Social mobilisation and participatory processes which hold regulators as well as hospitals accountable, while providing systematic support and technical advice to affected persons, can add major value to regulatory processes and ensure that ‘regulation on paper’ gets translated into ‘regulation for people’.
A works as a contractual teacher in a college, based in a rural area of Ahmednagar district. During the COVID second wave, he had to regularly carry out his college duties to somehow make ends meet. This is when he came down with COVID and became seriously ill. As his condition deteriorated, the desperate search for an oxygen bed began, and he somehow got a bed at a private hospital. His students, fellow teachers and neighbours raised Rs. 91,000 through contributions for his treatment. In addition his family had to take a loan to pay for hospital expenses which were escalating every day, and the bill from the hospital where he was finally treated reached nearly Rs. 2 lakhs – a large sum for this rural family.
Fortunately A recovered from COVID, but his struggle to deal with the massive hospital fees, which had left the family heavily indebted, had just begun. He came to know about the official process of collecting overcharging complaints, and submitted his application for audit of the hospital bill. The first round of audit by local officials declared that ‘there is no overcharging by the private hospital’. However after the involved civil society networks came to know about his case, they analysed his bill, documented various excess charges and insisted to district health officials to reopen his case, following which a revised audit was initiated.
Now doctors from the private hospital began to pressurise A. to withdraw his complaint; he started receiving threatening phone calls, and the hospital even sent goons to his house to intimidate him. A was under severe mental stress and even perceived threats to his life but remained firm in his complaint, since he was convinced that his hospital bill was inflated. The involved civil society networks met concerned officials and advocated for a fair audit, while presenting analysis of his inflated hospital bill and citing government regulations. Finally, the revised audit was completed, and health officials ensured that the private hospital refunded Rs. 79,000 to A as excess fees charged in violation of COVID regulations.
A’s case is an example of a remarkable process unfolding across Maharashtra, where hundreds of COVID patients and families who were overcharged by private hospitals during the epidemic have been organised by civil society networks to demand audits of their hospital bills, and have begun to receive refunds of excess charged amounts. These audits and refunds are being organised through a collaborative state government – civil society process, which demonstrates the catalytic role which can be played by social accountability in ensuring effective regulation.
During the COVID epidemic, Maharashtra witnessed the largest number of COVID cases and deaths among Indian states. It was also one of the first states to issue orders, in May 2020, regulating rates for COVID treatment in private hospitals, through making use of provisions of the National Disaster Management Act. During the COVID second wave in mid-2021, over half of the COVID hospitalisations in Maharashtra were at private hospitals, with frequent complaints of inflation of bills despite regulatory orders.
Analysis of bills for COVID treatment revealed massive levels of overcharging compared to government mandated rates. 1,954 patients (75 per cent of all cases) had experienced overcharging compared to the rates defined by official COVID regulations. On average, a whopping Rs. 21,215 per day had been charged by private hospitals for COVID treatment, which was nearly three times the official rates for COVID Intensive Care Unit care.
The state government appointed audit officials from mid-2020 onwards who conducted scrutiny of COVID hospital bills in certain large cities like Mumbai and Pune, which ensured containment of private hospital bills by significant amounts. However these measures proved insufficient for regulation of private hospital rates for COVID treatment, especially in smaller cities, towns and rural areas.
Keeping such experiences in view, two large civil society networks – Corona Ekal Mahila Punarvasan Samiti [CEMPS], which is working to support COVID widows and families of COVID victims, and Jan Arogya Abhiyan [JAA], which involves health activists, professionals and researchers, reached out to COVID patients and families across Maharashtra in the second half of 2021. CEMPS and JAA conducted an online survey covering 2,579 families of COVID patients as respondents, documenting the scale of hospitalisation expenses which they had experienced during COVID treatment. This survey was conducted in September 2021, collecting data from families of COVID patients spread across 204 blocks of 34 districts of Maharashtra who had undergone treatment in various hospitals, and had perceived complaints about excessive bills. Analysis of bills for COVID treatment revealed massive levels of overcharging compared to government mandated rates. 1,954 patients (75 per cent of all cases) had experienced overcharging compared to the rates defined by official COVID regulations. On average, a whopping Rs. 21,215 per day had been charged by private hospitals for COVID treatment, which was nearly three times the official rates for COVID Intensive Care Unit care.
