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Morning Medtalks with Dr KK Aggarwal 31st May 2018

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Dr KK Aggarwal    31 May 2018

Policy: Comments invited in 30 days

 No.F.22/7610/DAK/DHS/ Delhi Government ADVISORY

A committee comprising of nine members was constituted by the Honble Minister of Health, Govt. of NCT of Delhi for formulating a policy regarding allegations of excessive charges, refusal/ delay in providing immediate medical treatment to victims of crimes or road accidents, unfair employment practices, etc. by private hospitals/ nursing homes.

The committee deliberated on each aspect mentioned below and gave its recommendations:

(I) Mechanism to be developed so that all hospital should preferably only drugs mentioned in National List of Essential Medicines (NLEM)

  1. All doctors in NCT of Delhi practicing modern system of medicine should preferably prescribe drugs from NLEM list. Prior to prescribing non-NLEM drugs, the patient shall be counselled and a printed counselling material shall be provided for the perusal of the patient and his/her attendant. The same shall also be displayed at conspicuous places in the hospital.
  2. Drug Controller, GNCTD shall display the lists of wholesale/ retail chemist shops having stock of NLEM drugs on Delhi Government Website.
  3. It is recommended that Drug Controller, GNCTD should direct all wholesale & retail chemists/ pharmacies in NCT of Delhi, issued license under Drug and Cosmetic Act, 1940 and Rules made thereunder, to ensure the availability of NLEM drugs in their pharmacy.
  4. All nursing homes/ private hospitals registered under Delhi Nursing Homes Registration Act, 1953 and Rules made thereunder shall ensure the availability of NLEM drugs for indoor patients.
  5. It is suggested that NLEM drugs should have a distinct colour coding/sticker. Drug Controller, GNCTD to take requisite actions in consultation with Central Government for implementing the same.
  6. Disposables to be classified under NLEM and non-N LEM categories.

(II) (A) Prices to be charged by private hospitals for medicines and consumables

  1. NLEM Drugs:

Prices of NLEM have already been fixed by the Government and clinical establishments can bill these items on their MRP.

    b. Non-NLEM Drugs:

All clinical establishments shall bill non-NLEM drugs/ disposables at their respective procurement price + maximum upto additional 50% as mark-up against administrative/ handling charges or MRP, whichever is less.

  c. Consumables/ Disposables:

All clinical establishments shall bill non-NLEM drugs/ disposables at their respective procurement price + maximum upto additional 50% as mark-up against administrative/ handling charges or MRP, whichever is less.

 d. Implants:

All clinical establishments shall bill non-NLEM drugs/ disposables at their respective procurement price + maximum upto additional 35% as mark-up against administrative/ handling charges or MRP, whichever is less.

(II) (B) Price to be charged by private hospitals for investigations

A sub-committee has been constituted for capping the prices to be charged by private hospitals for investigations.

(II) (C) Not compelling patients to buy dins from in-house pharmacy

  1. This issue will become supererogatory once prices of non-NLEM drugs/ disposables are capped.
  2. The option of buying drugs from any pharmacy, in-house or otherwise, should be open.
  3. Exception can be for emergency/critical cases.

(III)  Packages fixed by private hospitals for operative procedures

  1. Package should be transparent without any hidden charges.
  2. Package should disclose whether it covers complication(s) or not.
  3. If a particular package does not cover complications, proper counselling should be done about all possible complications and their financial implications.
  4. Mechanism to be developed by hospitals/nursing homes for mandatory recording of counselling. Video recording should be preferred.
  5. Any additional procedure performed on the patient shall be charged at 50% of its original rate.
  6. Package covering complications i.e. High Risk package shall cost not more than 20% higher. High Risk package must be clearly defined so that there is no ambiguity.

(IV)  Billing and payments regarding unforeseen events, including death, during the course of indoor treatment tit. payment to be made by the family of a patient who has died while undergoing indoor treatment

  1. Hospital may consider levying extra charges in packages before surgery to insure the complication and this may be displayed at conspicuous places, especially at the admission counter, in the hospital premises.
  2. If the patient dies in the Emergency Room/ Casualty Department of the hospital within six hours of his/ her arrival therein, the hospital shall waive off 50% of the total bilL Any death occurring between six to twenty four hours of the arrival of the patient, the hospital shall waive off 20% of the total bill.

