Focus

Mounting Worries

Not only in India, but globally too, hospitals have to grapple with colossal pending bills, that burns a big hole in their pockets, driving many to bankruptcy. Nancy Singh finds out what strategies leaders follow to get their money back

Always in the limelight for all the good reasons, Chennai-based Frontier Lifeline Hospital (FLH) was recently in the news for an ugly situation. FLH refused to discharge 10 kids from Guyana, who had undergone heart surgeries there, as they failed to clear the hospital bills, amounting to $13,000. The kids were brought in by an international NGO, Kids First Fund. What followed was a media trial with dramatic scenes showing children locked in a big room holding placards that cried 'Help Us'. Eventually, this 'hostage drama' ended after 15 hours, after a 45-minute meeting between the FLH Chairman, Dr KM Cherian and NGO representative Varshine Singh, whereby the NGO was given six months to clear the pending bills. Obviously, this unwanted publicity led to a huge embarrassment for the hospital and left a bitter taste in their mouth. While healthcare industry brushed this aside as one-off case where situation went overboard, the truth is that this is not the first time when the patients/ relatives refused to pay or skirted away at the time of paying the bill.

Of Anger and Anguish

Heated discussions or an ugly brawl arising due to bills is a very common sight in many Indian nursing homes and hospitals that operate in this country. Says Dr Dhananjay Kelkar, Medical Director, Deenanath Mangeshkar Hospital (DMH), Pune, "Though, it is not a large percentage of the patient population, two out of every 100 may end up in a brawl with the staff, which is when you realise that they are not interested in paying. I don't think there is any hospital in the world that does not face the problem of bad debt."

Common Problem Areas

It is mostly the cases of death that results in high bad debts. According to Dr Ajai Kumar, Chairman & CEO, HealthCare Global Enterprises Limited (HCG), "Mostly cash payment is not an issue. The issue is with the 10 per cent of the class which is covered by insurance sector, be it the TPAs, ECHS schemes and so many other schemes." HCG runs into bad debt of a million dollars at any given point of time, informs Dr Ajai Kumar.

In early 2008, Pune-based Ruby Hall Clinic (RHC) owed almost a crore from Ex-Serviceman Contributory Healthcare Scheme (ECHS). The hospital authorities refused to comment if the dues have been cleared or not. Apparently, RHC was dragged to the consumer court for overcharging bills, long time back.

Another eye-opener is the very recent case of Reliance General Insurance Company Limited (RGCL). RGCL's pending bills to state Government hospitals and private hospitals under the Mizoram Health Insurance Scheme have skyrocketed to more than a phenomenal Rs 12 crore. The Mizoram Government had reached an agreement with RGCL in April last year to implement this healthcare insurance scheme that aimed to provide healthcare cover of Rs one lakh floater for one family per year. This scheme was meant to cover over 1.50 lakh families who were not entitled to receive state medical reimbursement for Government employees. The Mizoram Government had given a premium of Rs 27, 49, 18,783 to the company, as per the agreement.

Reportedly, the CGHS, last year owed a massive Rs 47 crore to private hospitals and diagnostic centres.

Sentiments Vs Money

In healthcare, the vulnerability quotient is very high, as here you just can't stop the treatment in the middle and neither you can ignore or refuse an emergency case, on humanitarian or ethical grounds. Therefore, it becomes a catch-22 situation. Bomi Bhote, CEO, RHC, Pune sounds helpless in such a situation. "As far as I know, there is nothing much that you can do apart for begging and pleading until the concerned person agrees! Hospital is not like a hotel where if you don't have the requisite amount you are not allowed to enter a room. Here, in healthcare you cannot just take off the ventilator just because the patient/ relative is finding it difficult to pay!"

