The generations who were born before 80’s retain a nostalgic memory of their childhood illness. There was this friendly neighborhood doctor- elderly, respectable, kind, soft-spoken, witty, smart. One can walk to his clinic round the corner, to join a long line of people. The parents would patiently wait for their turn, chatting with neighbors about symptoms and schools, and observed a busy ‘compounder’ who dispensed medicine bottles of dark colored bitter medicine according to doctor’s note. As a child, you were terrified to go in to get injection. You often did not notice actual injection, as the pain is drowned in your cry of fear and doctor’s witty remarks. You would suddenly start feeling great as you come out and pick up your bitter dark medicine. Overall, most of the time, one got better and cured after the doctor visit. The fee– paid in cash to the doctor- was a comfortably small fraction of one’s salary. Our vocabulary of ‘treatment’- (there was no such a word as- ‘healthcare’) is about 10 words, and involved less than 5 people- doctor, patient, compounder, nurse, dispensary, hospital, operation, medicine, illness, wellness.

No More. Our world has changed. There is now ‘healthcare’. There are many more diseases, many more types of treatments, much more varieties of medicines, many more hospitals, specialties, insurance, cards, paramedical professionals, insurance, laboratories, and there is google!

So here is the rundown on the hidden costs of health care.

The Doctor

The doctor indeed remains a favorite whipping boy (easy target) for all our misgivings about health care. The society expects and almost takes it for granted certain virtues of the doctor- brilliance, dedication, benevolence, compassion, hard work, selfless sense of duty, sacrifice (of personal time, health), honesty etc. The list is long. (It is a different matter that no such attributes are expected from any other profession.) It is not wrong to expect this, but the hard fact is, when students are selected for medical education, none of these attributes are tested, neither they are taught as part of the curriculum. The opportunity of medical education today is almost entirely based on parents’ paying capacity. When one pays millions, and spends more than 10 active years of prime of their youth in working 12 hours a day, how logical of society to expect this person to work exercising all those noble virtues, and not caring for money?

The Technology

In good old days, doctors’ years of experience and skills compensated for lack of technology. In the last three decades, advances in medical technology- laboratory, imaging, surgical equipment- have greatly aided treatment and reduced morbidity and mortality. A simple surgery today uses at least 10 different equipment, the cost of which is not always passed on to the patient. Many services like MRI scan, surgical microscope etc- can be made available only through donated equipment, as consumer cannot bear the cost. But the institution has to bear the cost of maintenance of the equipment, man power, technical support staff and their training.

Paramedical Support

This includes nurses, physical therapists, occupational therapists, cognitive and speech therapists, psychologists, dieticians and others, who have very important role to play and impact overall health care. Their contribution is often undervalued by the patients and the institution.

The Hospital

Anybody who had a pleasant experience of visit to the hospital, must have enjoyed the cool air-conditioned lobby, HD TV, clean corridors with sparkling floors, elevators, pleasant, respectful (non-medical) support staff, glossy brochures, plush carpeted visiting rooms with modern furniture. None of this has anything to do with the medical treatment. But we will rather go to such a place than the one without. As a consumer we don’t get a bill of this ‘pleasant experience’. But it has its cost that percolates in the overall cost. Most of the best hospitals in India are for-profit organizations, which are answerable to their investors.

Medicines

This is one aspect of health care that has remained so far rationally priced, thanks to the prudence of successive governments of India. However, the distribution and utilization is skewed and is far from ideal. Incorporation of control and rational use, would likely to add cost to the system.

The cost of administration, insurance and verifications

Contrast this with the nostalgic experience described above. The doctor as a sole owner of his enterprise- two or three rooms of his clinic to maintain, only one or two people to supervise and he accepts cash payment directly. Escalation of size of the enterprise brings in many facets, many more people- more people means more interactions, more nodes to supervise, more weak links prone to mistakes and errors. As health care delivery gets complex – there is high cost to administering this complexity. Coupling insurance industry with health care industry exponentially increases the complexity and costs. This is because now the health care delivery needs (proverbial) verification in triplicate! Also with a rise of a ‘litigant consumer’ in India, there is additional cost of risk management.

I believe that, healthcare in India today gives a bang for the buck- best value for the money spent. It is largely undervalued. It is equally true that the market is not ready to bear the real value of healthcare it receives. The misgivings of the consumer partly lie in the mismatch between expectations and reality. But it also lies in failure on part of medical community in delivering quality and in continuous pursuit of excellence and value addition (such as documentation, building patient rapport etc.) and also to certain dishonest practices of some members of medical community. To say that all fault lies with greedy doctors is to run away from real problems. We need systematic solutions to improve the system of health care delivery. There is a big role of the Government and Insurance industry to play to make sure that good health care remains affordable in India.

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