Most package rates at hospitals cover only regular procedures with no scope to accommodate complications or other differences in the physical response of individual patients to treatment. Some patients have a slower rate of recovery and need an extra day in the hospital after surgery. In other cases, the patient’s pre-operative test may throw up a surprise that needs an extra couple of days before the operation can be done. Those extra days and any additional procedures or treatments that may be needed are then charged separately. Often, patients with pre-existing medical conditions, which may increase the odds of a lengthier recovery period, are immediately declared ineligible for a package.
A senior cardiac surgeon at a posh private hospital in Delhi admits that treatment packages work only for certain patients because they are designed to offer only the minimum level of care and hospitalisation. For example, a package for a coronary artery bypass graft (CABG) – commonly known as a “bypass surgery” – includes six days of hospitalisation, post-surgery monitoring and stepdown care. But if the patient suffers blood loss during the surgery and needs a transfusion or a sudden drop in his platelet count necessitates a haematologist consultation, neither would be covered by the package. Some of the common complications of CABG such as limb weakness, vision problems or speech difficulty, need a referral to a neurologist. But neither the consultation nor the subsequent management is covered by the package even though a significant number of patients need them.
“In each of these instances, there will be additional billing for doctor consultations, interventions and medications,” the cardiac surgeon elaborates. “This is never explicitly explained to the patient at the time of admission. Only the risks of the operation are outlined, but the possible cost implications are not. No matter the branch of medicine, in almost every hospital package there are numerous such grey areas that are never disclosed beforehand.”
There is little oversight over how patients are being billed. Sometimes, doctors add packages that may not be in their domain of expertise at all – for example, a surgeon adding a clinical care package to their bill. While such interventions may occasionally be necessary, repeated inclusion of such unusual packages in a doctor’s billing should be treated as a red flag, because every such package includes a fixed fee for the doctor. But the internal audit mechanisms that can catch such transgressions barely exist; where they do, they are not looking for overbilling-related issues. For a patient with no knowledge of medicine or the ways of corporate hospitals, it is impossible to keep track of all the tests done during hospitalisation or scrutinise the final bill to check if any extra items have been added. Medical jargon can also be intimidating – few patients can distinguish between a test for C-reactive protein (CRP) which is a marker for inflammation and Complete Blood Count (CBC) which takes stock of the numbers of various blood cells to assess whether there is inflammation or infection. That is why even the most diligent patients who are in the habit of checking invoices closely may not be able to easily spot discrepancies in a medical bill.
However, sometimes the extra item on the bill is so blatant that it stands out even to a layman. Nikhil Sen, a photographer, was one such patient. He had been admitted to a prominent private hospital in East Delhi with acute pancreatitis. Discharged after three days, he found that along with all the other charges, he had also been billed for a urine test. “Even in my dazed, tired state I knew that at no point in time had I given a urine sample,” claims Nikhil. “The nurses had drawn blood several times. There were several blood reports though I had no energy to match the reports against the tests mentioned on the bill, but they could not have done a urine test because they never had a sample.”
When he flagged the issue, a manager told him that the test was essential, and if it hadn’t been done, he could give a sample right there and the test would be done. “But why should I do a test that is not needed for my treatment? Just because the insurance will pay for it? I refused,” Nikhil says. The manager too stuck to his guns, but after a few calls to the public relations department of the hospital, the charge for the urine test was reversed. Nikhil was lucky because the discrepancy between samples collected and tests billed was immediately obvious. Since his hospital stay was short, the bill was also only a few pages that could be easily checked. But after a long hospitalisation, a hospital invoice can run to several pages. In those cases, last-minute additions to the bill are difficult to verify.
