S Sundar has worked as a duty doctor at a 50-bed private hospital in Chennai for three years. Friday was the first time that the 30-year-old had no patient to attend to during his entire shift of seven hours. “I spent the day watching the Innocence Project series on Netflix,” he said.

The hospital took the decision to house the staff on campus ever since the nationwide lockdown was announced on March 24. Sundar has been allotted one of the general ward rooms for his stay, eating his meals in the hospital canteen. “We had a meeting on March 25 when we collectively decided that 50% of us will stay in for a month,” he explained. Apart from the difficulties in organising transport between home and work under lockdown conditions, this was done to limit exposure to the novel coronavirus which has caused the worldwide Covid-19 outbreak.

But a month later, even the reduced staff does not have much work.

The government asked hospitals to stop outpatient departments and elective or non-emergency surgeries. As a result, private hospitals around India are reporting a sharp drop in footfall – as high as 70%-80%, according to a study released by the Federation of Indian Chambers of Commerce and Industry. Hospital owners say this has caused a financial squeeze which might affect their ability to pay their staff.

However, the drop in patient admissions isn’t simply linked to the lockdown.

Even though the Union Ministry of Health and Family Welfare laid down guidelines on March 26 asking all hospitals to create separate wards for the isolation and treatment of Covid-19 patients, few private hospitals have opted to offer such treatment. Most private hospitals say they do not have the required facilities.

With coronavirus infections spreading in hospitals through unknown carriers, some private hospitals have even gone to the extent of denying admission to all patients, except in a life or death situation. “If a [Covid-19] positive patient walks in, we have to quarantine the entire building,” said a hospital owner in Chennai.

The Bihar government has accused private hospitals in the state on Monday of completely withdrawing from the fight against Covid-19. After the state health secretary Sanjay Kumar wrote a series of tweets about this, a government advisory asked private hospitals to resume services immediately.

According to the Federation of Indian Chambers of Commerce and Industry, private hospitals and nursing homes have more than 60% of beds in India, treat 60% of in-patients and employ 80% of doctors.

With many private hospitals turning away patients, the few that are taking them in are witnessing a higher demand for beds, said doctors who work in the private sector. Many hospitals are insisting that patients get tested for Covid-19 at private labs even if they do not have symptoms. Even patients admitted for non-Covid-19 care are being billed the cost of personal protective equipment.

This has pushed up hospitalisation costs for patients – with their insurance cover getting exhausted quickly.

Silent spread in hospitals

On April 13, at least 39 medical staff, including doctors, were asked to go on quarantine at the Max Hospital in the Saket area in Delhi. The measure was taken after two patients admitted with cardiac illness tested positive for the novel coronavirus. “Thirty nine healthcare workers, who were contact traced, have been quarantined within a separate and isolated wing at Max Hospital, Saket,” the hospital management said in a statement.

But it is possible the virus was spreading in the hospital days before it was detected.

On April 8, a 50-year-old man who lives in Sector 93A in Noida, the city in Uttar Pradesh’s Gautam Buddha Nagar that abuts Delhi, tested positive for Covid-19. He did not have any international travel history. Until April 5, he had been confined to Max Hospital since his mother had been admitted there, said a member of the residents’ welfare association of the locality where the man lives.

Gautam Buddha Nagar health department officials who did not want to be identified told Scroll.in that they were aware of the patient’s visit to the hospital and that contact tracing for the patient was done. They, however, refused to reveal any more details about the case.

The family of the 50-year-old patient, including his mother, father, wife and child and domestic worker, have all tested positive for the virus, said the member of the residents’ welfare association.

When asked about this specific case, a spokesperson at Max Healthcare said that it was “impossible to trace a hospital attendant” at the facility.

“We cannot just search for the hospital attendant who has tested positive,” the spokesperson said. “The moment he would have tested positive, we would have informed the authorities and then what we do is internal.”

He said all 24,000 health workers across Max Healthcare facilities in Delhi as well as patients and new admissions are going to be screened for Covid-19. The hospital has also decided to suspend visiting hours and restrict attendants only for the elderly and children admitted at the facility.

But this was not a one-off case.

Around 30 healthcare workers at the Cardio-Neuro Centre in AIIMS Delhi were advised to undergo quarantine after a 72-year-old man who visited the hospital with neurological ailment tested positive for Covid-19.

On April 6, at least 90 healthcare workers in the DY Patil Hospital in Pune were asked to quarantine themselves after an accident victim who had come in for emergency later tested positive for Covid-19.

These instances have sparked widespread fear in private hospitals, with many stopping non-emergency care altogether.

Health department officials and doctors participate in a mock drill practice for Covid-19 in Allahabad on March 18, 2020. Photo: AFP

Turning patients away

In Chennai, most hospitals now screen any patient coming in at the entrance of the premises. “If it is not an emergency case, we refuse admission,” a hospital owner said requesting anonymity. If the patient shows symptoms of Covid-19 like fever and cough or respiratory strain, the hospital refers them either to a government hospital or to a designated private hospital as per the patient’s wish.

