Too little and too much: Covid care in India

Authors: Chintan Maru, Sameera Ali, Balkrishna Korgaonkar

Covid presents a twin dilemma: patients receive too much and too little care. Indians with low severity Covid receive diagnostic tests and medications that have no health benefit. Those with moderate to severe symptoms struggle to get ahold of life-saving interventions and are literally gasping for oxygen.

India has mobilized tremendous resources to solve the problem of “too little” Covid care but the problem of “too much” may be trickier to fix and has received less attention.

How much waste is there?

We can understand the order of magnitude by looking at a common example, even if the health system lacks reliable data to calculate the total amount of waste. When we do this, we can see how solving “too much” care can unlock significant resources to solve “too little.”

*INR

Take a mild case of Covid. The Government of India’s guidelines suggest a simple combination of antipyretic, antitussive and inhaled budesonide. Whereas, according to a recent Lancet Comment, a typical prescription includes several drugs that have no evidence-backed benefit, such as azithromycin, doxycycline, ivermectin, hydroxychloroquine, vitamin C, vitamin D, and zinc. The guideline also notes that no diagnostics are necessary for a mild case, yet it’s common for Covid patients to receive a package of lab tests as well as a chest x-ray. We estimate the cost difference is ~7000 INR per case (notes on our back-of-the-envelope math below). To put that in perspective, for every 500 instances of such waste we are able to avoid, we could outfit one hospital with an oxygen generation plant that could serve patients for decades to come. This does not include other common examples of waste for mild cases, such as oxygen therapy and hospital stays, which can cost an additional ~10,000 INR per case.

Why do people buy Covid care that has little to no health benefit?

It’s first important to acknowledge that this phenomenon is not unique to Covid. Low value interventions pervade the health system. The overuse of antibiotics has contributed to India’s substantial antimicrobial resistance problem. Medical procedures like coronary angioplasty are overused, especially in the private sector. Hospital admissions are often unnecessary and/or last too many days.

A common explanation for these system-wide practices is greed — that healthcare providers recommend extra interventions when there’s profit in it. While that may be a big driver of provider behavior, it’s not something we can fix in the short-run. It also glosses over other factors. Patients are often biased toward taking action, demanding diagnostics or drugs of little value, even when they’re advised otherwise. Doctors sometimes order diagnostics out of fear of overlooking something, especially when overwhelmed by huge volumes of patients. A preponderance of misinformation may also be responsible for both patient and provider behavior.

Rather than assign fault to a single group, our preference is to approach systemic challenges with this adage in mind: no is to blame, but everyone is responsible. Which begs the question…

How can we collectively respond?

One action is to equip both providers and patients with the right information, setting mutual expectations for care. For several months, prominent clinicians like Tata Memorial’s CS Pramesh have been using their public voices to do this. Platforms like the Swasth Alliance have been working to communicate best practices down to rural providers and patients. The recent Covid management guidelines issued by the Government of India represent another useful step in this direction. However, without a carrot or stick to influence providers, these efforts may not change behavior. Vivek Jha and colleagues at the George Institute suggest professional associations reinforce clinical guidelines by issuing statements to their members. Even if these associations respond to this call to action, they don’t have methods to enforce guidelines.

Many potential solutions to low-value Covid care are out of reach in the short-term. India doesn’t yet have the data infrastructure to track the use of drugs and diagnostics. Nor does it have the regulatory framework and payment models to more effectively influence provider behavior.

We at Leapfrog to Value are experimenting with value-based care models that would transform how the health system measures, delivers, and pays for care. (Read more here). We believe in the potential of these innovations to improve the value of care across health areas, but we also recognize that they’re nascent and not at the scale required to be relevant in the current crisis.

So what can be done now? We’d love to hear your ideas in the comments here.

Notes on our math

This was a back of the envelope exercise. We welcome your feedback on the approach. We estimated the waste per mild case of Covid using the following principles and assumptions:

Using the Lancet article to identify common practices of low-value Covid care.

We included some of the diagnostics and drugs described in the Lancet Comment and excluded others:

• Included: Azithromycin, Doxycycline, Ivermectin, Hydroxychloroquine, Vitamin C, Vitamin D, Acetylcysteine
• Excluded: Favipiravir, Rivaroxaban and additional broad spectrum antibiotics

We use a middle range price in metro areas to determine prices:

• For drugs we benchmarked against mid-range brands/generics
• For lab investigations we used the tariff from Metropolis labs
• For hospitalization we assumed two day stay and benchmarked against costs fixed by Maharashtra government for Covid treatment in private hospitals
• For oxygen we assumed a single day and benchmarked against oxygen tariff of Manipal hospitals
• To compare waste to the cost of an oxygen generation plant, we used the price of a PSA plant in India, roughly 33 lakhs.