Irritating . . .

It was one of those very cold winter mornings. I slipped into the Acute Care Unit to find the previous night's Cesarian section patients doing quite well. The babies, cute and rosy, being sung lullabies to. The mothers blissfully proud of having delivered baby boys in deep sleep.

However, it was not difficult to diagnose the richer one of the two patients.

The lady on one bed was an epitome of affluence. Mink blankets . . . a separate mattress for the baby . . . brass spittoon . . .  a mini lakme make-up set on the bed-side table . . . a servant girl to hold the baby when the family is tired . .  . The male relatives were quite flashy . . . Ray-Ban glasses, leather jackets, one guy with a Nokia Xperia .. .. .. As I went about with the morning routine, I found out one of the relatives getting into a Scorpio. Sweets were distributed . . .

The other patient was a classic example of our average patient. Cannot be called to be poor as a church-mouse. They had food . . . it was quite simple. Lentils, rice and roti . . . The clothes were not less than at least 3 years old . . . there was quite an evidence that the quilts they used had seen at least a decade. There was no servant to hold the baby . . . the grandmother of the baby could be seen dozing off with the baby in her arms . . .  the male relatives were daily wage laborers .. .. .. Cell phones . . . yes, cheap duplicates of flashy mobile phones . . .

Well, you may wonder why all this description . . .

Just because, the former patient had a RSBY Smart Card signifying that she came from a family in the Below Poverty Line category and the latter had none . . . I came to know of it later in the afternoon, when I found that the first lady was shifted to General Ward . . . she was not eligible for Private Ward if the patient needed RSBY benefit.

It's not very often that we find such rich patients with RSBY card, but it is not rare.

I'm fine with everybody having an RSBY card, but it pains when we find patients who cannot afford one square meal a day not being included in this welfare scheme.

Which brings us back to a cardinal question being asked all over the world . . . at whose expense have the rich become rich? One need not have much sense to come to a conclusion . . . Yes, the rich are rich at the expense of the poor . . . those who live in the shanties and slums in the metropolitan cities, just outside the walls of those gigantic factories spewing smoke and what-not, farmers in the villages growing food for us but having no share of the big profits made by middlemen . . .

And now . . . welfare schemes being kept so much away from the real poor and marginalised . . . only to be used by the middle class and to a certain extent by the upper class . . .  

Who comes to us?

It has been some time since someone requested me to look at who accesses services in our hospital and we wanted to look at whether it was the deserving people who had the RSBY (Rashtriya Swasthya Bima Yojana) Smart Card with them. 

One of the major problems with all welfare schemes is that many a time it is middle class who corner away most of the benefits which are supposed to go down to the masses who have are worse off than them. 

Below are the preliminary results. 

The socio-economic score we used was the Uday Pareekh scale for rural areas. The duration of the study was 5 days somewhere in the first half of December. And we looked at all patients who came to general outpatient department on those 5 days. The number of patients who accessed outpatient during those 5 days were very less because of the severe cold. 

So, the first question .. .. .. We at NJH, consider ourselves to exist for the welfare of the most marginalised and backward community groups of our region. So, who are the people who access our services?

Socio-economic category	Nos of patients	Percentage of total
Lower class	46	24%
Lower middle class	115	61%
Middle class	27	14%
Upper middle class	2	1%
TOTAL	190	100%

The second question was about the number of people in each socio-economic category who possessed a RSBY Smart Card . . . a major welfare initiative by the Government of India for the poor. And below is the result. 

Socio-economic category	Number of patients	Number of patients with RSBY Card	Percentage of patients with RSBY Smart Card
Lower class	46	16	35%
Lower middle class	115	22	19%
Middle class	27	7	26%
Upper middle class	2	0	0%

So, there you are . . . It is the middle class who garner quite a lot of the benefits and more needs to be done to ensure that the benefits seep down to the more poor among our countrymen . . . However, I feel that 35% of the lower class possessing the RSBY Card is quite an achievement for the government. 

One can say that the sample size is small and it was done during a very lean season. I wish I could do the study during a very busy outpatient like what we have nowadays. I've a hunch that the results are not going to be much different. 

Comments are invited .. .. ..

(Acknowledgement: Special thanks to George Savio Chalam who helped us with the survey and part of data entry and Ms Pheba Zachariah who did the other half of the data entry and rechecked data)

Special Surgery . . .

In addition to the routine and the high risk obstetric work at NJH, we had a very special patient today. 

FD had been suffering the shame of a vesicovaginal fistula since the last 30 years. I suppose almost all of the surgeons who had been at NJH is very much aware of FD. She is from a neighbouring village. 

