On Dec. 23rd the Financial Times published our letter / commentary on the need to import doctors and export patients to alleviate shortages and cut soaring costs. These trade aspects of healthcare haven't yet been mentioned in proposed Obama reforms and incoming Healthcare Secretary Tom Daschle's recent book. Here is our published content (the FT uses "English English" and not "American English") :
From Prof Jagdish Bhagwati and Mr Sandip Madan.
Sir, In his characteristically insightful fashion, Clive Crook ("The long road to healthcare reform", December 15) alerts us to the problems that await the likely approach to comprehensive coverage of healthcare by Tom Daschle, the incoming US secretary of health and human services, as suggested by his recent book on the healthcare crisis.
But the fact that Governor Mitt Romney's similar reform in Massachusetts ran into the difficulty of finding doctors and other healthcare workers for the newly insured, and that Governor Arnold Schwarzenegger had to abandon similar efforts in California because of high costs, raises the question of why Mr Daschle and President-elect Barack Obama have not yet recognised that the systematic and comprehensive embrace of international transactions in medical services can make a big impact on both these problems.
Today, many foreign hospitals and physicians offer a world-class service for a fraction of the cost in the US. Expensive yet standard procedures with short convalescence periods, including heart operations and joint replacement surgery, are candidates for such treatment abroad.
By our estimates, 30 such procedures, costing about $220bn in 2005, could have been undertaken abroad. The "import" of medical services in just a quarter of those cases would have implied a saving in medical expenses of between $40bn and $45bn.
But the scarcity of medical professionals is equally crippling. Under President Lyndon B. Johnson's Great Society, a selected class of foreign doctors were allowed to "stay on" provided they worked for specified periods in under-served areas. The time has come to expand such programmes. We have recently suggested several ways this could be done, while amending the US immigration policy accordingly.
These programmes, "exporting patients" and "importing doctors" as one of us proposed almost 15 years ago, are now essential if comprehensive coverage of healthcare is to become a reality rather than simply an ineffective reform seriously undermined by shortages and high costs. Once you add the savings from online diagnostics and the reduction of administrative costs (conservatively estimated currently at $500bn annually) through further outsourcing of administrative services, the prospects for easing scarcities and costs are even more inviting.
But all this will involve getting over the jaundiced view of international trade that afflicts most of the new Democrats. Will they choose de facto protectionism, masquerading as "fair trade", and sacrifice the invaluable opportunity presented by possible international transactions in medical services? Or will President-elect Obama truly give us genuine leadership and have Mr Daschle override the anti-trade and medical lobbies that hold up effective healthcare reform?
Jagdish Bhagwati,
Professor of Economics and Law, Columbia University
Senior Fellow, Council on Foreign Relations
Sandip Madan,
Founder, Global Healthnet
Copyright The Financial Times Limited 2008
Tuesday, December 23, 2008
Saturday, November 22, 2008
A Common Doctor Blind Spot
Patient alert: Many doctors seem to have a blindspot while treating infections. This can subject patients to needless agony or worse. I have personally observed this at least half a dozen times in India and the US, and some cases ended very badly. In all of these the patients were intensively treated with all kinds of strong antibiotics, to no avail. Here they are in chronological order:
But in four of these cases at 1, 2, 5 and 6 above involving my great-uncle, brother Kaku, cousin Pavan and Daddy respectively the culprit was oral fungus, commonly known as thrush. The "good" bacteria in the oral cavity normally keeps this fungus in check, but antibiotics can kill this good bacteria. Then this very painful fungus infects the delicate lining of the oral cavity and typically shows up as white spots (though these may not be visible in the esophagus.) Once diagnosed, thrush is easily and rapidly treated. But if doctors who don't catch on and simply give more antibiotics can make the problem worse instead of better.
In case 3 involving my colleague Vivek, the culprit was amoebiasis where it was the amoeba that had invaded the liver. Again, while antibiotics don't work at all, anti-amoebic medications rapidly clear the condition - provided the doctors make the correct call.
Wanna guess what Raj had come down with in case 4? Well, it was malaria. The American doctors did not have this on their radar as it rarely occurs in the US. But the Indian doctor asked Raj if he had been abroad recently, and when Raj mentioned his recent trip to India, the doctor asked for his blood to be tested for the malarial parasite, and viola!
