Rhetoric and Reality

(Note: This article got published in Republica with minor edits)

If a newly diagnosed diabetes patient came to see me at Patan Hospital’s general medicine clinic, I would perform several tests to ensure proper care. I would check hemoglobin A1c to assess her severity of diabetes, test her kidney function, evaluate if she is throwing out protein in urine, test if liver is functioning properly, and measure cholesterol levels in the blood. For this visit, she would pay NRS 25 for registration but about NRS 2310 for the basic minimal testing that she requires for appropriate diabetes care. After all this, she will have to go home with a bag of medications that comes with obvious cost. Patan Hospital might take a pride in saying that it charges a meager 25 rupees for a patient visit, but that is just a miniscule portion of the patient’s actual healthcare cost.

The point is, doctor’s fee is a rather small portion of a patient’s healthcare cost. Main drivers of cost are tests, medications and medical devices. It gets especially ugly if unnecessary tests are performed and medications prescribed. And it is no news that our healthcare providers are incentivized to do exactly that. We have heard of our doctors receiving “cuts” for sending lab tests, prescribing certain medications and even referring patients to certain institutions or providers.

So, if I were a deliberating patient, I would choose a doctor based on how unlikely she is to order unnecessary tests or medications while not missing what are absolutely essential. I would like her not to have incentives tied to prescriptions and lab orders. I would happily pay a much higher fee than NRS 25 if these were ensured, because that extra cost is just one unnecessary test away.

Lately, newspapers have reported that the Ministry of Health and Population (MoHP) is planning to cap and enforce doctor’s fee. Furthermore, Republica reports that even the prevailing fees are lower than the cap. Why is this non-issue taking a front row seat? One has to concede, the MoHP officials are either very disconnected from patients’ realities or they are plain and simple stupid.

Even this cursory exercise tells us, doctor’s fee is not the biggest determinant of a patient’s healthcare cost. Accordingly, there are multiple high-impact potential targets for cost control. We have to ask, how we can cut down the cost of lab and radiological testing. How we can reign in an unethical practice of ordering unnecessary tests and medications for financial incentives. How we can make equipment and medical devices more accessible and affordable. In addition, we need to ensure that the cost of medications is reasonable. While the remedies are not as obvious or simple, any genuine cost cutting effort cannot circumvent debating and deliberating these issues.

Furthermore, whatever is a patient’s financial means, what matters ultimately is the health outcome. We want to get better at any cost. We sell our cattle, our land, and our hard-earned savings to seek treatment. When we put so much trust in these medical interventions, what should matter most is that the healthcare system delivers to that trust. We are not just seeking a cheap treatment but also an effective treatment. Quality medical care is actually what we seek. Of course we would like to pay less for it.

Unfortunately, our public debate hardly acknowledges the intricacies of patients’ needs and the corresponding complexity of delivering to that demand. It is no surprise that rhetoric of  “free health care” is so rampant. Anyone pausing for a moment and thinking can realize that there can be no “free health care.” Delivering health care needs infrastructure, personnel, medications and equipment that come with a cost. The best we can do is pool our risks and minimize the cost for the victims of diseases and injuries. It would indeed serve us well if we root ourselves on practical realities than rhetoric. This proposal of capping a doctor’s fee is a rhetorical exercise disconnected from the real needs of our patients. It is far detached from the potential to bring down costs.

Finally, it is about time that we are done with doctor bashing. The reality is, after we pass past the dreamy aspirations of medical school, we doctors walk a blurred line amidst necessities, greed and professional obligations. Larger structural issues, checks and balances in the system largely determine how we behave in our daily practice. The society in general and government in particular has the responsibility to address these structural issues and ensure effective regulatory mechanism. Yes, some of us have crossed professional ethical boundaries and behaved poorly. Where are those regulatory processes? Where is our government to hold us in check at those instances? More importantly, we should not forget that numerous of our junior doctors work in the muggy air of crammed emergency rooms with air laden with tuberculosis, intensive care units with bare minimum support and protection, medical wards with surfaces laced with resistant bacteria and filth, deprived of sleep, and for exhaustive hours that is inconceivable in any other profession. They work at incredible personal risks. While their peers, who work in lucrative development jobs, writing reports and policies that never see the light of the day, come home with a six-figure salary, these doctors satisfy themselves with NRS 10,000 per month. Vilifying these doctors in the process of lumping doctors for rhetoric’s shake would be an utter injustice.

The problem at hand does not lend to a simplistic assessment and equally cavalier attitude of using the governmental power. People do have a choice in whether they want to see a doctor who charges NRS 1000. We don’t need our government to father us in making that choice. What we do want is help in ensuring that we are getting our money’s worth. That is and should be the purview of a democratic government. But it is also exactly where our government is utterly ineffective and our government officials have no wit, will or ability. For starters, our tax paid government officials would do much service in cutting cost if they even just focused on stocking low-priced quality medications, performing quality affordable lab tests, and consistent and reliable radiological tests at public institutions. Instead of coming up with these wacky ideas!