For those who may not know, vesicovaginal fistula (VVF) is a communication between the urinary bladder and the birth canal that results because of a prolonged labour where the baby's head presses on the pelvis during child birth. It can also occur as part of malignancy infiltrating the bladder or birth canal and also in surgical procedures. 

FD's VVF resulted following a difficult child-birth. 

It is not that previous surgeons at attempted have attempted to do the surgery.

The challenge was that FD's husband was not much interested in her welfare and about getting the surgery done. 

FD's husband died in the severe cold wave which hit us few weeks back. And then, she decided that it's time for her to attempt her surgery. 

She had carried her shame for too long. 

The surgery lasted 4 hours. 

It was surprising .. .. .. The family already had a RSBY card and still, the husband had not bothered to get the surgery done. The husband's death had actually 'empowered' her to go ahead with the surgery. She was the decision maker now . . .

We request prayers for her quick recovery and the healing of the wound. It's not going to be easy. All odd's are against her . . . We pray and hope for the best for FD . . . 

Neglect and . . . Issues to contempate

Yesterday late night, we had a patient which is a prototype of the sort of patients we get here. 

We shall call her RN, a 30 year old lady who came at around 8:30 pm. 

From an antenatal point of view, a high high risk patient. A Cesarian section done about 18 months back. She was never taken for any antenatal check up. No hemoglobin values, no blood group, no body willing to donate blood . . . leave alone an ultrasound.

We usually follow the dictum of getting one pint of blood ready in spite of a normal hemoglobin value when the patient is a previous Cesarian section. We agreed to take her if the relatives could arrange one unit of blood. 

We waited for almost 3 hours for the blood. Which never came. 

Around 11:30 pm, the relatives started to make a big fuss on why the surgery was not being done. Our doctor on duty explained the reasons. They could not agree on what was being explained. 

I got called. I explained to them. They were ready to get the surgery done without any blood. With the consent that 'there can be unexpected complications which could be fatal to the patient'. The husband was ready to sign that even if his wife and child dies, he would have the surgery done at NJH. 

Meanwhile, the patient was in severe pain. There was severe scar tenderness. It was very obvious that the husband just wanted to get the surgery done somehow. He was hardly interested in the welfare of his wife or baby. 

He started to talk very rudely and was joined by 3 other male bystanders who also started berating the quality of care and our attitude. It seemed now that we were responsible for the sad state that this poor lady.

We all very well know that we were only facility where repeat Cesarian after a previous Cesarian was done for a radius of more than 80 miles. If I send her off, she will go to the nearest district hospital from where she would be refused any management. She could end up with a rupture. . . and could even die. 

And if she dies, there would not be much tears shed for her. Her husband will find another wife.  

We took a decision to take her in for surgery without blood. I could only pray that she would not have any complications. The lower segment of the uterus was very much thinned out. She could have ruptured in another hour if we had not intervened. 

Then, the nurse told me that she has got a Smart Card (RSBY). Well, this was her second pregnancy and therefore the Smart Card was swiped. 

Inside the theatre, I asked the lady why she never bothered to get a check up in spite of the fact that she lived within 10 miles of the hospital. She replied that her husband never bothers. She is his second wife and this child would be his 6th child. His first wife had died few years back after being managed in the village for fever. 

The surgery was thankfully uneventful. 

Now, questions that lingered in me - - - 

1. A patient who has regular ante-natal check ups in easier managed with regard to costs as well as predictability compared to a patient who never had any antenatal care. Should RSBY rules include a clause which makes it mandatory for patients to have at least 2 or 3 antenatal check ups in the facility where she plans to deliver? 

2. For RN's husband, this will be his 6th child. For RN, it is only her 2nd pregnancy. So, do we put her under RSBY or do we exclude her and make the family pay? 

3. What can be done to address the neglect that women and children face from their menfolk. I'm sure that it goes without a doubt that until our women and children especially girl child is cared for, our society is not going to progress much. Stories about of such neglect . . . but there seems no light at the end of the tunnel. 

Experience with RSBY (5)

There has been one major issue being faced by hospitals like ours in management of patients who come with the smart card.

The reimbursements alloted under the RSBY Program for hospitals is the minimum costs that any clinical establishment spends.

Kindly see the following clinical scenarios. They are quite common in settings such as ours.

