I would like to stress on the following points, which has affected medical practice not only in Mumbai but the whole of India.

1. Medical Council of India - implementation of rules and regulations and its effect on the standard of education.
2. Even though the Constitution provides that medical care is the responsibility of the Government, the Government has miserably failed.
3. Contribution of private charitable hospitals in health care.
4. Contribution of corporate hospitals in health care.
5. The impact of mediclaim and cashless services in the practice of medicine.
6. Medical Tourism.

All these factors have changed the health care scenario in India and naturally in Mumbai. Since the article is on private practice in Mumbai, I would like to elaborate what impact the above factors have on private practice in Mumbai.

Mumbai is a cosmopolitan city as compared to any other city in India. It is progressive because it represents a miniature India where almost all segments of the population of India are represented and it is not dominated by any linguistic section.

1. Medical Council of India implementation of rules and regulations and its effect on the standard of education.
About 7-8 years ago during my tenure as a member of the Medical Council of India, the City of Mumbai was known as The Mecca of Medicine in India but it is no longer a true statement. The imposition of the rules of Medical Council in the past 10-15 years that only full time people can be teachers had a very negative impact on the progress of medicine and clinical research in Mumbai. The medical colleges of Mumbai were held in high esteem like Vellore and All India Institute of Medical Sciences in the standard of teaching and producing research papers. In the National Conferences doctors from Mumbai dominated the scientific deliberations in the past but it is no longer true. Many urban cities in India could afford to have full time doctors because living with the salary that they got was possible. Some states like Tamil Nadu had for decades allowed full time doctors to practice so they could progress in practice, teaching and research and also not suffer financially.

Mumbai city has a long history of honorary doctors who withstood competition of the highest degree in the Bombay medical colleges and institutions for decades and showed their brilliance in teaching. This was totally demolished by the Medical Council of India, by enforcing the practice of having full time teachers only in these medical institutions.This was supported by the Maharashtra Government and the Mumbai Municipality. I do admit there are brilliant dedicated teachers even today in our medical institutions who hold full time positions but their percentage is very low. If you look at the academic records of the teachers in these medical colleges, by and large, it is not upto the standard required to be a teacher. All those who have brilliant academic records, stay in the teaching institution for a short time, say for 4 to 5 years to get experience and then go into private practice. This deprives the medical institutions of the high standard of expertise gained if brilliant teachers stay in the institutes for a longer period. I know that I am making blunt statements but facts are facts and nobody can deny them. However, after long years of deliberation the Municipal Institutions now have allowed their teachers, who have attained 5 to 10 years of experience, to do private practice. I hope that these professionals who have been given this chance will not misuse this privilege, by concentrating only on private practice and not paying attention to their parent institute, that is medical colleges. If this trend continues in the city of Mumbai, by another decade or so the city will regain its status of having excellent teachers and the flag that was held high for many years will fly again. Today in Mumbai, because of lack of teachers, many postgraduate seats cannot be filled, which is a very sad state of affairs.

One of the policy decisions the Maharashtra Government took was to form a University known as Maharashtra University of Health Sciences. When it was being formed about 7-8 years ago, 50 senior teachers got together, and I was made the Convener. We strongly opposed the move, but it is very hard in our democratic society to oppose the will of the politicians. All the traditional Universities like Bombay University, Pune University Nagpur University etc. which were held in high esteem in the medical community were cut off with the formation of this Maharashtra University of Health Sciences. Politicians have a large say in granting affiliation by this University and they do so at their own will. The state of Karnataka formed a medical University earlier than Maharashtra and today I can say with confidence that the medical degrees given by Karnataka Medical University known as Rajiv Gandhi University of Medical Sciences carry a much lesser value than that which were given by traditional Universities like Bangalore and Mysore in the past. In another decade or so the medical degrees granted by Karnataka will not have much value and this will also happen in Maharashtra. The politicians who formed this University are totally responsible for this state of affairs. However, due to some legal issues, the postgraduate degrees given by Maharashtra Universities are still with the traditional Universities but the politicians are also trying to take these to the Maharashtra University of Health Sciences. The effect of this Maharashtra University of Health Sciences will be known to the community in another decade. We senior teachers tried our level best to see that they do not take away the affiliation from the traditional Universities but we could not succeed. If the politicians wished to have a medical college at Nasik for political compulsion they could have established an autonomous University and left the other medical institutions to run the way they were running for generations. In the past when the affiliation was given by the traditional Universities like Mumbai, Nagpur, Pune and others, there was a control by the Executive Council now known as Managing Council by the Maharashtra University Act. This Managing Council usually comprises 21 members of different faculties who are well educated people and have excelled in their field and the majority are holding Ph.D degrees. They could decide on their own about granting affiliations to various colleges. This has been completely broken by the formation of Maharashtra University of Health Sciences, which is controlled by politicians. This has lead to deterioration in the standard of medical education in the state of Maharashtra, which was held in high esteem for generations. Formerly people used to come to the City of Mumbai to get trained for their postgraduate education from all over the country but today students are going from Mumbai, out of the state, mainly to the South for better training. This is certainly disturbing for the prestige of the city of Mumbai and the State of Maharashtra in medical education.