Imagine a situation where a patient was admitted in an emergency and has undergone an angioplasty. An angioplasty is a minimally invasive procedure in which blockages in blood vessels are removed. This is done with a balloon that pushes the offending clot out or by using a stent. A stent is a tiny mesh tube inserted into a weak vessel to make it more resilient. The cost of an angioplasty package changes depending on the type and the number of stents used for the procedure. A patient has no option but to take the doctor’s word on the type and number of stents used. That was the experience of a senior government officer when a family member was taken ill. “It was a Saturday, and I was home in Gandhinagar when my father complained of heartburn. We rushed him to the family physician’s clinic. He did an ECG and asked us to immediately take him to the hospital. When we reached there we were told that he would have to be taken for an emergency angioplasty.”
The doctor also told the family that there are many varieties of stents, some manufactured indigenously and some imported. A German import was advised as the best option in his case. “At that point, we were scared and confused. What did we know or understand about these things? We just said that we want the very best for him. They inserted three stents that day and one more the next day,” the officer recalls. This was before stents had been brought under price control, so the family ended up paying a few lakh rupees out of pocket despite having some government insurance coverage. Years later, when the old gentleman suffered heart failure and was taken to AIIMS in Delhi, the family learned that inserting four stents at one time was “very unusual”. Despite this, when he returned to the hospital in his hometown following the AIIMS stint, another three stents were put in.
It is common practice for hospitals to push for an “emergency” angioplasty after a routine or elective angiogram – an imaging technique that is used to check the health of blood vessels. This is never warranted, according to top cardiac specialists. In some situations, doctors advocate stent use in patients with 50% or 60% blockage, even though it is not advisable for those with less than 90% blockage. Unnecessary angioplasties can lead to complications such as restenosis, in which a thinned blood vessel that has been fixed narrows once again and causes an impediment to the smooth flow of blood. The patient also runs the risk of excessive bleeding even from small injuries because of the blood thinners that they must take for life.
Overuse of stents is one of the better-documented examples of overtreatment in India. Studies have indicated that stenting is only as effective as medical therapy and sometimes less so. In one review that was published in JAMA Internal Medicine in 2012, the researchers concluded that initial stenting for stable coronary artery disease shows no apparent benefit compared with early administration of drugs for prevention of death or complications such as myocardial infarction, or angina. CAD refers to coronary artery disease. The coronary artery is the blood vessel that supplies the heart muscle with blood. Any blockage in it can affect the efficiency of the heart’s pumping action. MI or myocardial infarction refers to what we commonly refer to as heart attack. Angina is the pain that is associated with constricted blood supply to the heart muscle. There are many such studies published in globally reputed journals, yet Indian surgeons’ preference for stents continues. In 2017, some of the biggest names in the field came out and said that one in every three stents implanted in Indian patients were probably not necessary.
Patients are easily swayed by doctors’ recommendations, so they might choose a more expensive option even if they can’t afford it, only because the doctor says it is “better” for them. That is how information bias directs choices. Lawyer Ashok Aggarwal’s work in helping poor patients access private healthcare, which they are entitled to under various agreements between Delhi government and private hospitals, has been mentioned earlier in this book. He tells me about the travails of one of his clients, who had been admitted with heart blockage under the non-paying patients’ quota at a big private hospital. The doctor told him that since he was a non-paying patient, he would only get the stent costing Rs 30,000 and not the medically appropriate stent costing Rs 1.5 lakh unless he was willing to pay the balance out of pocket. The patient was in a bind, because he did not want to compromise on his treatment but could not afford the expensive option either. This is the kind of Hobson’s Choice that patients are frequently required to negotiate when they access private healthcare.
This incident was from the time when drug-eluting stents (DES) were popular and prices had gone through the roof because there was no regulation. It was common to find stents priced at a few lakh rupees each and there were recurrent complaints of overtreatment and overcharging. It forced the National Pharmaceutical Pricing Authority (NPPA) to step in with price regulations. Now, despite criticism and opposition from the industry, the price of stents is controlled using the same formula that is applied to essential medicines. The latest revision in May 2024 fixed the price of bare metal stents at Rs 10,509 per unit and DES at Rs 38,267 per unit.
Excerpted with permission from Games Hospitals Play: Decoding Your Private Healthcare Experience, Abantika Ghosh, Bloomsbury India.
