The Hidden Costs of Care

George Mathew, an HR professional, was admitted to a hospital with an acute stomachache. The establishment where he spent three days is part of a big hospital chain with significant presence across North India. Post-hospitalization, he was handed a bill of over ₹75,000, of which ₹4,101— about 5 per cent—was listed as “other charges”. The document is a classic example of the myriad and often mysterious ways that hospital bills bulk up. These miscellaneous costs included admission charges, medical evaluation for the third-party administrator (TPA) and medical history assessment. He was also billed thrice for care, hygiene and infection control, one for each day spent in the hospital. The consultant fees made up a few pages of the invoice with a few more listing out the consumables such as syringes, gloves, infusion sets and wet absorption sheets that had been used. These charges were in addition to the bed charges of about `5,000 per day for a twin sharing room. It is interesting to note that the bed charges do not automatically include charges for infection control or basic care. Equally interesting is the fact that medical history assessment was separately invoiced when it would have been done by doctors whose fees were already accounted for.

In 2020, the Insurance Regulatory and Development Authority of India (IRDAI) attempted to bring a modicum of order into the billing processes of corporate hospitals with a master circular for health insurance TPAs (third-party administrators). The circular noted that billing could only happen on specific heads such as bed and nursing charges, ICU charges, OT charges, medicine and consumables, professional fees, investigation charges, package charges and miscellaneous charges. However, four years on, hospitals have introduced categories such as “disinfection fees” and “additional procedure charges” to sidestep extant regulations. This practice has been identified as one of the contributors to healthcare inflation.

In George’s case, doctors classified him as NBM (which stands for “nothing by mouth”), as he was unable to digest food. Only on the last day, to test whether he was capable of ingesting something without the excruciating pain making a comeback, he was given a small, semi-solid meal. So his bill had no charges for meals and consultations with a dietician—two categories that can be found in most hospital bills today. A medicine resident at a top hospital explains that earlier, hospital food was a simple affair and all patients would get the same meal. “But now all hospitals have a dietician who will visit the patient, ask a few questions about their food preferences and bowel movements and then make individualized recommendations,” he says. “Not all patients need specialized or even a personalized diet.” The dietician’s daily charge might seem small, but for a long hospital stay, it can form a big chunk of the bill.

Hospitals also charge patients for oxygen in the ICU, which was never billed separately until the second wave of Covid-19, and oxygen, for the first time ever, became a scarce commodity nationally. India’s healthcare behemoths were quick to pounce on a pandemic-triggered panic to turn oxygen into another source of profit. Despite already levying a Goods and Service Tax of 2.5 per cent on room rent, hospitals often add an additional “service charge” to the bill, emulating a controversial practice of the restaurant industry that may have finally been buried following a ruling of the Delhi High Court disallowing it. Hospitals continue to get away with it. A hospital executive based in Noida admits that the room rents are exorbitant at the hospital where they work while also involving significant exclusions. They do not include the cost of the patient’s food, dietician fee or oxygen; even the towel used for sponging the patient and the toiletries provided are separately charged in some cases. “Sometimes attendants will bluntly tell you that your room rent may be listed as ₹12,000 but is actually ₹20,000,” the executive said.

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Except during the recent pandemic, the central government has never regulated hospital pricing, choosing instead to hide behind the convenient fact that public health is for state governments to address. In 2019, the minister of state for health and family welfare, Anupriya Patel, told the Lok Sabha that taking corrective measures regarding inflated bills of insured patients falls under the jurisdiction of the state and union territory governments.

This reluctance to seek accountability from the private sector has far reaching consequences. In 2023, a report released by the insurance technology company Plum Insurance, entitled ‘Health Report of Corporate India’, estimates that at an annual growth of 14 per cent, healthcare inflation in India is the highest in Asia. It highlights that the average cost of consulting a general physician is ₹300 and ₹1,000 for a specialist. The sum further increases to `2,500 to consult a mental health professional. It is well known that consultation charges of specialists can vary widely based on location. Gurgaon resident Aditi Sinha discovered this when her husband contracted Covid-19 and suffered such severe lung damage that he was forced to move out of Delhi-NCR. “The pulmonologist in Goa charged `500 per visit,” she says. “But the doctor at the corporate hospital we went to in Delhi—who did not even do a chest X-ray to diagnose his discomfort—charged ₹3,000.”

Medical literature is largely silent on the billing practices of private hospitals, but hospital bills reveal many ways in which Indians pay extra for private healthcare. While inflation in healthcare does have a strong correlation to the living expenses of a city, excess charges are not limited to Tier I cities; they exist wherever branches of well-known hospital chains exist. Yet, the intrinsic faith most Indians still have in doctors ensures that medical bills are not scrutinized enough, so long as they are not beyond the patient’s means. Even the more sceptical ones may find it difficult to make sense of hospital bills, thwarted by the rampant use of medical jargon. But when families gather the courage to challenge random charges, they can be waived off. Corporate hospitals are usually eager to avoid anything that might lead to a public relations disaster, so threatening to publicise a dispute using traditional or social media can sometimes resolve matters in the patient’s favour.

Edited excerpt from Games Hospitals Play: Decoding Your Private Healthcare Experience by Abantika Ghosh, published by Bloomsbury.

Abantika Ghosh is a journalist and public policy professional who has covered the health sector for two decades from remote parts of India for The Times Of India, The Indian Express, The Print and The Statesman. She is also the author of Billions Under Lockdown: The Inside Story Of India's Fight Against Covid-19.

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