The striking findings of this survey were widely covered by media in the state, and experiences of major overcharging were shared in ‘Anger Assemblies’organised by CEMPS and JAA in Nashik (September 27, 2021) and Pune (October 8, 2021). Here, dozens of COVID widows and affected family members congregated to share their testimonies of double devastation; reeling from the death of a family member due to COVID, they had been further devastated by hugely inflated hospitalisation expenses.
Using this impactful study report, CEMPS and JAA representatives had a meeting with Parliamentarian Supriya Sule, Maharashtra Health Minister Rajesh Tope, and State health department officials on October 12, 2021, in which the findings of widespread and large-scale overcharging were presented. The demand was made that all such cases must be duly audited, and justice should be ensured to overcharged COVID patients and their families.
Advocacy efforts lead to government-authorised auditing of hospital bills
Subsequently, the Health Minister issued an order on November 11, 2021 to conduct audits of hospital bills and recovery of excess charges, regarding all COVID cases in Maharashtra with complaints of overcharging. This was a remarkable decision with risk of inviting backlash from the private sector, considering the fact that payments of such hospital bills had already been made by patients several months ago, and the process of demanding refunds might publicly ‘prove’ that identified private hospitals had exploited patients.
The Maharashtra Health Minister issued an order on November 11, 2021 to conduct audits of hospital bills and recovery of excess charges, regarding all COVID cases in Maharashtra with complaints of overcharging. This was a remarkable decision.
The involved civil society networks rapidly collected and processed grievances related to overcharging from across the state, submitting 462 overcharging complaints to the Health department during October and November 2021. While applications were received from all regions, nearly three-fourth of complaints were from five districts – Nashik, Pune, Ahmednagar, Solapur and Aurangabad. Complainants were organised through region-wise social media groups and online meetings to ensure effective coordination and follow up of each case.
However, issuing of audit orders and submission of documented complaints has been just the beginning of a complex and contested process, which demonstrated how implementation of legal regulation may need to be supported with considerable technical and social facilitation. Health professionals associated with JAA have so far analysed hundreds of technically complex hospital bills, (which sometimes run into several pages of separate items), pointing out specific items in each bill where the charges are in violation of COVID regulations. Based on this, once the audit process is completed by concerned officials, orders for recovery are issued to the concerned hospitals.
Victories, and lessons
So far, 50 COVID patient families have received refunds of excess charges from private hospitals (average refunded amounts being Rs. 25,000 per patient). These refunds have been achieved in the face of stiff resistance by many private hospitals, which adopted diverse strategies to deny refunds, ranging from refusing to provide the bill, citing technical loopholes, massively inflating medicine and investigation bills (which largely fall beyond regulation of hospital bed rates), avoiding responding to official orders, and even physically threatening complainants to withdraw their applications, as seen in A’s case. On a related track, consequent to advocacy by JAA, the Maharashtra government issued an order on November 15 last year mandating display of the 13-point patients’ rights charter inside all public and private hospitals across Maharashtra. This includes patients’ right to information, transparency related to charges and billing, and access to all medical records and reports, which can check further overcharging and enhance accountability.
The COVID epidemic has taught us many painful lessons regarding health systems, among which one of the most important ones is that if healthcare is completely left to the market, the results can be catastrophic: chaos, denial of care, and massive exploitation of patients.
So far, 50 COVID patient families have received refunds of excess charges from private hospitals (average refunded amounts being Rs. 25,000 per patient). These refunds have been achieved in the face of stiff resistance by many private hospitals.
Fifteen state governments across India recognised such market failures and issued orders for regulation of rates for COVID care in private hospitals in 2020 and 2021. Yet as the Maharashtra experience has shown, regulatory orders are necessary but not sufficient, especially in the Indian context where private hospitals have historically been largely unregulated, enjoying a culture of impunity regarding their rates and practices.
Social mobilisation and participatory processes which hold regulators as well as hospitals accountable, while providing systematic support and technical advice to affected persons, can add major value to regulatory processes and ensure that ‘regulation on paper’ gets translated into ‘regulation for people’. We can view the Maharashtra participatory hospital bills audit as a significant step, providing valuable lessons towards making private healthcare socially accountable.
If the COVID epidemic becomes an impetus for reorganisation of health systems in our country, there is no doubt that such social accountability of healthcare providers will become an essential agenda.