I recently spent nearly three months in India -- traveling, meeting people and examining the vast changes that have altered the landscape that was India.
It was after nearly thirty-five years that I stayed more than two weeks in India, and I had the opportunity to view the many changes that had occurred, not through the eyes of a 'tourist', but through the eyes of an experienced healthcare executive who felt and saw the tremendous accomplishments that have been made.
The Metro commuter rail system, the eight-lane divided highway from the airport to the city of New Delhi, the construction of numerous flyovers to facilitate traffic, the evolution of high-rise buildings, call centres and shopping malls in Gurgaon, the emergence of Noida as an extension of the capital, and the presence of technology centres in Bangalore -- all signs of a robust and thriving economy.
What was striking is the frenzy with which hospitals are being built, ostensibly to meet the demands of an expanding middle class population that now can afford the best in healthcare.
Not a day goes by that a new healthcare venture is not announced, either in partnership with a foreign company or by an all Indian business house.
But behind all this glitter there are some ominous signs of the ills that pervade the health care system. A coherent and sustainable plan that addresses the healthcare needs of the masses is strikingly absent. There are no national standards by which physicians, nurses, pharmacists and hospitals are trained.
Financial incentives between specialists and hospitals from referring doctors govern the way a substantial proportion of patients are treated. Guidelines and protocols for the management of disease, including the length of stay, are virtually non-existent and the ability of hospitals to determine the appropriateness of medical and surgical therapy seems years away.
Quality management remains an elusive dream; it is not sufficient to know the mortality rate of a surgical operation; one must know if the care was timely and appropriate. Judging from the incredible advances that have been made in information technology in India, it is noteworthy that these advances have not been applied on a large scale to healthcare.
The lack of an Electronic Health Record (EHR) prevents the development of transparency throughout the healthcare system. And compounding all this is the widespread use of spurious drugs that interfere with proper treatment. Above all, there is not enough historical evidence of what it costs for the treatment of a particular condition for insurers to adequately set their premiums.
So what is the remedy for all that ails the healthcare system? A few suggestions are timely and should be considered:
1. Develop and implement national standards for examination by which doctors, nurses and pharmacists are able to practice and get employment.
2. Rapidly develop and implement national accreditation of hospitals; those that do not comply would not get paid by insurance companies. However, a performance incentive plan that targets specific treatment parameters would be a useful adjunct.
3. Obtain proposals from private insurance companies and the government on ways to provide medical insurance coverage to the population at large and execute the strategy. It is healthy to have competition in healthcare, and provide health insurance to the millions who cannot afford it.
4. Utilise and apply medical information systems that encourage the use of evidence-based medicine, guidelines and protocols as well as electronic prescribing in inpatient and outpatient settings. This is possible though the implementation of the EHR; this will, in time, encourage healthcare data collection, transparency, quality management, patient safety, efficiency, efficacy and appropriateness of care.
5. Perverse incentives between specialists, hospitals, imaging and diagnostic centres on the one hand and referring physicians on the other need be removed and a level of clarity needs to be introduced.
6. Develop multi-specialty group practices that have their incentives aligned with those of hospitals and payers. It is much easier to teach the techniques of sophisticated medical care to a group of employed physicians than it is to physicians as a whole. It is also important that doctors are paid adequately for what they do.
7. Encourage business schools to develop executive training programmes in healthcare, which will effectively reduce the talent gap for leadership in this area.
8. Revise the curriculum in medical, nursing, pharmacy and other schools that train healthcare professionals, so that they too are trained in the new paradigm.
9. Develop partnerships between the public and private sectors that design newer ways to deliver healthcare. An example of this would include outpatient radiology and diagnostic testing centres.
10. The government should appoint a commission which makes recommendations for the healthcare system and monitors its performance.
The present system (and its escalating costs) is not sustainable due to its inefficiency and a lack of aligned incentives for improving performance. A country that has leapfrogged from rotary phones to a ubiquitous presence of mobile phones must make a similar change in healthcare.
It will not be easy and it will not be inexpensive. But it has been done in other parts of the world before and it can be done here too. The potential to create the best healthcare system in the world exists. It is time to commence the debate, develop a plan and execute it.
The author is the former President and Chief Executive Officer of Fallon Clinic, a 250-physician multi-specialty group practice in Worcester, Massachusetts, USA. He is now an independent consultant.
