Hospital Drug Deals

My in-laws' lengthy hospitalization at Inlaks in Pune exposed me to the gamut of practices and attitudes of the doctors prescribing drugs. Most of my observations are applicable to medical practitioners elsewhere in India and the world, including in the US. An eye-opener for me is how largely unseen doctors like pathologists can steer expensive drugs to patients.

But first the main takeaway: it can help a lot to seek multiple inputs, even informally, especially when expensive drugs or treatment are involved. I managed to identify some good and caring doctors and asked them questions like, "If our patient were your own parent, then what would you do or advise?"

As elsewhere, the Inlaks doctors can be divided according to their prescribing behavior into three types.

Type 1 had close ties with the pharma reps who frequent hospital hallways and waiting areas. These doctors aggressively prescribed expensive brand name drugs (when cheaper generics or substitutes were available), and especially so if you appeared to be a patient of some means. My in-laws were regarded as such because Anita and I live in the US.

Type 2 were the bystanders or silent collaborators of the Type 1's. They didn't actively push the most (unnecessarily) expensive drugs themselves, but tended to concur with colleagues who did, when specifically pressed on the issue, or consulted for a second opinion.

Type 3 were the ones I truly liked and respected. They were strongly guided by their patients' physical as well as financial well-being. They recommended expensive drugs and treatments if they felt we could afford these, AND if these had significant advantages over cheaper options. They also laid out any trade offs fairly. More importantly, they were uncomfortable enough with the behavior of Type 1's to be willing to call them out.

My sense of the Inlaks doctors is that about 20% of them are Type 1, 70% are Type 2 and 10% are Type 3. Dr. Y, a Type 3 whom I came to like a lot wryly noted that most doctors will support their colleagues because they expect to be similarly served when their own actions are questioned. That's why there are so many Type 2's, apart from this being the path of least resistance.

I had noteworthy experiences with some Type 1 and Type 3 doctors.

I regretfully categorized Dr. R as a Type 1 because he otherwise had many positives. He was highly experienced and competent, with a great bedside manner. It was his quick conclusion that Daddy may need emergency surgery, his ordering immediate tests and alerting the surgeon Dr. P that helped saved Daddy's life. Dr. R also sized up Mummy's condition and treatment well. But he spent much more time with pharma reps than his colleagues did. He prescribed a lot of expensive drugs for Daddy that his colleagues felt were unnecessary, or where cheaper substitutes could have worked as well. It's possible that Dr. R genuinely believed in the greater efficacy of the more expensive options, but I sought other opinions to settle nagging doubts.

It was also revealing to see how the Inlaks pathologist Dr. A and his staff from behind the scenes could foist expensive drugs on to patients. Their role may or may not have been in concert with others like Dr. R. Dr. A performed culture and sensitivity tests on Daddy's sputum and other samples. In this, the harmful bacteria present in the sample is cultured for 2-3 days and tested with various antibiotics to see which ones kill it and should be given. The only thing is, Dr. A only tested some of the costliest versions of some drug categories, and omitted the cheap ones that may have worked just as well.

Such practices create broader problems that go beyond draining patients financially. You, see, a lot of these costly new drugs have been introduced to combat germs that are resistant to the cheap conventional ones. They should be sparingly used only when others don't work, or else we'll quickly end up with bacterial strains that are resistant to the new drugs as well.

Case in point: Dr. A's lab tested tigecyclin to combat Daddy's infection caused by the pseudomonas bacterium. This tigecyclin is a tetracyclin-variant drug patented by Wyeth. It was shown to work, but costed $500 - $700, and they never tested for basic tetracyclin or its off-patent versions like doxycycline that cost as little as $20.

I learned about this only because I routinely sought out the opinions of other doctors, two of whom turned out to be Type 3's. One was Daddy's surgeon, Dr. P whom I've talked about in the previous post. The other was Dr. Y in the ICU who was passionate about his patients and visibly worked up over any instances of their inadequate care by the hospital staff.