2. Even though the Constitution provides that medical care is the responsibility of the Government, the Government has miserably failed
The constitution guarantees to provide health care and primary education to our citizens, our political leaders have miserably failed. It is only now that they are trying their best to give primary education and health care to our population. The recent proposal of the Finance Ministry to add 2% cess on income tax, to be used to give insurance to the population below the poverty line, is an indication that the Government of India wants to help the poor for health care.

3. Contributions of private charitable organizations in Mumbai in health care
Today with all the drawbacks, Mumbai city gives the best medical care to its citizens. There are 42,000 hospital beds in the city of Mumbai. The Municipal and Government hospitals maintain about 12,000 beds and the Charitable hospitals also maintain approximately 1200 beds in the city of Mumbai. The remaining 18,000 beds are provided by Nursing Homes and small hospitals. Both Municipal and Government hospitals do not provide even 25% of the medical care that the city requires. The budget of the Municipal corporation for medical care for this year is 830 crores and I am sure that approximately 150 crores may be spent by the Government for their hospitals in the city of Mumbai making a total of about 1000 crore of rupees for health care which is provided by the tax payers money. I must admit that the Municipality has the responsibility of spending money for preventive medicine as well. The remaining 75% of medical care especially secondary and tertiary care is provided by the charitable hospitals of Mumbai. These have been established by Philanthropists and are held on very high esteem in the whole country.

When the full time system was implemented in the medical colleges in Mumbai a large number of prominent teachers who were holding honorary positions had to leave and they moved to private hospitals for practice. This certainly had an effect on teaching in the medical colleges, which is now reflected in the quality of medical graduates from Mumbai who do not enjoy the same prestige as compared to the graduates passing from some of the premier institutions of our country. The students coming out of All India Institute of Medical Sciences, Vellore and many other Universities are holding significantly higher academic positions as compared to Mumbai today, which is a sad state of affairs. There are several instances where people who are trained in institutions especially in the South are migrating to Mumbai for practice and making a dent against the locally trained doctors, which is amply evident. This clearly sends a signal that the training in medical colleges has deteriorated and something needs to be done by the Government and the Municipality to improve the medical colleges of Mumbai city. The Government and the Municipality should increase the grants to the four medical colleges in Mumbai city, as these are premier institutions of this state for training of doctors.

The large private hospitals in Mumbai like Bombay Hospital, Jaslok Hospital, PD Hinduja National Hospital, Lilavati Hospital, SL Raheja Hospital, Nanavati Hospital and Breach Candy Hospital have contributed a lot to the health care of the city. Now there are many medium size hospitals like Cumballa Hill Hospital and Heart Institute, Saifee Hospital, Prince Aly Khan Hospital, Guru Nanak Hospital and many others which have also contributed a great deal. These hospitals have brought about a drastic change in the practice of medicine in the city of Mumbai. When highly trained professionals joined these private hospitals, they attained a significant name in professional services in the country. During the last several years, patients from all over India have been coming to these private institutions for best professional services.

The Association of Hospitals has a membership of 40 charitable hospitals but there are many other charitable hospitals who are not included in the list.

4. Contribution of corporate hospitals in health care
In the corporate sector Asian Heart Institute and Wockhardt Hospital have contributed significantly to tertiary care in the city. As more people get insured more tertiary care hospitals will be required. Besides companies like Wockhardt, Ranbaxy is also starting a chain of private hospitals. Foreign direct investment is also in the pipeline to establish hospitals in the country and the city of Mumbai.

5. The impact of Mediclaim and cashless services in the practice of medicine
With the introduction of cashless service primarily by the four government run insurance companies under Mediclaim there has been a drastic change. They have empowered third party administrators popularly known as TPAs. They are getting together and trying to replicate the health care delivery system in America, with its ills which have adversely affected the medical profession there. The TPAs want to control the professional charges of the doctors and are also in the process of trying to control the charges of the hospital. Unless the medical profession wakes up to this threat by the TPAs it will be too late and we will have to submit to them. In the end it is the patients who will suffer. People with vision must wake up, unite and counter the intentions of the TPAs and the insurance companies well in advance. They are playing the large institutions against the small nursing homes by focussing on the difference in the hospital charges and doctors fees.