(V)  To develop a mechanism for eradicating cuts and commission in medial practice

  1. Declaration on the bill that no cuts/ commission has been given to any person, including doctors (Allopathic, AYUSH, etc.); paramedics; individuals; organisations; etc.,
  2. Patient has the right to decide whether any consultation/ counselling are required by the referring doctor during his course of indoor admission in the hospital.
  3. Any charges paid to doctors/ individuals/organisations without consent/knowledge of the patient and not reflecting in the patients bill should be considered a malpractice.
  4. Salaries and consultation charges disbursed to all employees of the hospital, including doctors, shall not be made in cash. All payment made by the hospital for a sum of Rs. 20,000/- or more in a financial year has to be made by cheque/ banking channels only.

(VI)  Providing immediate medical care without any delay

  1. Clause 14.2 of the Schedule appended with Rule 14 of Delhi Nursing Homes (Amendment) Rules, 2011 states that the nursing home shall not refuse treatment to the injured/ serious patients brought to them due to any reason whatsoever.
  2. An order dated 21.02.2013 was issued to all Directors/Medical Superintendents of all hospitals in NCT of Delhi reg. providing immediate medical treatment to victims of crimes or road accidents.
  3. Cost of treatment of all medico-legal road accident victims, where the incident has occurred in NCT of Delhi, shall be reimbursed by the government as per DGEHS/ approved rates. Reimbursement shall be done only for those cases where the incident has occurred in the jurisdiction of Delhi Police and medico-legal case has been prepared either by the private hospital/ nursing home which has received the patient or by the private hospital/ nursing home where the patient has been transferred after stabilization.

(VII) Maintaining due dignity of dead person under all circumstances

  1. No dead body can be detained in the hospital for want of non-payment of dues
  2. Showing disrespect and inflicting indignity to the dead body, even in the form of detainment for want of non-payment of dues, is to be considered as an offence.
  3. No hospital under any circumstances shall show any kind of disrespect to the dead body.

(VIII) All necessary steps to be taken to avoid medical negligence and emphasis on patient safety 

Standard Operating Procedures (SOPs) to be developed and to be strictly abided

(IX) TO stop the practice of levying arbitrary items like compulsory donation, billing charges etc. by some private hospitals in the billing of patients

 Levying arbitrary items is unlawful and requisite action would be taken by the concerned authorities.

(X) Other issues

  1. All registered nursing homes/ private hospitals having bed strength of 10 beds or more to be empanelled under DGEHS scheme.
  2. A committee to be constituted for revising DGEHS rates and thereafter, these rates should be revised annually either on the basis of Wholesale Price Index (WPI)/ Dearness Allowance (DA).
  3. Consultation charges of doctors, room tariff, nursing charges, diagnostic charges, etc. should be displayed at conspicuous place in the hospital premises and/ or should be available in the reception/ helpdesk.
  4. Unused medicines and consumables must not be billed against the patient.
  5. Every nursing home/ private hospital to be linked with a large multispecialty/ super specialty hospital and to provide ambulance for shifting patient to the linked hospital or any other hospital.
  6. Hospital to develop a clear policy that if the primary consultant/operating surgeon is not available then which doctor shall be attending to the patient.

In order to strictly implement the recommendations of the committee, suitable/ requisite amendments will be made in Delhi Nursing Homes Registration (Amendment) Rules, 2011.

Keepers of all private hospitals/ nursing homes in the National Capital Territory of Delhi, registered under Delhi Nursing Homes Registration Act, 1953 and Rules made thereunder, are advised to properly adhere to the above guidelines.

(Dr. Kirti Shushan)

