The cost of a tablet

The wiry man, in his thirties walked slowly into the clinic accompanied by his equally thin wife and their five-year-old child. After going through his symptoms and signs, I understood that he was suffering from a spinal illness and prescribed him certain medications. Usually when I prescribe the treatment, whether it be surgical intervention or medications, I guess the patient’s affordability by ‘looking’ at them. Clothes, jewellery, footwear and phones — all of these give me an idea about how they would be able to handle the cost of their illness.

In the Western world, the treatment is purely based on science. The disease dictates the treatment more often than by the patient. However, in India, the patients’ socio-economic status plays a major role. The wife showed me a list of medications prescribed earlier by another younger colleague. I noticed that the medications were quite pricey while inexpensive formulations of the same drug was available. I gave them a new set of medications and later enquired with the colleague about his knowledge of price of drugs. His guesses were quite off target, which led me to think more on this.

The Indian healthcare system is contributed by both government hospitals including the tertiary, district, taluk hospitals and primary health centres, and the private hospitals, which include the clinics, nursing homes, small hospitals and huge corporate chains. The contribution from private healthcare system is huge in India and it is more than 60%. Doctors advise blood tests, scans, X-rays, and prescribe medications to the patients. However, how many doctors are aware of the cost of the individual tests they order or the cost of the medications they prescribe? Let us keep aside the minimal subset who rely on commissions from laboratories and scan centres who would be calculating their daily returns. A majority of doctors who work in big hospitals are unaware about the “cost” of their prescriptions. In a study among 2,500 doctors, 72% were “uncertain” about how much the tests, treatments, and procedures that they regularly recommended, cost their patients. And among the small percentage of physicians (28%) who have some knowledge of common medical costs, most are only “somewhat” (20%) certain of those costs.

In a developing country like India, this essential knowledge of medications is largely missing among the young doctors. Cost-consciousness in medical care becomes paramount where 60% live in poverty. Unlike other industries, the costing in health care is nebulous and extremely varied across the nation. The doctors who are at the helm of affairs should take active efforts to understand the affordability of the patient before prescribing treatment. This is a dual responsibility — evaluating the disease and providing the appropriate care but commensurate with the patient’s socio-economic status. A good doctor’s ability do not stop at delivering the correct treatment but also ensuring that it does not leave the poor indebted for life. This is more so true in the current scenario where the poor often mortgage their possessions and pawn their jewellery seeking what they assume as better treatment in corporate hospitals. Patients are often embarrassed to tell their doctors when they cannot afford their medicines. This can lead to further penury or may make them skip their medications resulting in disease worsening.

Telltale signs

The doctor should make an active effort to understand the patient’s affordability while eliciting the history and physical findings. The families’ garbs, a broken toy in the child’s hand, a bare yellow thread in the woman’s neck, a torn shirt collar and an unreserved train ticket among the pile of medical prescriptions would easily explain their financial status. The doctor should also be aware about the exact cost of the different medical tests that he orders for a patient. It should not be left to the patient and the cashier to deal with this. When one is aware of the cost while buying a thing, he/she should also be aware of the cost of his “suggestions” and “advice” too. The price of a medicine varies widely according to the brand and its combinations. A tablet can become cheaper from hundred to 10 rupees based on the brand, while the efficacy remains the same. Without a knowledge of the drug pricing, the doctor would not be able to help the poor patient. In confounding situations, the doctor should resort to generic medications or scour the Internet to provide alternative inexpensive drugs.

Indian healthcare has undergone huge transformation in the last two decades with increasing reliance on private healthcare. Barring the few egregious unethical doctors, the rest of the doctors practising in big hospitals require extreme vigilance, egalitarianism, empathy and active efforts to bring down the cost of healthcare. Though the government and the private management can do, or are doing, this at different levels, the doctors who are the delivering hands require sincere active efforts. While there should never be a compromise on the quality of treatment, medico-legal protection and patients’ safety, a huge difference in the cost of care especially to the poor patient can be ensured only by the socially conscious doctor.

rishiortho@gmail.com