1.    KP, a 15 year old boy is brought to the Emergency Department with a history of loss of consciousness since one day. On taking detailed history, we found out that the boy had been receiving partial treatment from a Registered Medical Practitioner (quack) in his village for fever since the last 10 days. On further examination, we find that he is going into respiratory depression and would need to be put onto the ventilator. He has Plasmodium Falciparum in his blood. He is in sepsis as he appeared to have developed aspiration pneumonia. He is also anemic which needs blood transfusions. The costs of treatment are much higher than what the RSBY Scheme will pay the hospital. Most probably, KP was having malaria. He was not given anti-malarials by the quack. If he had come straight to us at least 2-3 days since developing fever, we would have treated him in outpatient and would not have ended up with all these complications.

2.    JP, a 25 year old housewife, pregnant for the second time had been trying for home delivery since early morning. She has reached NJH at around late evening, saying that she cannot feel any fetal movements. We diagnose rupture uterus. And to our horror, a midline vertical incision on the abdomen. Her previous delivery was by Cesarian section. Her second delivery should have been in a hospital with all full fledged facilities. She has ended up in this situation because of trying to deliver at home. The cost of an elective Cesarian section or a V-BAC (Vaginal birth after C-section) in NJH would have been much cheaper. Her husband says that the family has a smart card.

3.    MS, a 20 year old young male with a snake bite was brought to emergency 8 hours after suffering a snake bite. He is from the nearby village. It is obvious that it is a krait bite. The patient is already in respiratory failure and is intubated fast. The Anti Snake Venom is rushed in. On asking why it took so much time to reach, the relatives tell us that they were trying black magic (jhad phuk). MS would not have been this sick had he come early. Now, the costs and the duration of care has increased exponiantially and his chance of survival is less.

I could go on and on. Basically, these are patients with the following characteristics –

a.    The reached the hospital late on account of their slack attitude.

b.    They were being treated elsewhere by unqualified healthcare personnel.

c.    They have received treatment which has endangered their life and brought in complications, which would not have been there if they had come straightaway.

The million dollar question is whether we should take them under the RSBY scheme. I would like to hear suggestions and opinions . . . 

Injustice . .. ... (RSBY)

The RSBY Programme, has been there with us from the last 8 months. The cycle for the Palamu district finishes by 30th November, 2012. Which means that we'll have to wait for re-enrollment to treat patients from December 2012. However, patients from Garhwa and Latehar would continue to benefit. 

Yesterday, we had a very well off patient come to us and waste quite a lot of our time demanding that we admit under RSBY. I had an issue as they were insisting on having a private room. They started off by bugging the nurses. Then, they demand that they see me. I happened to see the family while doing my night rounds. They started to boss about saying who they were and what all connections they had. It was nauseating. 

I could only think of some of my patients whom I had seen earlier in the day who were very poor, but did not have a RSBY Card. But, here was one patient with bystanders sporting branded jeans, leather jackets, gold chains on the neck . . . they were claiming that the patient was Below Poverty Line . . . 

The next day, the group was back. This time, they targeted the Nursing Superintendent. But, to no avail. They came again back to me. They wanted us to adjust. I stood my line. Ultimately, they got the RSBY facility cancelled for their patient and got her admitted in the private ward. 

I thought of doing a small exercise. There was about 40 patients in the hospital at that point of time. To my horror, I found out that 5 out of 9 patients who were in the private ward possessed the RSBY Card (and of course the BPL card) whereas only one out of the rest of the patients who were admitted in General Ward had the Smart Card. (we did not give any benefit to the patients in private ward)

So much for social equity. 

We've raised this issue in many forums. But to no avail. I'm not sure whom to blame. Everyone says that things will become fine from the next time onwards. However, I'm doubtful. 

We see this phenomenon of well off families possessing social benefit schemes for the poor very often. It is not very difficult to explain. Most of the time, when the people for enrolment arrive, it is usually the empowered people in the village who benefit. The people with no voice are left behind. 

Well, the story does not finish here. One of the relatives of this patient commented to one of the nurses that they shall teach us a lesson. They did not show any outward emotions . . . later, they were quite good to me. 

I got few call couple of hours later from couple of people who told me that they were from the press. They asked me about details of the RSBY programme. And how we were running it. 

However, there was no news report today morning. Maybe, they realised that it was futile to put any sort of report on this. 

Unfortunate, but true. How the high and well off retain their 'high status' in the society at the expense of the poor and the marginalised. 

Today, I happened to read the story about poor working conditions of factory workers who died in a fire in Bangladesh. Factories which manufacture apparels for the big brands. These big brands would do all possible to keep their names a secret. Another type of exploitation of the poor so that others can remain rich. 

From the last few years in the heartland of mines and factories, I can tell you that almost all of the success stories of shining India are at the expense of the poor and marginalised of this country. 

The exploitation of government welfare programmes by the rich at the expense of the real needy are just the tip of the iceberg . . .  And I'm sure that I would have enough people who would share similar stories. But, the question remains on whether anybody is interested in changing this. 