Director Health Services, GNCTD

Public Health

  1. Site to preserve: https://vizhub.healthdata.org/gbd-compare/#
  2. Over 2,000 super-speciality hospitals have decided not to be a part of the Modi government’s ambitious healthcare scheme Ayushman Bharat. According to them the government reimbursement rates are as low as 11-15 per cent of the actual costs of surgeries or procedures. The government said it is voluntary for hospitals to participate in the scheme, expected to be launched by Prime Minister Narendra Modi on 15 August and that the decision of these hospitals won’t affect its implementation.
  3. Hypertension or high blood pressure affects nearly three in 10 Indians and is responsible for 17.5 percent of all deaths and 9.7 percent of disability-adjusted life years in India, according to data released in 2017.
  4. Hypertension was also the fourth-leading risk factor for death and disability and responsible for over 1.6 million deaths in India—more than the population of Mauritius and double the population of Bhutan–in 2016, according to the Global Burden of Disease data collated by the Washington-based Institute for Health Metrics and Evaluation.
  5. Biosafety in laboratories: There are four biosafety levels (BSL) labs. BSL 1 lab has basic set-up with minimal risk to the individuals themselves because the organisms they handle are not very harmful. BSL 4 labs, on the other hand handle contagious organisms like ebola, Nipah etc. The lab is located in a separate building or in an isolated and restricted zone of the building. Workers are required to change clothing before entering and must shower and decontaminate all materials before leaving. The entrance and exit doors must be on different sides and automated. Labs The equipments are quite advanced, and security is top notch. Manipal and Pune are the only two top level (BSL 3 and 4) labs in the country.
  6. Produced by the AICR and the World Cancer Research Fund (WCRF): Overweight or obesity is a cause of at least 12 cancers, as follows: liver, ovarian, prostate (advanced), stomach (cardia), oropharyngeal, colorectal, breast (postmenopausal), gallbladder, kidney, oesophageal adenocarcinoma, pancreatic, and endometrial.
  7. Life style cancer preventing changes: Healthy weight, physically active, consume a diet that is rich in whole grains, vegetables, fruit, and beans, Limiting consumption of fast foods and other processed foods high in fat, starches, or sugars; red and processed meat; sugar-sweetened drinks; and alcohol intake, Not to use high-dose dietary supplements for cancer prevention; instead, the goal should be to meet nutritional needs through diet alone.
  8. AEFI surveillance: There has been an increase in reporting of AEFIs over the years to about 1500 per year. However, there is still gross under-reporting of AEFIs considering that more than 600 million vaccine doses are administered routinely each year and additional doses are given during campaigns. At least 5000-6000 AEFI cases should be reported each year. (Views: this must be emphasised, or the media will report each side effect as a sensational story)

Clinical

  1. The US Food and Drug Administration has provided marketing clearance for a device capable of detecting specific sepsis-causing bacterial pathogens directly from a whole blood specimen in around 5 hours. T2 Biosystems’ T2Bacteria Panel has been approved for the direct detection of bacterial species in the whole blood specimens of patients with possible bloodstream infections. Its processing speed significantly improves on the market’s previous standard of 3-day blood culture tests.

World Health Assembly

  1. Delegates agreed a resolution that aims to reduce the number of people around the world who are either killed or are physically or mentally disabled by snakebite. An estimated 1.8 - 2.7 million people are bitten by venomous snakes each year, with between 81 000 and 138 000 people dying as a result. For every person who dies following a snakebite, another four or five are left with disabilities such as blindness, restricted mobility or amputation, and post-traumatic stress disorder.

Snakebite overwhelmingly affects people from poor agricultural and herding communities and was categorized by WHO last year as a high-priority neglected tropical disease. Poor prevention, health worker training, diagnosis and treatment of cases of snakebite, as well as a lack of available tools, are all holding up progress on addressing the global burden of the disease.

Acknowledging the urgent need to improve access to safe, effective and affordable antivenoms for snakebite, delegates urged WHO to accelerate and coordinate global efforts to control snakebite envenoming - the life-threatening disease that follows the bite of a venomous snake.

  1. Worldwide, 23% of adults and 81% of adolescents aged 11-17 years do not meet the global recommendations for physical activity. Prevalence of inactivity is as high as 80% in some adult populations influenced by changing patterns of transportation, use of technology, urbanization and cultural values.

Financial Health

  1. Similarly, assessee is a cardiologist purchased the second hand machines for use as spare parts to existing equipments is allowable as revenue expenditure. Refer Aswanth N.Rao v ACIT 326 ITR 188.
  2. The Supreme Court held that warranty is an integral part of the sale price and if the warranty expenses are properly ascertainable and discounted on accrual basis deduction is allowable u/s. 37 of the Act. Refer, Rotork Controls India P. Ltd. (2009) 314 ITR 62 (SC).
  3. Repair expenses incurred by the assessee on the rented premises are allowable u/s. 37(1) of the Act. Refer Alkem Laboratories (P) Ltd. 28 DTR 11.
  4. Director’s Bonus: Bonus paid for services of working directors cannot be disallowed just because they hold a few shares in assessee company. Refer ACIT v Mandovi Motors (P) Ltd 8 Taxmann.com 255.

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