^SRI VENKATESWARA   NETHRALAYA ** Eye Hospital & Lasik Centre***     

1. Some BIG Advertisements appear frequently in newspapers ,magazines & TV (almost every 10 minutes) about "Worlds Cheapest Lasik" for as low as Rs 28,999/-? Why are they so desperate & Why do they lie ? Can it be offered even cheaper??

The Advertised price of Rs28,999/-( 575 USD) or still cheaper prices of Rs 24,999/-( 500 USD) etc of certain Chains of Eye Hospitals is a marketing model designed to enhance the uptake of addon procedures priced at at premium such a femtosecond laser etc. Such Base prices are not all inclusive and will never be for the latest state of the art procedure suited to your case. Advertised Prices follow marketing models that utilizes gimmicks/celebrities/ Hype/ Fear/ Grandiosity in a desperate attempt to attract the patient only.. & once the patient agrees to the procedure, the cost will exponentially rise on one account or the other. Besides, Eye Hospital Chains rarely provide personal care and customised solutions. They are more known for their factory like atmosphere where patients are treated as commodities and attention to individual detail and needs are rarely covered to the routine patient unless you are a VIP - In which case everything is provided without asking.

Patients are brought in with lure of cheap lasik through mass media advertisements, commercials etc, but once inside, there is a heavy counselling effort to upsell other add ons, which may not be warranted in over 95% of the cases. Such add ons may be related to the different methods of flap making ( With a microkeratome / With a Femtosecond Laser),Flap less Lasik or SMILE,  Different Technologies of Laser Delivery, Tracking, Iris Registration etc. Some of them are indeed useful in some patients with complex parameters, but patients are given the impression that such add ons will make a progressive corrective impact in all cases at all times and if the patient is willing to pay, then he must go for it irrespective of whether he will benefit from it in a significant manner.  This strategy is successful in boosting the cost to 3X to 4X of the advertised price in most cases.

2. As I want the best for myself, could you tell me more about problems that may occur in "Big Hospital / Chains" that can result in poor satisfaction in 3-5% of patients?

Although Lasik is a very successful procedure the world over with over 95% success rate, there is a 3-5% of patient population that is still unhappy with the results for quite a few reasons. While some reasons may relate to improper patient selection, overpromising the results prior to surgery, underdelivery on the results, poor handholding of the patients during this entire exercise etc, some of the poor satisfaction scores are purely related to the business models of the Large Hospital chains that encourage a "Factory like" approach instead of " Individual needs" based approach.

                 Problem No 1= "Continuity of care"

The Main  problem with Major Centres and EyeCare Chains with multiple doctors would be lack of Continuity of Care. In the name of the Chief Medical Doctor, Usually, the preoperative assesment is done by some overzealous hardselling doctor belonging to some "A" team who overpromises on the results to make you agree to the procedure while the procedure is actually performed by some doctor belonging to some "B" team who will see your face/eyes for the first time just prior to the procedure while the Postoperative Care is provided by some junior doctor belonging to some "C" team who will be a trainee doctor trying his luck to climb up the value chain.

          Problem No 2 = "Medical Process Outsourcing(MPO)"

Let face the truth, When patients seek quality care for their ailments it usually requires individual attention, significant chair time, detailed evaluation, balanced approach to investigations, experience in clinical skill in understanding the patients needs, and skillful diagnosis.

           While this is virtually impossible to provide in a large volume targeted Big hospital/chains, Patients are likely to be dis-satisfied because the doctor patient one to one relationship is compromised at many levels due to Medical Process Outsourcing (MPO) to Junior Doctors/Technicians/Paramedics with varying levels of skill /expertise/ knowledge/ commitment . This results in windfall benefits to the Hospital where patients think the star doctor in a branded hospital is in full control of the quality of care being given by his team members, but in reality the team members are chosen by the HR managers of the Hospital who base their recruitment on lower and lower remuneration attracting poorly skilled or trained junior doctors/techs/ paramedics. This then results in varying results for the same medical condition. Patients rarely get to choose their doctor based on skill, knowledge and expertise for resolving their problems,.. rather what happens is that the hospital/doctors with their projected "STAR/BRAND" value gets to choose the patients based on the patients high paying capacity, complexity of the case, poor literacy levels, pts with low level expectations who do not ask too many questions. This group of patients form a significant major proportion in developing countries as access to quality health care provided by the state is poor forcing a large population to seek available private healthcare irrespective of the business models practiced.