A senior doctor who visits hospitals in Chennai, Bengaluru and Hyderabad said non-Covid-19 admissions are restricted by many hospitals to patients who are regulars. Even this, the doctor said, is a “risk” that had to be taken to keep the hospital running. That is, some hospitals admit this minimum number of patients to ensure some amount of cash flow. “How else can they pay their staff?” he said.

Delhi government has warned hospitals against turning patients away. After reports emerged of hospitals insisting on patients getting tested for Covid-19 even if they did not have any symptoms of the disease, the government issued an advisory on April 15, asking hospitals to refrain from doing this. If a patient tests positive later, it said the ward and equipment in the hospital should be decontaminated and regular functions should carry on.

However, many hospitals say there are practical difficulties in implementing the government orders.

In Tamil Nadu last week, the government shut down at least five private hospitals not designated to treat Covid-19 patients after they handled fever patients who later tested positive for the novel coronavirus. One hospital told The Times of India that it was asked to shut down even though it had followed the protocol for handling fever patients, including entrance screening and personal protection equipment for medical staff.

“On the one hand, governments want us to treat patients,” said a hospital owner in Chennai. “On the other hand, hospitals are being asked to shut down for handling cases.”

Financial distress

On April 16, the Federation of Indian Chambers of Commerce and Industry released a study in which it said that Covid-19 pandemic has caused adverse impact on the private healthcare sector resulting in 70%-80% drop in footfalls and 50%-70% drop in revenue in the last ten days of March.

Dr Alok Roy, chairman of the Kolkata-based Medica Group of Hospitals, said that the financial distress accentuated by Covid-19 lockdown has forced several standalone and small nursing homes in tier II and III cities to shut down. “Many others are at high risk of closing down soon since their cash flows have dried up,” he added.

Hospital owners and doctors in several cities confirmed this trend.

A hospital staffer in Srinagar. Credit: Tauseef Mustafa

The cash crunch was so severe, said the owner of a private hospital chain in Pune who did not want to be identified, that many hospitals in the city have already cut salaries for their staff by 50%. “We are trying to negotiate with the landlords to reduce rent and cut any other fixed costs that we possibly could,” he said.

According to a senior cardiologist in Chennai, elective surgeries and referrals for testing from out-patient services constitute a major chunk of the revenue for any hospital. Both these avenues have now been shut, putting private hospitals in a serious financial distress.

He said the pandemic posed a higher risk for smaller hospitals. While large corporate hospitals with infrastructure had the capacity to take safety measures needed to treat patients, smaller hospitals and nursing homes, which constitute 80% of all private sector medical establishments, lacked the resources.

“What happens when patients cannot access smaller hospitals? They are forced to go to the bigger ones,” the doctor said. “The middle class has a peculiar problem in India. They don’t want to go to a government hospital even if the same facilities are available for free.”

The fear of overcrowding during the Covid-19 outbreak was further discouraging them from accessing public hospitals, he said.

Ballooning costs

The consequence is that prices have gone up in the few private hospitals that are treating patients. “Intensive care even for non-Covid-19 patients has become costlier as you are either asked to get the Covid-19 test to admit yourself or you are charged for the PPE kits that are necessary for the hospital which has Covid-19 patients,” said a Chennai-based hospital owner.

With revenue drying up because of reduced footfall, the owner of a private hospital chain in Pune said it would be impossible for smaller hospitals not to transfer the cost of the protective equipment to the patients. “Plus, given the scarcity of PPEs, we are paying a premium to acquire them from the market,” he said.

In some cases, he said PPEs were essential for the patient’s safety, even if they do not have Covid-19. For example, cancer patients who come in for chemotherapy already have compromised immunity. Many cancer patients are also senior citizens and are at high risk of the infection. “It is absolutely crucial that they do not contract the infection at the hospital,” the owner said.

However, this has resulted in problems for patients. A 65-year-old cancer patient in Chennai, who went in for post-surgery chemotherapy at a large corporate hospital, said the bill was almost Rs 6,000 more than last month’s session.

The patient also had a hard time with the health insurance company, which insisted on the hospital not including the PPE cost in the chemotherapy package. “It took three days of back and forth to process the claim,” the patient said.

In fact, doctors said that some hospitals seek an advance deposit for the PPE anticipating problems with insurance claims.

Hospital owners Scroll.in spoke to said if the same trends continued, many small and medium hospitals would be forced to retrench staff. This could have a serious impact on India’s response to the pandemic. At the moment, the government hospitals are able to handle the situation as the number of cases are not high enough to overrun them with Covid-19 patients.

But if the threshold is breached and the country witnesses overwhelming numbers, unprepared private hospitals could mean little or no capacity addition to the government hospitals. “Frankly, the government has not given much thought on the role of the private hospitals in this pandemic,” a hospital owner said.

Vijayta Lalwani contributed reporting from Delhi.