members informed about this lack of facilities and take consent. Good communication can reduce the rapidly increasing problem of violent attacks on doctors and healthcare establishments. ‘Adequate information’ for consent should include not only the competency of the doctor to treat the case, but also include the competency of the doctor and/or the hospital to manage any emergencies or untoward incident in a non-emergent situation. Any breach in this duty is negligence. This, I believe, is an area which we need to work on. It is the inability to manage complications that leads to violence. As doctors we SERVE our patients and the community and provide • Service which we have professionally trained for, which is • Excellent i.e. anticipated • Responsible, give our 100% to the patients and take responsibility • Value – Group; each member of the group knows the duties of another, so no gap in service may result • Enthusiasm: A positive happy atmosphere This is how we can avoid incidents of assault and violent attacks on doctors from happening. Dr KK Aggarwal National President IMA & HCFI Recipient of Padma Shri, Dr BC Roy National Award,Vishwa Hindi Samman, National Science Communication Award & FICCI Health Care Personality of the Year Award Vice President Confederation of Medical Associations of Asia and Oceania (CMAAO) Past Honorary Secretary General IMA Past Senior National Vice President IMA President Heart Care Foundation of India Gold Medallist Nagpur University Limca Book of Record Holder in CPR 10 Honorary Professor of Bioethics SRM Medical College Hospital & Research Centre Sr. Consultant Medicine & Cardiology, Dean Board of Medical Education, Moolchand Editor in Chief IJCP Group of Publications & eMedinewS Member Ethics Committee Medical Council of India (2013-14) Chairman Ethics Committee Delhi Medical Council (2009-15) Elected Member Delhi Medical Council (2004-2009) Chairman IMSA Delhi Chapter (March 10- March 13) Director IMA AKN Sinha Institute (08-09) Finance Secretary IMA (07-08) Chairman IMAAMS (06-07) President Delhi Medical Association (05-06)

Majority of doctors fear violence and are stressed out, reveals IMA study

Majority of doctors fear violence and are stressed out, reveals IMA study The all-India survey highlights the unsatisfactory nature of the job and the urgent need to create awareness New Delhi, 01 July 2017: A landmark all-India survey released by the Indian Medical Association (IMA) on the occasion of Doctors Day has found that about 82.7% of doctors in India feel stressed out in their profession. While fear of violence is the main stressor in many doctors (46.3%) followed by fear of being sued (24.2%) and fear of criminal prosecution (13.7%). The findings come in the light of the many atrocities faced by the medical fraternity today, the most disturbing of which include violence against doctors and their criminal prosecution. The anxiety of doctors over the issues plaguing the profession is evident by the fact that about 56% of them do not get a comfortable 7-hour sleep most days of the week. Conducted online over a period of 15 days, the survey received responses from 1681 doctors including general practitioners, physicians, surgeons, gynecologists and super specialists working in private OPDs, nursing homes, corporate hospitals or government hospitals. It is an eye-opener on the extent to which doctors have been affected. About 62.8% of the doctors surveyed are unable to see their patients without any fear of violence and 57.7% have thought of hiring security in their premises. Speaking about the survey, Padma Shri Awardee Dr K K Aggarwal, National President Indian Medical Association (IMA) and President Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement, said, "The medical profession is undergoing some of the toughest times today with its nobility and integrity at stake. Today medicine is just another profession, and doctors have become like everybody else: insecure, discontented and anxious about the future. This survey was aimed at analysing how happy and satisfied doctors are with their profession. The results prove the fact that doctors are not very happy with what they are doing and a large part of it is due to lack of patient trust in them. The emotional, mental, and physical attacks on doctors are at an all-time high. More than half of the doctors surveyed indicate that they suffer from increasing anxiety. A sizeable chunk does not want their children or grandchildren to take up this profession. Most doctors are of the opinion that while they chose medicine because it was worthwhile and noble, the profession has been reduced to nothing but a charade today." It is pertinent to note that a large number of doctors suffer from blood pressure and diabetes. Another notable factor is that about 76.3% also get anxiety quite often. As per a nationwide study conducted by IMA earlier, doctors face maximum violence while providing emergency services, with as many as 48.8% of such incidents reported from intensive care units (ICUs) or after a patient undergoes surgery. The main reason reported behind such violence is unnecessary investigations or delay in attending to a patient. Adding further, Dr Aggarwal, said, "On this Doctor's Day, it is important to make people aware that this growing discontent and anxiety among doctors can have serious consequences for patients. Unhappy doctors will make for unhappy patients. The fear of lawsuits; runaway malpractice liability premiums; and last but not the least, loss of professional autonomy has led to many physicians looking at themselves as mere pawns. This survey is a definite proof of that." The 'Doctor–Patient' relationship is a sacred one and this survey points to the fact that the dignity of the profession should be maintained. Doctors are also human beings and not healing angels. Victimizing the medical practitioner if the patient does not respond to treatment is unacceptable as are other atrocities against doctors. Another study conducted by the Indian Medical Association (IMA) highlighted the significance of soft skills for doctors. The survey showed that patients expect their doctors to be courteous; almost 90% of patients wanted their doctors to introduce themselves to patients, acknowledge the patient, give every patient a patient listening, impart complete information about the diagnosis, investigations, and treatment and revise and review what the patient has understood. About 40% of the patients said that the doctor should also thank them for giving an opportunity to treat. So, stay ALERT: Acknowledge and Ask, Listen, Explain, Revise and Review, and say Thank you to the patient.