I asked Dr. A why the much cheaper alternatives to tigecyclin were not tested on Daddy's sputum sample. Dr. A's unsatisfactory response was that he stocked a limited number of drugs for testing, and that his lab "did not concern itself with the costs (of the drugs)." When I expressed my dissatisfaction he agreed to test a fresh sputum sample against drugs that other doctors suggested, like doxycyclin, so I had a fresh sample submitted. But we still had to start Daddy's treatment with the costly tigecyclin since we couldn't wait another 2 - 3 days for the new culture and sensitivity results.

Then Dr. A quietly "rejected" Daddy's new sputum sample as being insufficient in quantity and discarded it without testing. By then it was too late to test another sample since Daddy's tigecyclin treatment had already started and killed off the invading pathogens.

I'm convinced Dr. A acted this way to avoid being exposed if the cheap doxycyclin turned out to be just as effective as tigecyclin. I voiced my concerns to the Inlaks Medical Superintendent who oversees all medical matters. She promised to thoroughly look into these practices though I wonder if anything came of it.

What I do know is the immense value of identifying and dealing with Type 3 doctors. I relied on four of them at Inlaks - apart from Dr. P and Dr. Y, there was the head of surgery Dr. L and orthopedic surgeon Dr. D. Even though we ended up using tigecyclin we were spared other unnecessary treatments.

But being a Type 3 isn't easy. I could see the pressure on Dr. P who was Daddy's attending physician. Guided by his convictions Dr. P would cut out treatments (especially costly ones) that he felt were unnecessary. This often put him at odds with more senior colleagues like Dr. R who could impact his professional career, yet he followed his conscience. I hope he and others like him are appreciated and do well.

Medical Blunder and its Aftermath

We faced this situation while in India last month: How to react when a dedicated and otherwise competent doctor makes a grave mistake that puts the life of your loved one in limbo?

Our spirits were high on October 1st. It had been almost nine days since my father-in-law (Daddy's) emergency surgery for a ruptured duodenal ulcer. Anita had joined me in Pune, and my mother-in-law (Mummy) was also doing well in an adjacent private ward in the same Inlaks Hospital. Both were to be sent home the following day.

Daddy's surgeon Dr. P had said that the first 6-7 days were the most critical in Daddy's case. This is because the sutures to repair the large perforation of the duodenum are very vulnerable to the strong acids in the stomach, and can typically give out by day 6. If they hold past that, then the prognosis is very good. Daddy was now past that critical period. He had some problems with cough, pneumonia and weakness following the surgery, but this was under control and considered normal for someone of his age who was inactive after a major surgery.

Daddy's IV lines were removed and similar preparations were made for his urinary catheter as well. Dr. P came in and removed the external staples that had held Daddy's almost 2 feet long abdominal incision together. He then urged Daddy to try and resume normal activities including walking as quickly as he could.

An hour later things went terribly wrong. Daddy was coughing hard, and as a result suffered a burst abdomen, meaning that his recently stitched abdominal wall gave out, spilling out some of his insides. Anita raised an alarm and Dr. P. was there within five minutes. He and his juniors hastily tended to the gaping wound, temporarily taped it up, assembled a surgical team and began an emergency surgery within 45 minutes to repair the damage.

The cause of the problem? Daddy is 89, and many of Dr. P's colleagues told us that they'd have not removed the staples for at least 12-14 days after the surgery (instead of the nine days as happened here) and have taken other precautions to protect the healing wound.

The trauma of this second surgery and its consequences placed Daddy's life in the balance for the next couple of weeks. Apart from blood and fluid loss his complications included pneumonia, kidney malfunction, severe hospital acquired infections and heart complications. He was in pain and delirious or semi-conscious for several days. Anita and I cancelled our flights back to the US and postponed subsequent programs in this period. Fortunately, Daddy pulled through, slowly recovered and is now recuperating at home.