Mixed bag of happenings . . .

The whole of this week has been quite peaceful at NJH compared to preceding weeks. The reasons are manifold . . . First of all there were couple of bandhs, which put us on tenterhooks. Then there was a spate of festivals starting off with the Viswakarma Puja, going on to Teej, then Ganesh Chaturthi and today Karma Puja . . . Still, it was amazing that we crossed 100 patients almost every day. 

The biggest miracle last week was VO, the young man who was in the ventilator for almost 6 days. The amazing thing was that he survived a brief period of time when our oxygen cylinders ran out on account of the bandh. It is quite heartening to see him sitting up today morning as I went for rounds.

VO along with his father . . . 

Later towards the end of last week, our Ophthalmologist's grandson who was born after a high risk pregnancy became sick with unexplained episodes of hypothermia and later hypoglycemia. He was referred to a higher centre where he's on his way to recovery. We praise God. 

Today morning, we had a 10 year old boy coming in with a history of 5 days fever. Below is a snap of his investigation report. 

The family had an RSBY card . . . unfortunately, the boy's name was not on the card. However, considering that he was from a neighbouring village, we offered him free admission. Unfortunately, before I could talk to the relatives, the parents too the child home. I hope he makes it.

The family of the young boy is the reason why there has to be a robust public healthcare system. In spite of the fact that we are able to give subsidized treatment to a certain extent, the poverty of our country is such that quite a large portion of our population would be left out if we don't have a system where healthcare would be easily accessible both in terms of distance and affordability.  

We have the daughter in law of our retired staff admitted with Preterm Premature Rupture of Membranes at 31 weeks and a baby in transverse lie and intrauterine growth retardation. It is much more than what we can handle . . . but the family is absolutely sure that they don't want to take her anywhere else.  Please pray for the family and the young lady . . . 

The best part was that we could finish finalising our calendar for the year 2013 . . . And the day I went to finalise the printing of the calendar, we had a total of about 200 patients in outpatient. 

It has been busy, sometimes disappointing, but ultimately a very fulfilling week of serving . . . Sorry, it's only half the week over . . . There's 3 more days left. 

RSBY Success Story . . . But . . .

On the 24^th of last month, MDO, a 20 year old young man was searching for some thing in his house late in the night, when he was bitten by a krait on his hand. As is the prevalent practice, his relatives summoned a local faith-healer who assured them that everything was alright.

However, as time passed, the father realised that something was amiss. MDO was not able to breathe properly and was looking very sleepy.

NJH, being very near to his home and one of his cousins being a chowkidar in the hospital – the family rushed MDO to NJH.

On arrival at NJH, Dr Johnson attended the call. MDO was hardly breathening and was bluish all over. There was no response to stimuli and his pupils were mid-dilated and hardly reacting. MDO was intubated and was put on the mechanical ventilator. The relatives were explained about the very small chance of survival. It was about 1:00 am of 25th August. 

Meanwhile, our chowkidar, Mr. Jamuna who was MDO’s cousin told us about the RSBY Smartcard (Rashtriya Swasthya Bima Yojana) the family had. It was brought immediately and was promptly blocked for treatment of snake bite.

It was only recently we were having a discussion of snake bites being covered under RSBY as there was a major increase in costs of Anti-Snake Venom (ASV).

Since, we were yet to come to a conclusion on the increase in ASV costs, we decided to treat him fully under RSBY.

By the 25^th morning, when I came for rounds, MDO’s pupils were fully dilated and fixed. There was no reaction till about 26^th afternoon.

He was in the ventilator for 80 hours. And intubated for 104 hours. 120 hours of Acute Care admission. . . 30 B-type oxygen cylinders . . . 20 ASVs - the cost of which alone is 13000 INR

MDO is getting discharged today. The problem was that his total bill had come to a whopping 45000 INR and RSBY was going to pay us 10500 INR.

MDO with his father

We’re not sure on how to approach this. The family is ready to pay us 7500 INR more. But, as per RSBY policy we are supposed to be giving cashless service. I’ve sent a mail to our Insurance Providers explaining about our predicament. I hope that they would respond positively.

The interesting part is that we have 3 more patients in the ward with krait bite. And all of us are in some part of their ventilatory support . . . I’m glad that we have 2 ventilators . . . But still, we’ve to refuse all patients who could end up needing a ventilator since yesterday . . .  eclampsias, snake bites, severe pneumonias etc . . .

The recent increase in cost of ASV make it quite difficult to treat snake bite victims under any protocol of snake bite management under RSBY. I hope that the concerned authorities would take note and do the needful . . . 