Facts & Figures

You may dub the debt issue as an occupational hazard, until you realise that it piles up to millions of dollars, driving so many healthcare institutes on the road of bankruptcy. Take for instance, the US-based South Miami-Dade County (non-profit hospital system) whose bad debt piled up to $131 million a few years ago, which was an increase of a whopping 254 per cent compared to its previous records. According to the American Hospital Association, the cost of overall uncompensated care (including bad debt and charity) for the US' 4,897 registered community hospitals scaled up to a phenomenal $34 billion in 2007. The majority of hospitals surveyed also noted an increase in the proportion of patients unable to pay for care. Uncompensated care was up eight percent from July to September 2008, versus the same period last year, according to the report. Coming back to India, unfortunately there is no official figure to authenticate the situation, but the situation would be no less grim, considering that 80 per cent of India pays out-of-pocket for healthcare.

May I Help You

"Technology not only helps in avoiding human errors, but also increase the overall efficiency" - Dr Rajan Pai CEO Manipal Education and Medical Group

"Paying in installments is a practical strategy as many cannot afford to pay a hefty amount in bulk" - Dr NC Borah Chairman GNRC Hospital, Guwahati

One effective strategy for coping up with the bad debt is exploring the idea of retail-like strategies wherein you assist the patients in the bill-payment process. Most of these strategies are special discounts, payment plans and online payment options. Many hospitals follow this strategy. For instance, take the case of HCG. "Firstly, we keep the doctors out of the financial matters, as their job is just to treat. We have a dedicated team of Medical Social Workers (MSWs) who regularly counsel family on these matters. They are trained in such matters," says Dr Ajai Kumar of HCG. The hospital has team of 40 MSWs. DMH has recruited two officers in its hospital called as 'Charity Officers' whose role is to regularly assess the paying capacity of the individuals and thereby decide who are entitled for 'charity' or at a discounted rate.

Pick & Choose

Instead of demanding huge sum of money in bulk, giving the patient some time and choice to pay in installments is by far the most effective and handy strategy. Normally, hospitals give an option of installments of up to six months. Says Dr NC Borah, Chairman, GNRC Hospital, Guwahati, "This is the most practical strategy to adopt by anyone as many cannot afford to pay a hefty amount in bulk."

Adds Nag Kumar, General Manager-Operations, Yashoda Hospitals, "We basically give the patient varied payment modes, with taking some amount in advance and making their expectations clear in due course of treatment, as to the amount that would be needed later-on, and the modes in which they can pay the same."

Flexibility is the mantra of the day. In the US, patients are offered numerous choices to pay, such as through mail, in person, credit card through an automated telephone system, and off-late online, wherein patients can set up a one-time payment or a recurring payment plan.

The Challenge

Discussions on payment methods is where hospitals meet with some of the greatest challenges. A fundamental issue for quite a few hospitals is trying to make patients understand that they are responsible for all, or a part of their healthcare costs. "It is actually a very difficult situation for the staff to get patients understand the relevance of the costs. For instance, in our hospital we get a lot of patients telling us that XYZ procedure costs cheaper at other places and with great difficulty we have to make them understand every detail and the reason of the costs," sighs Dr Ajai Kumar.

Ex-Serviceman Contributory Healthcare Scheme owes Ruby Hall Clinic a crore	An NGO owes bill amounting to $13,000 to Frontier Lifeline Hospital
The billing department of Deenanath Mangeshkar Hospital can make adjustments in bills without seeking any prior approval	Yashoda Hospitals gives varied payment modes to patients

Educating the Staff

Efforts are necessary on staff training. Dealing with revenue cycle matters with the staff at a health plan level is one thing, but dealing directly with the receiver of hospital's care is quite another. To handle this, hospitals are roping in financial services employees and imparting special training in customer services. For instance, Wockardt Hospitals and Apollo have round-the-clock customer service or floor executives to help the family/ patient at every step of the stay and clear every kind of confusion. "Handling patient expectations is the key target of communications. Training typically includes role playing and practicing scripts so that staff can respond appropriately to questions or concerns of patients," says Vishal Bali, CEO, Wockhardt Hospitals Group.

Giving staff more authority has yielded success. For instance at DMH, the billing department has complete freedom regarding the kind of adjustments that need to be made without seeking any prior approval.

Talk, Talk and Talk!

