The ICU costs make up 20-30 per cent of all hospital costs. ICU accounts for 10 per cent of all hospital beds and 20-25 per cent of the hospital revenue. It is also resource intensive. However, it’s difficult to establish cost-effectiveness in a health system like India which is not only multi-layered but also multi-dimensional. But, we can look at economic efficiency to reduce the cost of ICU. This, in turn, will reduce the financial burden on the hospital, motivating it to further invest in ICUs. It will also lower the cost of treatment for the patient in the long run.
Need for critical care in India
Healthcare need in India is on the rise. It faces the dual burden of communicable diseases and chronic non-communicable diseases. Added to this is the growing number of elderly which is expected to see a 300 per cent rise in the next 30 years. “India has around 100 million elderly at present and the number is expected to increase to 323 million, constituting 20 per cent of the total population, by 2050,” reveals a report jointly brought out by United Nations Population Fund (UNFPA) and Help Age International. Most of these diseases require ICU treatment and will push the demand for ICUs further.
According to a WHO publication by Dr G Gururaj, Professor and Head, Department of Epidemiology, NIMHANS, Bangalore, “Every year in India, nearly a million deaths occur due to road traffic injuries, falls, burns, poisoning, drowning, suicide, workplace or occupational injury, natural disasters, violence, etc.” These critically ill patients need ICU infrastructure for better outcomes to avoid death.
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It is estimated that there are about 70,000 ICU beds in India. “This includes all types of ICU beds across all hospitals and small nursing homes in India that cater to five million patients requiring ICU admission every year,” informs Dr Ramakrishnan. There is both geographical disparity in the distribution of these beds as most of the ICU beds are located in or near larger cities. Also, of the ICUs located in large cities, most are in the private sector. These private sector ICUs are state-of-the-art with modern equipment and good intensivists, but they are expensive. In the meanwhile, less costly ICUs in the public sector suffer from lack of funding which results in limited resources, lack of infrastructure, trained intensivists and support staff. “Average ICU cost for a patient on life support systems is around Rs 50000 to Rs 60000 per day in a private hospital,” says Dr Narayana Swamy Moola, Senior Consultant Intensivist, Narayana Multispeciality Hospital, Whitefield.
Cost centres in ICUs
There are many cost related problems in an ICU set-up. A working group in the UK identified six ‘cost blocks’ i.e. factors responsible for high cost of operating ICUs. These are costs of staff, clinical support services, consumables, estates, non-clinical support services and capital equipment.
Capital equipment
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Cost of life saving equipment constitute a major chunk of the total cost of setting up an ICU. “This includes mainly the central and bedside monitors, invasive and non- invasive ventilators, IABP, syringe pumps, dialysis machine and some miscellaneous items,” says Dr Vijay D’Silva, Director of Critical Care and Medical Director at Asian Heart Institute, Mumbai. “This cost will depend on the specification of the equipment (high-end vs low-end) and will also include maintenance and servicing cost of these equipment,” he adds.
Most of the equipment used in India are imported. “Capital equipment accounts for nearly 50 per cent of ICU establishment cost in India as most of them are imported from the US or Europe,” explains Dr Moola.
If ICUs use equipment manufactured in India then this cost can be substantially contained. “By reducing the import component of equipment and sharing a pool of equipment between ICUs in common geographical location or leasing them one can reduce the capital equipment cost,” says Dr Moola. Another option is to negotiate the price with the manufacturer.
“Negotiating the cost of equipment and consumables is required to limit capital equipment cost,” says Dr D’Silva. This is easily said than done. Yet there is hope as the market for medical supplies and disposables is dominated by the indigenous manufacturers and less costly disposables are now being imported from China and Vietnam and other East-Asian countries. In recent years, Indian manufacturers have also invested in high-end equipment manufacturing and the government should incentivise such efforts for more Indian life-saving products.
Land cost
This is defined as the cost of estate and maintenance and utilities necessary to maintain the ICU structure. Understandably, cost of land in larger cities is at a premium and alternate location which are inexpensive but strategically located should help control this cost factor. “The land cost forms 20 per cent of establishment cost,” says Dr Moola. “It varies widely depending on geographic location,” he adds. Many hospitals in India face space constraints as old infrastructure does not allow for new ICU or extension of existing ICU.