Despite his blunder my relations with Dr. P and his colleagues remained warm and cordial. I have repeatedly been asked two questions. First, did I genuinely harbor no ill will towards Dr. P, or did I just mask my true feelings? Second, had this happened in the US, would we have sued and made Dr. P pay heavily for his mistake?

To the first question, I obviously very much wish that Dr. P had played it safe and none of this had happened. But after it did, I still had good feelings about him. We continued to have an easy relationship and I'd even joke about the colorful shirts worn beneath the white coat of one of his cheery-faced residents when they'd visit us in Daddy's room. Here's why:

• I believe Dr. P's prompt action and skill during the first surgery on September 22 was a big factor in enabling Daddy to pull through. So I attribute Daddy's being home and improving today to Dr. P's initial action
• Dr. P is overall an accomplished surgeon who is also very responsive. Like many of his colleagues (and not at all like in the US) he had given me his cell phone number at the time of the first surgery and was directly accessible on that when I needed him. (Of course I tried not to abuse this privilege)
• I perceive a big difference between negligence that may come from not putting in the required time or effort, and "just" a misjudgement. I knew that Dr. P never lacked for sincerity, dedication to Daddy's welfare, or hard work. His unfortunate miscalculation in removing staples prematurely stemmed from a concern about their continued insertion causing a surface infection. I'm sure the consequences will guide his future judgement and help other elderly patients
• We were fairly high profile at Inlaks (partly because it is rare for both husband and wife to be simultaneously checked into adjoining deluxe wards, and that too by a son-in-law visiting from the US.) Dr. P's mistake was widely known among his colleagues. He paid enough of a price in that sense without me raising the subject with him
• Dr. P as a person was decent, caring and straightforward. He was uncomfortable when other doctors tending to Daddy prescribed medications that he felt were unnecessary or even needlessly expensive (yes, some of that pharma - doctor linkage seemed to exist here, too.) As coordinating physician he struck off some of these medications or expressed reservations about them, even at the risk of running afoul of his colleagues. I felt I could trust his commitment and intentions
• Once the second surgery became necessary, Dr. P did everything necessary to reduce its risk. General anesthesia for a second time in a frail patient is a major risk, so he performed this surgery using spinal tap and local anesthesia. He also got his team to waive overtime charges for performing it after hours. He closely monitored Daddy's condition and incessantly advised and encouraged him

Coming to the second question, how would we have acted had the same lapse occurred in the US? We wouldn't have sued Dr. P for all the reasons above. A sued physician pays a huge price even when he is fully insured. This price is in terms of damage to his record and reputation, the distraction of defending a lawsuit, and increases in future premiums.

However, in the US the extra cost following the second surgery may have exceeded $100,000 even at negotiated rates. A substantial chunk may have been payable out of pocket and I would probably have asked the hospital to waive or substantially reduce this. At Inlaks in India the extra charges only came to about $3,500. Given how everyone pulled so hard for Daddy's recovery I didn't seek any reduction in this. In fact when it was Daddy's time to leave he asked me to give some gifts to the staff that had attended to him so well.

Long Stay in an Indian Hospital

I have been out of blog circulation for a while, having just returned from a five-plus week unscheduled trip to India. Anita joined me for three weeks in this period. We spent all our day time hours and half the nights as well in an Indian hospital in Pune where both of my parents-in-law were admitted. In the process I learned a lot about one of the many decent hospitals in India that would not make the cut as a medical tourism destination. Here's how it happened.

We heard in mid-September about how my mother-in-law's (Mummy's) health condition worsened after she was bedridden after a couple of falls in the bathroom. She also had difficulty swallowing and stopped eating. The doctor making house calls suggested that she be moved to a hospital for extensive tests and possible treatment. The only way we've moved her out of their second story apartment that lacks elevators is by stretcher and then transported her by ambulance.

