MASQUERADER

Pack 'age' in a package

Anoop Kohli, 02 March 2010, 01:11 AM IST

The free market forces in this country just flattened out the tariffs. Healthcare is just about reaching your doorstep. It may drive reverse through the 'exit' gate and drive out from the 'entry'. Look at the flyers you keep getting every now and then. A basic ' cardiac package' that includes the relevant blood tests as cholesterol, sugar, urea, an ECG, treadmill, echocardiography and a cardiac consultation all for Rs. 1450 ( terms and conditions apply).

It is a very attractive flyer, good printing and paper. Only one thing amiss. The cardiologist consultation is mentioned as the last item. Shows that the idea came from a fertile, marketing mind. So what, under normal circumstances, the consultation alone would cost Rs 800, and treadmill, around the same. That means that the echo, ECG and crucial blood tests are for free. These are the wonders of competition and the health industry's efforts to make medical care affordable.

But how can they manage such massive discounts? There could be many answers. First, could it be that the actual costs of the tests, including treadmill, have a 100% plus margin, and the company is ready to underwrite such unusual profits in patient interest. Second, as the cardiologist consultation comes as the last item, and his decision making has been made so easy with the full panel of tests, he may also be forgoing his fees, or maybe since the decision is no longer that of experience, but can easily be handled by a software, any medical practitioner may do, as senior cardiologists may not oblige, and the cost has been written off? But what is the harm. After all, the tests were to be done anyway, and that alone is proof of the disease. If you had met a specialist, he would have charged his fees, and ordered the same tests, and that would have cost twice as much. Genius in accounting and management sprucing, has made a heaven of a difference in medical costs.

I would still be bothered as to why the specialist was the last in the menu of eight items. Setting aside the costs for a moment, the legitimate and scientific process demands that the specialist examine the case first, and then choose the investigations in order of priority. Fewer investigations may do for a particular case. For instance, in case of a healthy, and active patient, just the cardiogram, that too as a protocol compulsion may be enough. The blood tests are fine, but others like treadmill and echo may actually not be required. You may then end up paying the same amount, but two tests less. Is there still something wrong with the initial deal?

Actually, there is quite a bit. If you were to hit 500 blood tests in a camp at random, at low costs, even with strict specifications, there could be a 5% variation in collection of samples (as to being absolutely empty stomach, etc ), 2% or thereabouts as technical or such errors and 5% tests which are borderline. If these are then analysed retrospectively by a clinician, his own bias for safety may lead to an addition of 3%. You now arrive at a 15% figure of persons at risk. You may also like to consider the less strictly defined tests as the treadmill. There are non-specific changes that were not addressed by the specialist prospectively. A person may have a pre-existing condition that may give abnormal tolerance patterns. The positives coming from this may further add up, because, whenever a test is asked out of indication, and is even borderline abnormal, it becomes a recorded fact and legally can only be rectified by a repetition, or ruled out by a higher test, as angiography in this case.

The chances of a test being 'false positive', correlate inversely with the incidence of a disease. That's the Bayes' theorem for you. In simple terms, doing a single cardiac test in a population of 30-plus, which gives a 10% borderline or positive result (remember, borderline will be taken positive unless proved otherwise), is more erroneously inflated, than 10% positive result in a population of 50-plus, which, may in fact, turn out to be closer to the real figure.

The sequence of a consultation followed by what are relevant tests is still the only, as well as the best, method of assessing and treating disease. It also becomes the duty of the specialist to judge the results in the clinical context. Advice, including some crucial suggestions and preventive measures as weight reduction, exercise, smoking, food habits, is essential, before you may expect even half the benefit from a drug.

Let's sum up. The fixed protocol of all the tests being offered as a package at a lower price, may not be a financial benefit in particular, as quite a few who do not require the tests are paying for it, and have a chance of getting a positive verdict on a false premise, that may encourage repeat or higher tests. Crucial advice regarding disease management may lose priority, with no good done at all.

Should one go to such neighbourhood camps? Sure, if you have missed out on some medical care. See that you are examined by the consultant first. If that not be the case, take advantage of the low costs, but book a formal appointment with a specialist, so that you are put on the right track.

All medical establishments run on revenues. So do you. Now go for the crucial entity known as 'expert advice'. If that be foul too? That's where the competition actually begins. Ask and ensure answerability! But just wait a bit longer. If tomorrow, the tariffs drop to Rs 1100, chances are quite a few will consider that this advice was biased. The collective forces of matter have always ruled the mind. Such is the destiny of mankind!

As an intern, I heard this from a hapless patient,

"Humne socha thaa ki haakim se karenge fariyaad,
Par woh kambakht bhi uska chahanewala nikla"

(I thought I would complain to the chief,
But he too turned out to be her admirer)

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RakeshGoel says:

March 02,2010 at 04:24 PM IST

Dear Dr. Kohli
Realy we need specilist but only after forwarding by the generlist(M.B.B.S/ M.D)
Lick the cases refer to supreme court from high court.

N. D. Saha says:

March 02,2010 at 06:23 PM IST

The suggestions to consult a specialist before going for medical tests on economical consideration is obviously well intentioned and justifiable. But the problem is, experts now a days are extremely reluctant to think of symptomatic treatment and are generally prone to test based diagnosis.Because they have little time and patience to concentrate on patients problem, they are found more interested to give speedy disposal of cases on consideration of more income from larger number of consultation seekers.There might be a few exceptions but that are only to prove the practice.It is widely alleged that physicians in general barring a negligible few have an unholy nexus with the testing laboratories that acts as the prime motivation to advise pathological tests regardless of necessity. In other words prior consultation of experts bears greater risk of monetary loss and extra tension and stress causing harm to the patient.The physician's craze for more earning or his devotion to extend medical service to the patients,which of the two gets priority to them has become difficult to ascertain.

drnaidu says: Bookmark this discussion

March 02,2010 at 07:51 PM IST

health should be nationalised and no private sector.unnecessary tests and operations are done for the sake of money wither from insurance or from rich fellow,which always it is hyperdiagnosed.because of wrong policeis of BJP and LEFT and no opolcies of congress people are suffering

(Reply to drnaidu)- Anoop says:

March 03,2010 at 07:25 PM IST

Reply to all. We cannot deny that a person can get a test at much cheaper rates than before. Commercial packages as these may finally be a necessity of times, and maybe the tests get subsidized because many more are done to many, that the costs are bearable for the one who needs them. Economic forces are here to stay. We can lighten the burden by bringing larger urban-rural populations under the umbrella. Finally, the consumer can ask for a 'binding' opinion as correct as is possible. Appropriateness of tests also needs to be discussed. Specialists cannot wash their hands of their responsibility. Proffesional 'gatekeepers' both from the medical field as well from the financial arm of today's medicine should take up posts. Any entrepreneur, who wants to play a long innings shall see wisdom in covering a wider population at reasonable costs to keep his balance sheets intact. Than let the burden fall on just a few. We now need to spell out in as many words, a 'model' system of medical practice, whether that be public or private. These words and spellings shall come from the people, and the proffession and ministeries may just like to redefine their commitment to the population. Health, quite appropriately should become an agenda for the next election.

Anoop Kohli