For example, if a patient is insured for Rs. 5 lacs by paying a premium of Rs. 5,000/, the insurance company is bound to pay by law the charges of the hospitals and the doctors upto Rs. 5 lacs but the excess amount is to be paid by the patient if the charges exceed Rs. 5 lacs. Today with the introduction of highly specialised heart care like angioplasties, the hospital charges including the intensive care unit charges and materials in some cases goes up to around Rs. 10 lacs. Medicated stents cost Rs. 1 lac and 30 thousand and if 5 to 6 stents are introduced into the coronary arteries, the expenses are bound to be very high.

The Association of Hospitals in Mumbai of which I am an office bearer are trying our best to counter the strategy of the TPAs. I understand all the TPAs are trying to get together as a union to put a curb on the medical profession which many doctors are not aware of. The Association of Hospitals is trying to combat this menace which is likely to hurt the medical profession and the patients. But I also urge my colleagues to control their professional charges for the services they render a reasonable amount even though the patients are insured for a higher amount. For example if the patient is insured for 5 lacs and the hospital bill comes to Rs. 1 lac, there are instances where doctors demanded 4 lacs of rupees as fees because the patient is insured for Rs. 5 lacs. This is not morally correct. It will send wrong signals to the Insurance companies. All these issues are important because this attitude of the doctors in the 50’s and 60’s in America resulted in a drop in their income due to regulations by the Insurance companies and the Government. History always repeats itself and what happened in America will happen here unless we wake up and prevent this by discussions, negotiations, understanding the problems of the hospitals, doctors, insurance companies and TPAs.

I would like to give you an example. Recently my friend who practices colorectal surgery in America met me in Mumbai. A few years ago he used to get 2,500 dollars for colon resection and follow up for a period of three months. Today he is paid only 1200 dollars for colon resection and he has to take care of the patient for three months. The hospital charges for the above procedure are 14000 dollars. If this 14000 dollars is not paid to the hospital they would stop providing services. However they could get away by paying only 1200 dollars to the surgeon. There was no unity among the doctors and insurance companies took advantage of this situation. Some of the TPAs I understand have employed insurance agents from America for advice and are trying their level best to control the doctors and the hospitals. The medical professionals and the hospitals need to co-operate with each other so that the insurance companies do not have a handle to fight. We, in particular doctors should be united so that no insurance company will be able to throttle us. Medical Insurance is coming in a big way to our country and we must be prepared. In Cumballa Hill Hospital and Heart Institute until about three years ago 95% of the payment was done by the patients and 5% was by insurance companies. Today 60% of the payment is done by insurance companies and 40% is done by the patients directly. It will not be long before 100% of the payment is done by the insurance companies.

6. Medical Tourism
There is a lot of hype about medical tourism especially in the city of Mumbai.

Good health care demands a ratio of 4 beds per 1000 population. Even in Mumbai this does not exist and in the suburbs it is less than 2 beds per 1000. With the growth of population, the infra structure development for secondary and tertiary care is mandatory. Only the private sector can do this and the Government should encourage investments in health care by them. Many cities in the country are encouraging the private sector to build hospitals by giving free land. Mumbai city is unique in the sense it can get the funds but the land is not available so the Government should be liberal in giving land to the private institutions with special FSI consideration. This is the only way hospitals in Mumbai can come up with good infrastructure. The conditions that the Government puts for land and FSI allotment to develop infra structure in Mumbai should be economically viable.

I do not know what impact medical tourism will have on the practice of medicine in urban areas particularly Mumbai. We have to first take care of our own patients before we entertain patients from abroad for financial gains. It will be unfair to deny good patient care to our citizens and entertain medical tourist because they are able to pay a higher tariff. As the days go by, nature has its own way of settling issues that affect the common man. So I do not want to predict anything about medical tourism but I am only concerned that we need to create better institutions in our city and our medical colleges should be adequately funded by the Government. Teaching institutions are the backbone of the medical profession. These are the places where the present generation of experienced doctors train the future young doctors. The medical profession training is by a process of apprenticeship where seniors impart practical knowledge to juniors. This cannot be done by machines and information technology.

Chairman, Cumballa Hill Hospital and Heart Institute, Mumbai - 400 036.