Straight from the heart - Enough is Enough: ‘Chalo Dilli’ on 6th June

Straight from the heart Enough is Enough: ‘Chalo Dilli’ on 6th June Dr KK Aggarwal National President IMA Dear Colleague The Indian Medical Association (IMA) has declared “Chalo Dilli” movement on 6th of June to bring to the attention of the nation that the medical profession is being strangulated from all directions. Justice has been denied to doctors even within the frame work of the constitution of India. • Why is everybody silently watching violence against doctors? We become doctors to serve and not to harm the community. We are not against accountability but no one can be allowed to take law in their hands. Violence against healthcare professionals is occurring with growing frequency in India and there is often an attempt to soften the outcry by blaming the medical professionals being the cause of provocation. While every hospital and healthcare facility should identify high-risk violence prone areas in their establishment to be manned by adequate number of doctors, CCTV cameras and adequate security, all healthcare providers, who are victims of violence, must be adequately compensated. A well-structured and effective Grievances Redressal mechanism at each clinical establishment should be established (both for patients or their relatives and for the healthcare providers), timely and transparent root cause analysis of every case of violence should be done and entered in a centralized IMA registry. It’s our luck that Hon’ble acting Chief Justice of Delhi Smt Geeta Mittal and Hon’ble Justice Anu Malhotra in a suo moto order dated 3.05.2017 have made IMA as a party in the case. Directly or through the court, we want the Ministry of Health and Family Welfare, Government of India to urgently and promptly implement MCI suggested amendments of making soft skill communications compulsory for UG and PG curriculum. Also based on the inter-ministerial committee recommendations, the Central Government should enact a central act against violence at the earliest on the lines of one enacted in 19 states and make the violence against doctors as non bailable offense punishable with up to 14 years imprisonment on the lines of abatement of a murder because violence against doctor can end up with death of other unattended patients. • How come we are suddenly being tried as criminals? Of late, medical professionals are being tried under criminal law for medical negligence. In order to establish criminal liability, it is important to ascertain whether intent to harm (mens rea) was present or not. But in criminal negligence cases, intent to harm has been replaced by gross negligence. Gross negligence itself is not defined in IPC. Moreover, criminal law punishes only affirmative harm but in medical negligence failure to act in a prudent manner also is a crime. It should not be forgotten that medicine, especially emergency medicine, is inherently risky. Adverse outcomes or mistakes do not necessarily mean that care was negligent or that health care providers are criminally at fault. The sections of IPC 304 A (death due to negligence), 336 (act endangering life or personal safety of others), 337 (causing hurt by act of endangering life), 338 (causing grievous hurt by act of endangering life) are being frequently applied against medical practitioners. Moreover, sections of MTP Act, PCPNDT Act, POCSO Act, HIV-AIDS Act, West Bengal Clinical Establishment Regulatory Commission Act etc. are also being applied against medical practitioners for technical reasons and medical professionals are prosecuted. To treat a patient, the medical professionals often have to take calculated risks and take decisions. If they fail to do so it may further complicate the situation. So it becomes difficult to define gross negligence. Besides, one has to consider Section 88 of IPC, which saves medical professionals from criminal liability when the act is done in good faith. Hence, Section 304 A and similar sections of IPC should only be considered along with Section 88. Yet with every passing day, doctors are being prosecuted under 304 A when there is no mens rhea between the doctor and the patient. Under the new acts including the PCPNDT Act, even clerical errors are being linked to penal provisions. In West Bengal Clinical Establishment Regulatory Commission Act, the word used is ‘shall’ for imprisonment of up to three years for any violation of the act. We want de-criminalization of clinical practice. • Why are the limitations of the government being faced by the doctors? It is the constitutional duty of the governmental to provide free drugs and investigations for primary care and emergent care. The very fact that 80% of health care services are handled by private sector means either the services of the government are not up to the mark or they do not have enough infrastructure. The private sector is doing the job of the government. Then why so many exams for the medical students, so many registrations for opening a new medical establishment and so many windows for accountability? Why can’t we have single window registration and single window accountability? • When it is the government who has allowed the same company to manufacture generic-generic, trade generic and branded generic medicines at differential prices, then why punish and defame the doctors? Why take away the prescription rights of doctors and give it to un-qualified chemists. Why is the government allowing pharmacies to be run by outsourced non-professional chemists? It’s not the doctor’s job to search for the cheapest brands. It’s like government saying that we will allow drugs to be sold at variable prices but you should not write the costlier ones. In other words, we will give licenses to five-star restaurants but no one is allowed to go there. The right to choose the brand or the company name is with the doctor who owns the legal responsibility of the case. If the brand is chosen by the chemist, who will be responsible if the patient dies during treatment. • Why do we need a government? Why not a Supreme Court Monitoring Committee or twenty nominated members to run the government? If not then why attempts for an autocratic, bureaucratic, undemocratic, non-representative, 20-member nominated body including 8 non-medical persons to oversee medical education, ethics and practice by abolishing a democratically elected federally represented 168 members Medical Council of India (MCI). If you feel the IMA Act needs amendments, go for that. • The country is already short of doctors then why an MBBS graduate who has gone through 36 examinations in 3 dimensions to get his degree is being asked to sit for another 3 hour MCQ paper to obtain his license under NEXT. • By promoting AYUSH to practice modern medicine are we not finishing the very existence of AYUSH in the country? Scheduled drugs should only be allowed to be written by MBBS or BDS doctors. • The floodgates of modern medicine practice are being thrown open to quacks and no action is taken. No unqualified person should be allowed to prefix doctor in front of their name. • When medical profession is considered noble and doctors provide subsidy in the consultation to all patients then why compensation is awarded in crores basing it on the patient’s income? And why another act to compensate in West Bengal Clinical Establishment Regulatory commission? • Why are professional decisions taken without taking the medical profession into confidence? Why can’t IMA be in every policy making committee of the government. There is no end to the injustice heaped on the medical profession. Every doctor in India should participate in the “pen down strike” on 06.06.2017 while “IMA Satyagraha is walk in protest”. All Medical Colleges in the country SHOULD remain shut as well on 06.06.2017. Let us not compromise on our demands • Central Act against violence • Stop NMC and Amend IMA Act • No to NEXT • Decriminalization of medical practice and clerical errors • Modern medicines to be prescribed only by MBBS or BDS doctors. • Professional autonomy in prescriptions. • Immediate implementation of the inter-ministerial committee recommendations. • Amendments in Clinical Establishment (Registration and Regulation) Act 2010 and West Bengal Clinical Establishment (Registration, Regulation and Transparency) Act 2017. • No unqualified person should be allowed to prefix ‘Doctor” before their name. • No chemist should be allowed to sell or run a pharmacy without a degree in pharmacy.