My father-in-law (Daddy) simultaneously developed high fever caused by a suspected viral infection. This was followed by side effects of some nasty medication that was prescribed, but we expected this to pass relatively quickly.

Since Anita and her two brothers are all living in the US I left for Pune for what I thought would be a short trip to have Mummy and Daddy checked out and treated. My direct flight on Delta Airlines from JFK to Mumbai was surprisingly comfortable and I headed straight to Pune by road, arriving there within five hours.

While Pune doesn't have JCI accredited hospitals popular with medical tourists, it does have some decent private ones. The three we considered were Jehangir (now owned and run by the famed Apollo group), Ruby Hall (aka Grant Foundation) and Inlaks & Budhrani (run by the charitable Sadhu Vaswani Mission.)

The former two are reputedly more posh and professional, but I settled on Inlaks on the advice of two of my in-law's relatives who said (a) the doctors and staff there are more caring and less driven by profit, and (b) this hospital is run by the Sindhi community to which my in-laws belong, and they'd have more access and attention from the top operatives if this is needed.

My in-laws were admitted to Inlaks just a day apart. Contrary to expectations Daddy's case turned out to be far more serious. He had a large perforation of a duodenal ulcer that was building for years but one we were all unaware of. At age 89 he went through two emergency surgeries nine days apart, which were the first in his life. He spent 25 days in the hospital, and his situation looked grim for quite a bit of this time.

Fortunately, Daddy and Mummy are now home and recovering well. Here are some notable aspects of our experience:

• The hospital costs were very low by US standards. Daddy's 25 day stay in a deluxe single occupancy room, a score of specialist consultations and two surgeries could have easily cost $200K in the US, even at negotiated rates. At Inlaks it came to about $6K. Similarly, Mummy's 19 day stay and treatment cost about $1,600.
• In addition to these hospital costs, I also for good measure engaged round the clock help-maids (called "maussis" or "aunts" who help clean and care for the patient) privately for both Daddy and Mummy. They cost a total of about $20 per day and made things a lot easier.
• A lot of the hospital staff was very caring. The nurses and aides would call elderly patients "Uncle" or "Aunty." Those in the ward would visit Daddy in the ICU the times he was moved there just to see how he was doing. When the time came somewhat to our amusement Daddy was reluctant to leave the comforting cocoon of hospital care.
• I came to know many of the doctors and administrators, and developed distinct impressions about them. I was struck by the competence and humanity of a sizable number of them.
• The hospital adjoins the Osho ashram founded by Swami Rajneesh (first made famous by the Beatles who visited it decades ago) and is popular with many Western visitors. I found several of them coming to Inlaks for medical attention and chatted with some of them. They seemed happy with the care overall. That said, I don't consider this hospital suitable for medical tourists, who should expect a more upscale, sterile and professional environment. But if you're not too choosy, you get decent care and can't beat the price.
• A lot of the nurses had very arduous tasks and often seemed to be understaffed and under stress. I was surprised at how little they were paid - netting about $150 a month in cash or even less. There seems to be a strong case for paying them much more without hurting financial viability.
• Anita has a phenomenal extended family. I joke that when I married her I didn't realize I'd get such good relatives as dowry. Her cousin Rita insisted on coming from Mumbai to Pune with maid in tow for 5 days and was invaluable in taking charge of Mummy's care in hospital while I dealt with Daddy's situation. Another set of cousins Ashok, his sister Indru and her husband Gul (who own the Sun-n-Sand hotel chain) came from Mumbai to visit. They gave us the penthouse suite of their Sun-n-Sand Pune 5 star deluxe hotel (located less than a mile from the hospital) and full run of all facilities and an army of liveried staff through our stay there. Gul specially called and Ashok threatened to "kill me" when I protested I couldn't accept such lavish help. But it made a huge difference. Then there's Meena and her parents Hira Uncle and Dru Aunty (Mummy's sister) who were always there with help and advice. The list goes on and we're blessed.

