"Healthcare is broken and needs to be fixed”
This has been the rallying cry in all parts of the world before we were all thrown into a pandemic. It was heard in countries that had nationalized healthcare and private healthcare or a mix of both.
The pandemic has reinforced that belief even more since no country was really prepared for what happened when COVID-19 hit. Of course, some countries dealt with it better than others. However, that is a discussion for another time. Instead, let us focus on why everyone felt healthcare was broken, to begin with, and how we can use this pandemic as an opportunity to slam hard on the reset button and restart healthcare in a meaningful, safe and fiscally responsible manner in India.
In the last 54 days of the lockdown (till 17th May), we have seen that outpatient visits have dropped significantly, emergency departments have been empty, elective surgeries have not been done, laboratory tests have decreased and purchase of medications have come down. In spite of all this, the number of deaths has decreased by 30 percent compared to the same time last year. Some of this could be related to the fact that road traffic accidents had decreased due to the lack of vehicular traffic. However, this does not explain the decrease in deaths from strokes, heart attacks, pneumonia and other common illnesses that used to fill up our intensive care units and are some of the most common causes of deaths. This is definitely a cause to stop and think why this is so and what can we do once we learn to live with the COVID menace.
Current Practices & changes required
Outpatient care
In India, here is an underlying need for fixing the ailing healthcare system by providing comprehensive insurance including outpatient insurance i.e. any medical treatment that does not require hospitalization or an overnight stay at a medical facility of any sort. This will help in improving healthcare indices and decreasing the cost of healthcare in India. The only reason not to see a doctor is financial or the problem gets better before the doctor visit. All of us who have been practising know that most of these visits are more for reassurance and medication adjustments can be done remotely.
What the pandemic has shown us is that at least 30-40 percent of doctor visits can be replaced by video consultation and this is now an accepted as the 'new normal' by patients and doctors. Video consultations will lead to greater access to appropriate, accountable and much more affordable outpatient care for patients and will decrease the cost of providing care for the doctors and hospitals by reducing the cost of infrastructure and manpower. This should be the rule rather than the exception going forward. These consultations should be augmented with home delivery of medications, lab sample collection, point of care testing and home therapy.
It is also well known that many of the tests done and medications prescribed are not necessary or inappropriate during outpatient visits. It has been noticed that with video consultations the number of lab tests done have come down and so have prescriptions for antibiotics in particular and medications in general.
Inpatient care
Indian inpatient care has been more regulated than outpatient care due to the various insurance policies and schemes. In spite of this, there is very little standardization of care. COVID-19 has taught us that protocols are useful and are required to ensure that all patients get the same treatments that are considered safe and effective by professional bodies. We should do the same for non-COVID admissions as well. If most of the patients got similar care we will be able to standardize the cost of care for most of the common inpatient admissions.
We should also ensure that we make every effort to decrease the length of stays for inpatient admissions to what is actually required. The longer anyone stays in the hospital the worse it is for the patients medically and financially. Going forward we should definitely try to decrease any extra hospital exposure to COVID for our patients by decreasing their average length of stay (ALOS). The patients who are discharged early can be taken care of with video consults, remote monitoring using the technology available and provision of home care if required. The insurance companies should incentivize early discharges and pay for post-discharge care for at least for a few days as they will be saving money as home care will be significantly less than inpatient hospital care. Early discharges will help hospitals and well as they can turn around beds for more patients faster and hence can have hospitals with fewer beds, thereby decreasing their capital expenditure without decreasing their capacity to accept more patients.
Intensive care
This is the most important care that a patient receives in a hospital as it is mostly lifesaving care. However, for the same reason, there is not much oversight as to how many invasive procedures and invasive monitoring methods are performed and if accepted protocols are used in a given patient. The pandemic has taught us that even in ICUs the appropriate protocols can be used successfully across countries. We should look at using digital clinical decision support systems in the ICUs to prompt doctors to use the right protocols and procedures for all non-COVID patients as well. This will help hospitals standardize treatment and costs for ICU care. This will help us calculate the exact cost that is required for most of the common ICU admissions. This will help the insurance companies and the government to set premiums and reimbursement that are realistic and affordable for patients and fair to the hospitals.
We have also learnt that low-cost equipment can be manufactured and used during a pandemic. We should ensure that equipment like low-cost respirators that don’t have the bells and whistles are allowed to be used at least in low resource settings and help save lives from non-COVID diseases as well. The pandemic has also highlighted the severe shortage of intensive care specialists like never before. The solution for this should be the widespread adoption of tele-ICU, a technology that has been tried and tested and available in India for quite a while now.
Finally, to reset and restart the healthcare system in India post COVID we will need help from stakeholders like the government and insurance companies to help the care providers adapt to the 'new normal'. The government will need to expand and clarify the telemedicine guidelines, the doctors and hospitals should be protected from medicolegal issues if they have followed the accepted protocols and guidelines. There should be clear guidelines regarding low-cost equipment, home monitoring and home healthcare. The insurance companies should be encouraged and helped to provide outpatient insurance and immediate post-discharge insurance for all the above-mentioned strategies to work.
It is quite obvious from the above discussions that there are many lessons that we can learn from the COVID pandemic. This crisis is a perfect opportunity for us to practice carpe diem. But will we?
The author is a Pediatrician working in Bangalore.
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