The NITI Aayog’s healthcare plan should not end up emulating America’s supermarket system
One repressed, inconspicuous theme can be discerned across the timeline of development of healthcare in the United States since the early 20th century. As the Mayo brothers’ initially modest set-up (Mayo Clinic) prolifically expanded into the prototypical ‘multispecialty group practice’ in the U.S., concerns that such arrangements would be bereft of the personal touch in patient care were vociferously raised.
This continued through the evolution of more and more organised structures like Health Maintenance Organisations (HMOs) in the forthcoming years, which were criticised for turning healthcare into a marketable commodity sold by unfeeling healthcare providers in supermarket-like institutions, destitute of traits like empathy, regard and loyalty. That such concerns didn’t pick up systemic momentum in the U.S. is axiomatic, as much as the fact that U.S. healthcare ended up as one of the most impersonal healthcare systems.
The NITI Aayog’s proposed 15-year plan for Indian healthcare entitled “Health Systems for a New India: Building Blocks — Potential Pathways to Reform” outlines prospects of such an infelicitous turn in Indian healthcare. While the report makes otherwise commendable proposals for health system strengthening — including elimination of informality, merging of fragmented risk pools, and reduction of out-of-pocket health spending — the proposal to consolidate small practices into larger business-like organisations appears problematic on multiple fronts.
That nearly 98% of healthcare providers have less than 10 employees is identified as a negative trait, to be dealt with through a set of incentives and disincentives favouring consolidation. Apart from cost and competition-related concerns, an enthusiastic pursuit of it could portend an exacerbated commodification of healthcare from the bottom-up. The report’s bent towards the U.S. HMO model further adds to such a foreboding.
Loyalty and longitudinality form vital pillars of the patient-physician relationship. The edifice of these is built upon a substratum of mutual trust, warmth, and understanding that accrues over time between a patient and their personal physician. Momentary and haphazardly physician-patient interactions in a system that limits access to one’s ‘physician of choice’ are incapable of fostering such enduring relationships. It is in this context that the role of a family physician becomes instrumental. Apart from providing comprehensive care and coordinating referrals, a family physician’s longitudinal relationship with their patient helps in a better understanding of the patient’s needs and expectations and in avoiding unnecessary clinical hassles and encounters — which in turn reflects in better outcomes and increased patient satisfaction.
Widespread commercialisation of care over the past few decades has entailed that the family physician is a dying breed in India today. And it would be of little surprise to learn that this has a sizeable role in impairing the doctor-patient relationship, manifesting popularly through violence against healthcare providers. In a setting of overcrowded public hospitals, and profiteering healthcare enterprises, where the patient-physician interaction is largely fleeting and transactional, mistrust in the healthcare provider and its gruesome implications are not difficult to anticipate.
Advantage of small clinics
Studies have demonstrated that healthcare received in small clinics indeed scores higher in terms of patient satisfaction than that received in larger institutions. This increased satisfaction manifests as better compliance with the treatment regimen and regular follow-ups, culminating in improved clinical outcomes. Kelley JM et al, in a systematic review and meta-analysis of randomised controlled trials, have established that patient-clinician relationship has a statistically significant effect on healthcare outcomes. Indeed, disregard for this aspect in health services design is bound to entail a sizeable cost to the health system.
However, the subtle, fuzzy, and perceived non-urgent nature of this problem keeps it from assuming significance to policy- makers — as a result of which doctor-patient relationship considerations are largely invisibilised in the policy discourse in favour of more pressing concerns like lack of funds and manpower. Time and again, however, this omission has surfaced in the performance of health systems worldwide. As India looks forward to a long-term healthcare plan, neglecting this consideration could be of sizeable consequence.
The need for empathy
A popular myth often floated is that considerations regarding emotive aspects of healthcare such as empathy and trust are disparate from, and thus cannot be realistically factored into, hard-headed health policy and system design considerations. But, in reality, these are entirely amenable to cultivation through careful, evidence-based manipulation of the health system design and its components. It would necessitate, among other measures, installing an inbuilt family physician ‘gatekeeper’ in the health services system who acts as the first port of call for every registered patient. The NITI Aayog’s long-term plan provides a good opportunity to envisage such long-called-for reforms, but that would require not the U.S. model but the U.K. model to be kept at the forefront for emulation. We have already taken a minor, yet encouraging, step of sorts by introducing Attitude, Ethics, and Communication (AETCOM) in the revised undergraduate medical curriculum.
One hopes that the pronouncement of this long-term healthcare plan doesn’t indicate adoption of U.S.-like healthcare policies. The plan needs to be revisited to ensure that healthcare clinics delivering patient care don’t transform into veritable supermarket stores marketing medical services any further.
Dr. Soham D. Bhaduri is a Mumbai-based doctor, healthcare commentator, and editor of the journal ‘The Indian Practitioner’