80% doctors concerned about violence at work: IMA Survey

80% doctors concerned about violence at work: IMA Survey A survey conducted by IMA for consultant specialist doctors has revealed the frightening epidemic of violence against doctors. New Delhi, Jan 09, 2017: IMA is committed to promoting and providing a secure environment to healthcare professionals to practice their work. In this regard, a survey was conducted documenting the concerns of consultant specialist doctors regarding increasing incidences of violence and aggressive behaviour aimed at them. One of the most staggering results of the survey suggests that about 80% of doctors have had to face some degree of violence or aggression from patients and their relatives. Padma Shri Awardee Dr K.K Aggarwal - National President Indian Medical Association (IMA) & Heart Care Foundation of India (HCFI) and Dr RN Tandon – Honorary Secretary General IMA in a joint statement said, “Maximum violent outbursts were faced by doctors working in emergency care. According to 90% of the doctors surveyed, patient’s relatives often subject doctors to unruly behaviour, verbal abuse and physical assault post surgery”. Some other significant findings of the survey were: • 83% of the doctors said that their patients get upset if the doctors are late in their appointments. • 30% of the patient’s relatives do not stand up when the doctors enter in patient’s room. • 17% of the consultants felt that fee splitting is unethical. “One other problem in this context is under-reporting of such incidences by doctors. While doctors may feel confident in voicing their concerns under the veil of an anonymous survey but when it come to routine practice, they are often reluctant to report such behaviour either out of fear or due to regard to patient’s distress and well-being, which they consider of supreme concern. Most of the reported cases were when the issue had gone out of hand, and the doctors feel that their own or family’s life is under threat”, added Dr Aggarwal. The rising incidences of such cases highlight the urgent need of boosting security measures at hospital premises. Strengthening doctor- patient relationships to ensure accountability and openness is also likely to play a key role in reducing violence and diffusing tense situations often encountered in the medical setting.