The ugliest of situations can be avoided by practicing some level of caution coupled with constant communication to the patient and family, in general. "From my personal experience, bad experiences are quite rare if you continuously keep on informing the patient about what the doctor is doing and the ramifications of the cost involved at every step of the treatment," feels S Subramanyam, GM - Operations, Apollo Hospitals, Hyderabad. In cases where Apollo finds out that the person is genuinely poor or not in a state to pay money, the hospital does try to waive off the fee. "To tell you the truth, there is no set protocol or standard strategy involved. You have to deal with it on a case-to-case basis. These incidents happen once or maybe twice in a month, and so we make an effort to sit with the patient/ family to clear his/ her doubts. A problem does arise when during the treatment process, the patient suddenly dies and the family does not agree to pay. In such times, after assessing the entire situation, we may even waive off the entire fee, if the family is found to be very poor," informs Subramanyam.

Follow-up Consistently

When someone refuses to pay, you should communicate and try to sort out matters with patience, without forgetting that the person with whom you are having the discussion is not in the right frame of mind or in the best of his/ her moods. Bali feels that the best thing to do is to follow-up. "In spite of everything, there have never been cases where it's a complete 'no'. The delays or lags do exist, but it's never the case that the claims do not get cleared at all," he avers.

Patient-Friendly Billing

One important reason for all the confusion and chaos is lack of 'patient friendly' billing process. The simpler it is, the lesser the confusion. Many a times, it is the case that the bill is given in the end or the patient is shocked to realise the 'hidden charges' which he/ she was not earlier told about. Moreover, with the rising awareness amongst the masses with the power of consumer court in their hands, the patients do end-up escalating such matters to the court.

Says Suyash Borar, COO, BM Birla Hospital, Kolkata, "One should simplify the entire billing or policy process by appointing a dedicated staff whose job is to make things easier for the patient to understand the limitations of his/ her policy and breakdown all the charges and mentally prepare the person about what he/ she should be expecting." BM Birla Hospital either demands a guarantor or gets a signatured contractual bond before the treatment. This has helped the hospital in not owing any major pending bills till date.

You Can Still Trust Blindly

Private healthcare is often criticised by many healthcare activists who shun them as 'money-spinning' machines with no place for 'emotions'. But a closer look, when it comes to money matters, shows that everyone in the industry are not too worried about bad debt. Leaders opine that trust is the fundamental principle on which they function. The logic is that not everyone is dishonest or here to cheat. They are all confident that everyone is willing to pay for quality healthcare, provided they have some options. Agrees Dr Kumar, "Ninety-eight per cent of the cases whose payments are overdue, do end-up paying. Albeit you have to negotiate and follow-up, but this is not a country where people are deceitful or insincere." Ideally, HCG allows 50 per cent of payment through installments. Another logic that works is the entire fear-complex that if you do not pay, the doctor would not end up treating! This also makes the relative weary and he/ she leaves no stone unturned without worrying about any monetary issues.

Technology Does Help

Technology is playing a pivotal role in the entire de-cluttering of the billing process. Agrees Subramanyam from Apollo, "I am in healthcare since the non-IT times and today I am witnessing the benefits of IT real-time. The billing department is one of the major beneficiaries of technology. The patient can get even minute-to-minute update about his bills right from the time he got himself registered."

Ditto is the case with Manipal Hospital, Bangalore. Dr Rajan Pai, CEO, Manipal Education and Medical Group, feels that technology not only helps in avoiding human errors but also increases the overall efficiency. "Online tools automatically verify coverage for insurance patients. All the policies and the terms and conditions that are applicable for the insured patient just gets available at the click of the button. Hence, even the front staff can be more co-operative in simplifying the rules and regulations and communicate things faster."

What Next?

With insurance expected to rise in India, the situation may aggravate further. If appropriate action is not taken or attention is not paid in this direction, the problem is going to grow manifold.

Having said that, claiming the pending bills may sound simpler than it actually is, as it involves human beings in the most sensitive state and a place where every life counts and time is more precious than money. But eventually, it is the job of the service providers to keep the family/ payer in loop at every step, to avoid further confusion and chaos and this is where the difficult part begins again!

nancy.singh@expressindia.com