         Problem No 3= "Multiple Tactics used to mislead unsatisfied patients"

In an unregulated environment where the patients have the least voice when they are not satisfied with the overall result, the above arrangement is a sureshot recipe for frequent suboptimal clinical outcomes. When the results refuse to fall in place and the patient is deemed to be unhappy, each provider drops his responsibility and starts blaming the patient or someone from the other team. Tactics commonly used for unhappy patients are denial of immediate follow up appointment dates, long waiting hours, shifting the patient from one room to another for unnecessary investigations, Preventing the patients from speaking to other patients, Limiting immediate access to hospital patient data, Multiple doctors speaking to the patient in one voice, Motivating the patient to slowly believe that it was somehow his condition that is responsible for poor outcomes, or as a last resort motivate the patient to philosophically accept his "fate".

  Sometimes the doctor who operated the case, leaves his job and his patients to another hospital where patients are then redirected as the hospital will not take responsibility for poorly satisfied patients of a former employee. 

  Sometimes if a doctor has a lot of unsatisfied patients which has reached unmanageable proportions, the doctor is transferred to another city and a new appointee takes over who will suggest more additional procedures at a greater cost.

 If after many such tactics patients are still unhappy and keep asking uncomfortable questions either physically or on various online fora , then a new team that consists of lawyers, Online Marketing Executives along with hospital Management executives take over and "badger" the patients attitude, motives, background and character.

  With these tactics, The patient then starts to realize the futility of engaging the system to address his/her needs having fallen victim to the defects of a Heavily Advertised, Large, Branded Practice where individuals fail to take responsibility for suboptimal clinical outcomes as their primary responsibility is towards the welfare of the Hospital company and its investors who control the expenses to realize their profitability first.

              Problem No 4 = Big Hospitals/Chains dont depend on good results and happy patient referrals through word of mouth as that takes a lot of time, they depend on illegal and unethical advertising with false overpromises for attracting new patients in an exponential manner

Since Doctors in Quantity Centric Big Hospitals/Chains are protected by a large banner as well as malpractice insurance, individual patient satisfaction is not the top No 1 priority in each and every case...rather unsatisfied patients are just reduced to overall numbers in the daily statistic of the hospital..and business goes on as usual as newer patients are anyway brought in not by Old satisfied patients/ Word of Mouth but by Unethical but Attractive Advertisements in TV/Radio/Newspapers which are played in rotation sometimes desperately every 10 minutes.  Such Advertising is banned both by the Hippocratic Oath that doctors take as well as the Code of Ethics Guidelines issued by Govt of India. These Advertisements are disguised  and disseminated as Noble Patient Education programmes whose only purpose is to trick and deceive the prospective client into buying a service at any cost.

3. Is the Doctor not the "BOSS" and the final authority in BIG hospitals?? If yes, why do doctors agree to work in such hospitals??

That is a wonderful question. Most Sectors in the 21st century have degenerated in our capitalist society pursuing shareholder value above everything else. BIG corporate Hospitals and corporate doctors are no exceptions as they too have to survive with the profit motive on top of their minds and fight it out in the same environment. Patient Interest & Social Responsibility is very much lucky if it finds itself at least at the bottom of the priority list.

Read the following only if you are keen on understanding the problems with the Health Care delivery mechanism as it exists today in our society. Otherwise i suggest that you skip this question by clicking here and going on to the final paragraph in this article.

• Look at some recent medical research.

• This survey in the US showed that "BIG"hospital ownership of private physician practices has increased dramatically in the past 6 years. In 2008, 62% of physicians owned private practices. This year, only 35% of physicians maintain independent private practices. Only 9% of physicians “mostly agreed” that "BIG"hospital employment of physicians would increase quality of care and decrease costs. 81% of physicians described themselves as “overextended” or at full capacity.