I intend to describe some aspects in more detail in the days to come. It's good to be back in the US. My brother-in-law Prakash who lives in Pittsburgh is now with my in-laws for the past few days and doing a great job caring for and settling them down.

Exercise Don'ts And Dos

I know, I know. Diet and exercise is the nauseatingly repetitive advice for best warding off many health problems. And unlike claims by some enthusiasts about the "high" you enjoy while exercising, the best part of my workout by far is when it is all over for that day.

Exercise for me has been purely an obligatory part of physical maintenance, and I used to follow a home regimen some days a week. So if you've been having problems overcoming inertia or a hectic schedule I'll encourage you to be more active. But trust me, I feel your pain.

Fifteen years ago my (then future) sister-in-law Deanne first helped overcome my reluctance to enter a gym. She introduced me to some exercise equipment and I've been a fairly regular gym goer since then. I'm glad it's paid off, but I've had sporadic problems because of wrong exercises or poor form that I learned about and corrected only subsequently.

But today I happened upon this excellent article with illustrations on WebMD.com about nine bad or least effective exercises, and better ones in their place. I'm guilty of at least three of those nine lapses, and wish I had seen this article earlier. It's certainly worth a look.

For those who don't like the concept of gyms or using exercise equipment there's also this useful article about seven "most effective" exercises that can be done at home. Five of these require no equipment at all and in the other two dumbbells or simple home objects can substitute for the barbells shown. Of course there are several lists of "best exercises" featured in magazines and other publications, and this is just one of them.

Finally, here's the Wikipedia description of the classic 5BX / 10BX system for men and women (with a link to download it) that takes just 10 - 15 minutes a day. I used this for many years after it was taught early in my service career, and still like to go back to it from time to time.

Ignore Obama Critics (At Least) On This

This is a dual surprise for me. First, the New York Times (NYT) today questions some of their favorite candidate Obama's assertions. And second, these criticisms are misplaced and Obama is actually on target this time. Let me explain.

I think Obama's healthcare proposals have many shortcomings, including not mandating coverage as pointed out by Paul Krugman way back in February. But I fully agree with his stand in today's article "Health Plan From Obama Spurs Debate."

Put simply, Obama vows that if elected President he will lower projected healthcare costs by $200 billion or 8% by the end of his first term. He backs this with some calculations and analysis put forward by his healthcare advisors including three Harvard professors.

Yet the article goes on to say that pundits and "analysts question whether significant savings would materialize in as little as four years, or even in 10." I'm wondering about these naysayers and the kind of mental straitjackets they've put on their thinking and analysis. I believe that an 8% reduction in health costs in 4 years' time is very conservative and easily achievable.

In our May 27, 2008 OpEd in the Wall Street Journal or its fuller version we describe the potential gains from free trade (or globalization) in healthcare alone. The US can save $70 billion annually from further offshoring of remotely delivered administrative and diagnostic services. Exporting patients for 30 major procedures suitable under medical tourism that cost $220 billion in the US can save $40 billion. Another $40 billion can be saved by alleviating the artificial scarcity of doctors by importing foreign trained doctors from accredited institutions abroad. So the annual savings tally just from free trade in services comes to $150 billion.

Now factor in the savings from allowing drug imports, curbing "lock in pricing" abuses or overcharging by PBMs, and for Medicare to directly negotiate drug prices. Assuming a 20% reduction in drug prices (which is realistic, given that drugs in Europe cost almost half of what they do in the US) will yield savings of $50 billion.

So here you have it. $200 billion of reductions without even tapping the huge savings from reduction in unneeded procedures, better electronic record keeping and tort reforms that cut down on defensive medicine.

Theatrics In Medicare Bill, Bush Veto, Override

As Paul Krugman said in his July 11th column in the New York Times, the passing of the Medicare amendment bill by Congress was a welcome development. McCain was on the wrong side of the issue here and unsurprisingly a prominent absentee in the senate vote.