(Consent to publish the photograph and the story has been obtained)

RSBY . . . The story so far . . .

It has been more than 4 months, since we were empanelled under the National Health Insurance Scheme - called the Rashtriya Swasthya Bima Yojana. Our parent organisation, the Emmanuel Hospital Association has taken quite a bit of lot of effort that all the constituent hospitals are enrolled under the scheme as well more and more people are successfully enrolled. 

Just wanted to put in some statistics related to the RSBY Programme for the three months of March-May 2012.

Regarding outpatient care, we've been giving free registration and consultation to all patients who come with RSBY cards. The statistics so far . . . 

	Nos. of patients	Loss due to registration (in INR)	Loss due to consultation charge (INR)
MARCH	143	4290	7150
APRIL	251	7530	12550
MAY	291	8730	14550
	685	20550	34250
TOTAL LOSS in Outpatient			54800

Table 1

Coming to the in-patient care, the details are as follows - 

Months	Nos. of patients	Amount blocked (INR)	Received reimbursed (INR)	Actual treatment costs (INR)
MARCH	40	139950	100750	141694
APRIL	40	204000	163780	227443
MAY	43	185325	141625	210481
TOTAL	123	529275	406155	579618

Table 2

If we convert into percentages this is what we have got - 

Months	% of blocked amount reimbursed	% of actual costs reimbursed	% of the actual treatment cost which is blocked
MARCH	72.0	71.1	98.8
APRIL	80.3	72.0	89.7
MAY	76.4	67.3	88.0
	76.7	70.1	91.3

Table 3

Well, the above table (Table 3) tells us quite a lot . . . The major issue is with reimbursement. Now where are the challenges?

1. One of the major issues is the 24 hour clause kept for reimbursement. Let's look at an example. If a patient had come at 8 pm in the evening of 10th July, 2012 and we decide to keep him for 2 days in acute care. If he gets shifted out of acute care at 8 am on the second day (12th July, 2012), we receive only one day of ICU treatment. To qualify for 2 days, we need to keep him in ICU till 8:00 pm and then shift him out - which may not appear practical. The same appears for general ward patients too. 

2. You may notice that the actual treatment costs was very near to the blocked amount. However, later, the situation changes and the actual treatments is almost 10% lesser than the amount which is blocked. The only explanation I have is the following - 

    a) During the first month (March) we had more of cold cases (hernias, hydroceles, cataract surgeries etc). From the next month (April onwards), we had more of emergency cases coming in the cost of care of which are on the higher side. 

    b) Another development during the same period was the increase in medicine cases.

3. Another area where we are loosing money is Cesarian sections. The actual costs is about 12,000 INR whereas the amount allotted is only 4,500 INR. 

4. My surgeon was of the opinion that abdominal surgeries are under-alloted. There is almost always a need for blood transfusions which increase the costs.

5. Many a time, patient is referred before one day is over. In such cases, there should be a rule that we can take the bill from the patient. 

THE MAJOR ISSUES - 

1. We feel that the allowed amounts for blocking in medicine cases are on the lower side.

2. In emergency care (both medicine and surgical cases), the costs involved are usually on the higher side. A hernia coming for elective surgery is much cheaper than hernia coming for emergency surgery because of strangulation etc. 

3. Severe anemia is a common problem in our region and is most often nutritional. Many times, they require multiple blood transfusions which are very expensive. 

4. The rates for abdominal surgeries including Cesarian sections need to be revised. 

SOLUTIONS - 

1. Allot an addition of 1000 rupees for all cases (one time payment per admission) who come into emergency with acute onset of symptoms.

2. Delink blood transfusion costs from the RSBY package. 

3. Increase ICU costs to Rs. 1500 per day and General Medical Ward costs to Rs. 750 per day. 

4. Increase the rates of abdominal surgeries especially Cesarian sections. 

FINAL WORD - 

We are quite happy with the support being provided by Star Health especially the State C-ordinator, Mr. Sarfraz and the district point person, Mr Sanjeev Bansal. 

Considering that the hospital makes a loss of almost 20,000 per month on RSBY patients in the outpatient department, it would be good if the solutions suggested are implemented in some form or the other. 

However, we would like to commit ourselves to the success of this amazing scheme in spite of the losses we've incurred. It goes well with our commitment to the poor and the marginalised. We are proud that we are associated with this. 

The RSBY has already become quite famous for the impact it has brought about in the lives of the common man. We look forward to the day when the enrolment will cover almost the whole of the population and the burden of a imminent illness dragging people into poverty becomes a story of the past. . .