The takeaway: it seems to be a fairly common doctors' blind spot. If conventional treatment isn't working ask your doctor early on if he / she has considered and ruled out non-bacterial and non-viral infections like those caused by fungi, amoeba and parasites.
- Over forty years ago my father's uncle suffered a slow and agonizing death from virtual starvation after being hospitalized and then released. He refused to eat anything, and by the time they figured out why, it was too late.
- My brother Kaku as an infant was afflicted with this infection and suffered for weeks after a hernia operation. It even transferred to my mother who was breast-feeding him. Finally, a very good and experienced doctor diagnosed the problem and it disappeared quickly.
- Vivek from my college and subsequently my IAS batchmate in HP had a severe illness in the late 70's that landed him in one hospital in India and then another for several weeks. He had high fever, loss of appetite, yellow eyes and other symptoms of hepatitis that had doctors stumped since he did not respond to conventional treatments. Starting from a healthy body weight he lost about forty pounds in that time before doctors in India's famed AIIMS hospital correctly identified the infection. They then quickly (and easily) treated him, bringing him back from the brink.
- In the late 80's my friend Raj was hospitalised in LA for several days with high fever and other symptoms that defied any treatment. Finally, a doctor of Indian origin happened upon his case, asked him one very relevant question, then ordered a test that confirmed that doctor's suspicions and prescribed medication that rapidly cured Raj.
- About 10 years ago my young cousin Pavan in the US who was a medical student had a tonsillectomy. A few days later the pain in his throat was so acute despite all the medicines he received that he couldn't eat. Based on her experience (and high intelligence) my mother who has no medical background guessed at the problem and asked Pavan's family to bring it up with his doctor. The doctor after needless delay finally listened and Pavan was treated, but his prolonged suffering caused him to miss his medical board exams that year.
- Just last month my father-in-law (Daddy) was recovering from two major surgeries at Inlaks hospital in Pune, including complications of pneumonia and hospital acquired infections. His lungs cleared and surgical wounds healed after a strong regimen of antibiotics, but he continued suffer from cough and persistent throat irritation. He couldn't sleep, asked to gargle every 15 - 30 minutes even at night. The Inlaks doctors ordered more antibiotics and tests and thought the irritation was due to residual infection in the breathing passages, as well as the feeding tube that was subsequently inserted because Daddy wouldn't eat or drink. But the problems was as bad or worse for several days after the feeding tube was removed and he was taken back home. Then I had Dr. I examine Daddy at home. Dr. I is very intelligent and sought after though he doesn't have quite the fancy qualifications of the Inlaks doctors. He had Daddy open his mouth wide, depressed his tongue and peered at the back of his throat with a flashlight. That was enough to provide the answer and clearing the condition in two days, though this was after two weeks of avoidable suffering and debilitation.
But in four of these cases at 1, 2, 5 and 6 above involving my great-uncle, brother Kaku, cousin Pavan and Daddy respectively the culprit was oral fungus, commonly known as thrush. The "good" bacteria in the oral cavity normally keeps this fungus in check, but antibiotics can kill this good bacteria. Then this very painful fungus infects the delicate lining of the oral cavity and typically shows up as white spots (though these may not be visible in the esophagus.) Once diagnosed, thrush is easily and rapidly treated. But if doctors who don't catch on and simply give more antibiotics can make the problem worse instead of better.
In case 3 involving my colleague Vivek, the culprit was amoebiasis where it was the amoeba that had invaded the liver. Again, while antibiotics don't work at all, anti-amoebic medications rapidly clear the condition - provided the doctors make the correct call.
Wanna guess what Raj had come down with in case 4? Well, it was malaria. The American doctors did not have this on their radar as it rarely occurs in the US. But the Indian doctor asked Raj if he had been abroad recently, and when Raj mentioned his recent trip to India, the doctor asked for his blood to be tested for the malarial parasite, and viola!
The takeaway: it seems to be a fairly common doctors' blind spot. If conventional treatment isn't working ask your doctor early on if he / she has considered and ruled out non-bacterial and non-viral infections like those caused by fungi, amoeba and parasites.
Friday, November 14, 2008
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.
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.
Sunday, November 2, 2008
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:
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.
Tuesday, October 28, 2008
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:
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.
Wednesday, August 20, 2008
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.
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.
Wednesday, July 23, 2008
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.
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.
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