Cost of Intensive Care in India

The cost of critical care is widely recognized as being both expensive and increasing. It remains a challenge to accurately assess the cost of intensive care due to lack of standardized methodology. There is also considerable heterogeneity between countries and even within the country in allocation of resources and distribution of critical care services and cost of personnel and price of drugs. The indivisibility and intangibility of several health care outcomes is also a concern, particularly while evaluating cost effectiveness. More importantly, when it comes to health care needs, the emotions and ethics of the society is often compelling and most are willing to accept the cost even in situations where effectiveness is not clearly established. The objective of this article is to review these issues and develop a framework through which cost of Intensive care in India can be analyzed.

There are only very few studies looking into cost of intensive care in India. This is not surprising as critical care medicine is relatively a new field though it has evolved significantly over the past decade. In order to understand the cost, it is important to understand the current organization of critical care services in India and its inherent diversity and the reader is referred to an excellent review on this subject.

It is estimated that there are about 70,000 ICU beds available including all types and across all hospitals and small time nursing homes in India that cater to five million patients requiring ICU admission every year. India currently spends Rs.103,000 crore on healthcare, which is projected to grow to Rs.283,000 crore by 2012. However, government and international agencies will only be able to spend Rs.30,000 crore over the next 10 years on healthcare infrastructure. Therefore almost 80 per cent of investment will have to come from the for-profit private and charitable sector where Critical Care accounts for 20 to 30 per cent of a hospital's budget. In the absence of comprehensive insurance cover, more than 80% patients have to pay out of their pocket for health care services. Despite growth in economy and development of a middle class population with purchasing power, it is well accepted that one episode of hospitalization is enough to account for 58% of per capita expenditure pushing 2.2% below the poverty line. Even more disconcerting is the fact that more than 40% of those admitted to an ICU had to borrow money or sell assets. Understanding these issues create ethical dilemma for the clinician, particularly when the clinical status of the patient suggests a poor outcome. Unfortunately, the common man perceives that miracles regularly happen in ICU and lacks a realistic expectation of critical care outcome.

Hence patient affordability to access critical care services becomes an important factor and from a service provider's angle, payments may become a problem. In a for profit model, perceived financial gains may not be realized in turn forcing the organization to reengineer capital budgeting with its potential impact on service delivery. On the other hand, several government run ICUs where costs of care may exceed available funding, are noted to have limited resources, lack of infrastructure, trained intensivists and support staff. Thus routine hospital care is dependent on some form of formal or informal cost-sharing process and when the cost of intensive care is added to this burden, the clinician is faced with the dilemma of overall sustainability of the unit. Nevertheless, in appropriately selected patients, the prospects for survival in ICU are much greater than care in the general ward. It is, therefore, essential to analyze the accurate cost of intensive care and translate it appropriately for better resource allocation to benefit the critically ill.

Cost control measures

Any cost minimizing strategy has to be internally fashioned than being externally imposed to optimize results. At the same time quality of care will suffer if cost cutting is the sole determinant of care. Hence a balance is required and in this regard, the cost block methodology apart from providing a framework for estimation of costs is also useful in analyzing methods to minimize it. Moreover optimization of various other factors such as organization/staffing, reduction of errors/critical incidents, ongoing audits/staff training, practicing preventive intensive care/application of telemedicine etc can impact these blocks in turn bringing down the total ICU costs.

Implementation of preventive intensive care

Despite formulation of ISCCM position statement on Limiting life-prolonging interventions and providing palliative care towards the end-of-life in Indian intensive care units, the legal implications are unclear. Still end of life decisions and rationing takes place with considerable variation between public and private sector hospitals. On the other hand the apparent economic benefit of alternative care for critically ill patients represents cost shifting rather than cost saving when patients do not die but instead continue to receive care elsewhere. Home care is an option but considering the unique constraints of both nuclear as well as joint families in India, it is unlikely to translate into a cost advantage. In view of these complexities, it is prudent to analyze ways to minimize ICU admissions or practice measures to decrease length of stay by either early optimization or preventing secondary complications. In this regard advent of Medical emergency teams (MET) is of note. Another area not explored or studied in the Indian context is improving emergency department (ED)-ICU axis, as the relationship is a mutual one, with each affecting the other in a continuous feedback loop. Involvement in ED care as sepsis team or trauma teams with interventions such early goal directed therapy, institution of non-invasive ventilation, stabilization following trauma etc can improve subsequent quality of care and outcome and reduce costs. Professional bodies and experts advocate adherence to clinical practice guidelines and implementation of protocols and care bundles to achieve the latter objective.

Minimising errors and critical incidents

It is well proven fact that medication errors and other near misses add to the cost of care and is more common in ICU context. In India, absence of a nation-wide reporting system and blame free culture prevents staff from either admitting or reporting mistakes. This makes estimation it's true incidence and impact on ICU costs difficult. Solution to circumvent this include staff training, close supervision and developing a web-based anonymous reporting gateway.

Financial and management training for ICU leaders

Most doctors have very little interest in matters pertaining to finance and accounts. This is not surprising as management and financial training is not part of medical curriculum. So the minority of physicians who have an interest in this line are forced to look outside the realm of medical education and depend on other educational organization and bodies to pursue training and accreditation in this track. Despite this unhappy marriage of finance and medicine, it is going to stay and assumes growing importance as reflected by the theme of this article. Hence it is imperative that ICU director is trained in financial decision-making. This in turn allows the intensivist to execute appropriate accounting methods, capital budgeting and resource management. Also acquiring negotiation skills will be useful in dealing with financial directors, hospital managers and other personnel funding the ICU. All these invariably translate into cost containment.

Conclusions

In this review by analyzing cost of intensive care in India, we refrained from arriving at an arbitrary number or range indicting the cost of ICU care on a daily or monthly basis as we felt it is impractical of little use. Also we didn't elaborate on insurance plans, which are currently not designed to cover the cost of critical illness. On the other hand an attempt was made to define key problems in Indian Intensive care, develop a framework for cost analysis and address some cost minimizing measures. Health systems in every nation need innovation and improvement. But it is also important to appreciate that remedies imported from commerce have consistently yielded inferior care at inflated prices. Hence apart from our professional, moral and ethical obligations as care providers, it is imperative that we deliver quality care cost effectively.