In a move that plainly sought to protect special interests, President Bush followed through on his earlier threat and vetoed the bill. But Congress moved quickly for a dramatic override of Bush's veto, so the bill has now become law. Apart from preserving the doctors' Medicare fee rates the bill reduces the subsidies payable to health insurers who offer Medicare Advantage plans.

Here are some interesting features about all this activity:

• This is one of the rare times that Republicans were caught between two powerful special interests in healthcare who are both typically strong Republican supporters. The doctors and the AMA ended up on the winning side and the large private health insurers on the losing side
• Many Republicans switched votes only after doctor groups targeted them in effective ad campaigns in their home voting areas, specifically publicising their opposition up to that point on the bill
• Many Republicans ignored directives from their own party whips and Congress leadership, and of course broke from Bush on this as well. Facing difficult re-elections can be effective in prodding lawmakers to do the right thing
• By tying the Medicare fee protection for doctors with doing away with subsidies for insurers, the Democrats (and some like-minded Republicans) have won a high stakes game of chicken

The logic behind encouraging private insurers to run any Medicare type plans is that they will do so more efficiently and cheaply than a more wasteful government. But the private plans have been costing the government 13% to 17% more than what the government incurs in running its own plans. So what's the justification for these private plans with their extra subsidies? So far I've heard nothing beyond empty catch phrases like "more patient choice."

Still, the financial implications of this bill are miniscule ($20 billion over five years) compared to the $2.25 trillion US healthcare expenditure in 2007. Even for these amounts this is basically a transfer of wealth between industry players that doesn't of itself lower total costs. Hopefully it is a prelude to other reforms that bring US health costs somewhat in line with those in the rest of the developed world.

Is Medical Travel Good For The Host Country?

There was this New York Times article of June 1, 2008 titled "Royal Care For Some Of India's Patients, Neglect For Others." It describes the state of the art care in opulent surroundings received by a US medical tourist getting his heart valve replaced in Wockhardt Hospital, Bangalore. This is contrasted with the miserable plight of India's poor patients in government-run hospitals like the Bowring Hospital on the other side of Bangalore that lack the most basic equipment.

The article doesn't explicitly say this, but I hear concerns about medical tourists soaking up India's scarce medical resources that should instead serve its own people. Such sentiments are voiced by a small minority of populists and parochial elements in India. Interestingly I saw several such views expressed by US providers in forums discussing our own WSJ OpEd of May 27th. It reminds me a bit of the protectionists who seek to block cheaper foreign goods from entering the US because of their professed concern for the poor, exploited workers abroad.

But most Indian planners and leaders want to promote medical tourism. They believe that medical tourism is a win-win, to use a cliche, with benefits going beyond foreign exchange or trade gains, to actually help Indian patients. I fully subscribe to this opinion.

The elite private Indian hospitals we've talked with say that richer patients (including medical tourists) heavily cross-subsidise poorer ones. At a fraction of US rates, what is charged by elite Indian / South Asian hospitals may seem dirt-cheap by US standards. But payments by patients staying in luxury or deluxe rooms are far higher than for patients in wards or shared rooms in the same hospital. The higher revenues allow not just for cross-subsidy but also to enable the hospitals to acquire the advanced facilities and equipment, and to attract the most qualified doctors.

The private hospital "general ward" rates in turn are much higher than the cost of care in government hospitals. The increased revenues and demand should mobilize resources on the supply side. Luxury hospitals are sprouting all over the major cities. The one aspect that central planners must address is the need to vastly increase the supply of good doctors, nurses and other healthcare workers by plowing some of the revenues into expanding medical education and training. At least from their speeches and policy declarations it looks like the leaders and bureaucrats in healthcare are working on this issue.

So Western medical tourists are good for India and should avail of the facilities there with a clear conscience. Also remember that presently they make up a very small sliver of the total clientele of even the top Indian hospitals with JCI accreditation.