Consumables
Consumables constitute a large proportion of the ICU cost. In India, most of the hospitals provide limited consumables. Some even give patients the option to buy consumables from the market. Most government hospitals have limited stock and thus push the patients to purchase these as need arises. Drugs are also purchased by the patient. Some of the life-saving drugs are very expensive and the hospitals do not hold stocks of these medicines. It is then the patient’s family who seek these drugs in the medicine shops. “Blood, blood products and drugs like antibiotics are big cost centres,” says Dr Moola. “More than 50 per cent of the expenditure on drugs is for antibiotics. Other expensive drugs such as Activated protein C and Recombinant factor VIIa, are also used exclusively in the ICU in India,” says Ramakrishnan. Use of such drugs have increased considerably in the past few years for better outcomes but have also added to the cost of ICU treatment.
Manpower cost
Critical care is labour-intensive. Intensivists and nurses are an integral part of ICUs. And in India it’s difficult to find trained ICU staff. So the cost of manpower is not only hiring good doctors and nurses but also the cost of detaining them. High level of attrition and migration to Western countries is a regular feature of this cohort and it creates a huge shortage of staff, which in turn affects quality of care and hence possibly costs. On the other end, staff are underpaid and non-favourable treatment of the staff, particularly nurses, contributes to high migration rates. Better working conditions based on improved protocols and active training and support are some of the ways to retain staff.
Clinical support service
A critically ill patient needs constant support from different departments of the hospital. This is provided by departments which are directly related to patient therapy but are not supplied by the ICU. “Clinical support services includes physiotherapy, radiology, dieticians, other speciality clinical services such as cardiology, nephrology, laboratory services, etc,. in addition to clinical consultation with other specialists,” says Dr D’Silva.
In the private hospitals these are billed separately, adding to the overall costs. This is a major profit generating area in private health care sector with unconfirmed anecdotal reports of misuse. In the ICUs of public sector tertiary care centres, laboratory and support service charges are less than private sector costs but are not available due to various reasons. Judicial use of support services will contain this cost in some respect.
Non-clinical support service
Apart from direct therapeutic costs, an ICU requires operational and functional support like housekeeping, stationary, etc,. “Non-clinical support services are required for the functioning of the ICU, but are not specifically related to an individual patient’s therapy,” says Dr Moola. “These include costs for catering, cleaning laundry, uniform, administration costs of the staff directly employed by the ICU and miscellaneous expenditure such as stationery, telephone, photocopying etc,” he adds. Though this constitutes a very small proportion of the overall cost, alignment of these with other departments may prove optimal and thus curb costs in ICU. Reliable data are lacking in this context but earlier studies quoted a low investment as well as operating and maintenance costs for these categories in India.
Cost control measures
For the cost control measures to work it is important to include all stakeholders in the programme and the strategy has to be drawn internally rather than follow any cost-cutting model made by external consultants. Another determinant is the quality of care. Quality of care is an important consideration and the strategy that focuses only on cost cutting deteriorates quality of care. A balanced approach is the need of the hour.
“Rational use of antibiotics and other costly medicines; recycling some of the consumables; minimising errors and prevention of critical events; financial and management training for ICU leaders are some measures that help minimise ICU costs,” opines Dr Moola. “Improving ICU – ED axis, as the relationship is a mutual one, with each affecting the other in a continuous feed back loop also helps,” he adds.
“Pointers to reduce cost include measures to reduce wastage; training of staff to improve efficiency; defining polices and having standard operating protocols; antibiotic policy to control unwarranted use; medication policy to reduce medication errors and critical incidents and clinical and financial audits,” says Dr D’Silva. “Re-sterlisation of disposables is also widely practised in India but it is not legally sanctioned and the law is vague on this topic,” he adds.
Medical errors are not openly discussed in India, let alone its impact of cost. “In India, absence of a nation-wide reporting system and blame free culture prevents staff from either admitting or reporting mistakes,” opines Dr Ramakrishnan. “This makes estimating its 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,” he adds. Financial education is important for an ICU intensivist to understand and participate 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,” says Dr Ramakrishnan.
Cautionary intensive care
Preventing life-prolonging interventions and providing palliative care to patients in the end-of-life situation is not well defined in India. In most cases, patients’ families are advised to take the patient home or to a less expensive ICU. The law of the land is not clear on this, which adds to the burden on the intensivist. “Limiting life prolonging measures and procedures in end stage disease is a very touchy approach and the law is not well defined in this situation also,” says Dr D’Silva.
Home care is the last alternative for these patients. Recently, some providers are looking into providing specialised home care in India. These providers help create ICU like set-up at home for the patient, but these are available only in the private set-up and are expensive.
It is also important to analyse ways to minimise ICU admissions or practice measures to decrease length of stay by either early optimisation or preventing secondary complications.