• This survey showed that government regulations regarding electronic medical records are being implemented but that 75% of physicians believe that the electronic medical records increase costs and do not save time. 68% of physicians do not believe that the regulations improve productivity and 48% do not belive that the regulations support coordination of medical care.

• This study showed that time lost in dealing with electronic medical records was “large and pervasive”, costing physicians an average of 48 extra minutes a day – during which they could have been performing other tasks such as patient care.

• However, as more physicians move to "BIG"hospital based practices and exhibit less autonomy, think about who stands to gain and who stands to lose from such transitions.

• Ask any Hospital HR / Medical services Administrator as to who the boss in the entire system is - and he wont hesitate to tell you that  even meritorious Doctors work under him as he reports directly to the management and the management  mostly consists of  Unmeritorious Self financed Private Medical College educated -Donation Seat "DOCTORS" and Bankers and Children of businessmen from Wealthy Families . These people know very little medicine as most of them have passed out of private medical colleges by bribing their way to the question papers ( just like how they came in to the medical school by paying  crores of capitation fees ),..but are well versed in "armtwisting methods" to reign in the work force. In fact starting from pay raise, incentives, attendance, sanctioning leaves, promotions, perks like paid foreign vacations etc and punishments like having to work in peripheral rural camps, night duties, sunday/festival duties, harassment/embarassment at internal appraisal meetings- corporates have a internal structure that promotes a culture of nepotism to those who fall in line with the concept of " Maximal Profitization" and observe the motto - "Boss is always right". Doctors may have their own reasons to fall in line and retain their jobs if they are  unable to start their own practices. Doctors who refuse to fall in line have to start their own practices in due course to change the system and provide patients with alternative options against all odds that they believe is fair to both the doctor and the patient and will lead to successful outcomes. Once the profit motive is established, LEAD, FOLLOW or Get out of the WAY is what gets a doctor into the big league.

• To maintain a favorable balance sheet, "BIG" hospital executives need to gain control of their physicians. Most "BIG" hospitals have already taken an important step in this direction by employing full time a growing proportion of their medical staff who agree to be subservient.

• Transforming previously independent physicians into employees has increased "BIG" hospital influence over their decision making, an effect that has been successfully augmented in many centers by tying physician compensation directly to the execution of hospital strategic profit enhancing initiatives.

• As a result, the challenge of managing a "BIG"hospital medical staff continues to resemble herding goats and sheep.

• Merely controlling the purse strings is not enough. To truly seize the reins of medicine, it is necessary to do more, to get into the heads and hearts of physicians. And the way to do this is to show physicians that they are not nearly so important as they think they are. Physicians have long seen the patient-physician relationship as the very center of the health care solar system. As "BIG"hospitals go forward, physicians must be made to feel that this relationship is not the sun around which everything else orbits, but rather one of the dimmer peripheral planets, a Neptune or perhaps Uranus.

• How can this goal be achieved? A complete list of proven tactics and strategies is beyond the scope of answering this question, but some of the more notable one's include the following:

• Make health care incomprehensible to physicians. It is no easy task to baffle the most intelligent people in the organization, but it can be done. For example, make physicians increasingly dependent on complex systems outside their domain of expertise, such as information technology and coding and billing software. Ensure that such systems are very costly, so that solo practitioners and small groups, who naturally cannot afford them, must turn to the BIG hospital. And augment their sense of incompetence by making such systems user-unfriendly and unreliable. Where possible, change vendors frequently.

• Promote a sense of insecurity among the medical staff. A comfortable physician is a confident physician, and a confident physician usually proves difficult to control. To undermine confidence, let it be known that physicians’ jobs are in jeopardy and their compensation is likely to decline. Fire one or more physicians, ensuring that the entire medical staff knows about it. Hire replacements with a minimum of fanfare. Place a significant percentage of compensation at risk, so that physicians begin to feel beholden to "BIG"hospital administration for what they manage to eke out.

• Transform physicians from decision makers to decision implementers. Convince them that their professional judgment regarding particular patients no longer constitutes a reliable compass.

• Refer to such decisions as anecdotal, idiosyncratic, or simply insufficiently evidence based. Make them feel that their mission is not to balance benefits and risks against their knowledge of particular patients, but instead to apply broad practice guidelines to the care of all patients. Hiring, firing, promotion, and all rewards should be based on conformity to hospital-mandated policies and procedures.

• Subject physicians to escalating productivity expectations. Borrow terminology and methods from the manufacturing industry to make them think of themselves as production-line workers, then convince them that they are not working sufficiently hard and fast. Show them industry standards and benchmarks in comparison to which their output is subpar. On the off chance that their productivity compares favorably, cite numerous reasons that such benchmarks are biased and move the bar progressively higher. If medical errors happen in the process, use them to further leverage the doctor to fall in line with the hospitals motives. The "BIG"Hospital has a system to limit the publicity to such errors in case the doctor falls in line, while if the doctor refuses to accept the employer as the almighty, the "BIG"hospital also uses a system to portray such errors as negligence and damage the reputation of the doctor.

• Increase physicians’ responsibility while decreasing their authority. For example, hold physicians responsible for patient satisfaction scores, but ensure that such scores are influenced by a variety of factors over which physicians have little or no control, such as information technology, hospitality of staff members, and parking. The goal of such measures is to induce a state that psychologists refer to as learned helplessness, a growing sense among physicians that whatever they do, they cannot meaningfully influence health care, which is to say the operations of the"BIG" hospital.

• Above all, introduce barriers between physicians and their patients. The more directly physicians and patients feel connected to one another, the greater the threat to the hospital’s control. Introduce the patient to a variety of inconsequential tests, equipments, technicians, paramedics and other low level health care workers before they finally get to see the doctor. Make the patient feel like as if the doctor is only the last completing link in the chain and he is usually helpless if asked to provide care  on his own without these assisting aids.

• When physicians think about the work they do, the first image that comes to mind should be the"BIG" hospital, and when patients realize they need care, they should turn first to the "BIG"hospital, not a particular physician. One effective technique is to ensure that patient-physician relationships are frequently disrupted (in the form of change of physicians/encouraging crossreferrals to other care providers/ employing doctors who do not know the local language so that an interpreter nurse's help is always taken/ preventing doctors from seeing patients in private or in their clinics etc), so that the "BIG"hospital patient relationship remains the one constant irrespective of the doctor involved in providing care. Acquiring local practices, predatory pricing, Insurance companies networking and kickback programme for channeling the organized insurance cashless patients to a particular BIG Hospital, Hyperextended Credit periods, large scale promotional campaigns etc are all strategies to disrupt the existing doctor patient relationships in any given geographic territory. If these do not succeed in breaking a doctors relationship with his patients, then planting fake stories in the dishonest media, false honeytrapping using imposters, circulating defamatory videos with fake patients, etc will usually do the trick and break the resolve of the doctor to pursue "INDEPENDENT SOLO PRACTICE". 

•  BIG Hospitals, Administrators and their managements do not see themselves as  middle men / facilitators of Doctor Patient relationship with minimal clinical role, rather they see themselves as the centre of the clinical solar system around whom patients & doctors revolve in a speed and manner that is convenient to them.

As far as Lasik laser treatment is concerned, successful outcomes are most likely to happen when the entire care whether Prelasik, Lasik and Post lasik or for that matter any other intervention- is the responsibility of a single provider and course correction/ customisation as per patient preferences is easier. Single providers still depend on the traditional Word of Mouth referrals from old satisfied patients and will strongly resist using tricks/gimmicks or other unethical means of attracting patients.

The Quality of work that we do will ultimately determine our practice reach and the focus is always on the patient satisfaction and not on the competition.

So in that sense, Our patients don’t complain about our cost because we are reasonably priced for the high safety margin that we provide besides being all inclusive.

At 300 $ / Rs 15000/- for a simple laser vision correction procedure for both eyes, we are proud of the level of honesty that our pricing reflects. Only those patients who have cylindrical powers and higher order abberations are advised to consider higher packages.