The Tamil Nadu government’s free cochlear implantation programme, the largest in the country, is struggling to free itself from its dependence on private hospitals. From January 2015 till June 2017, private hospitals had done 1,208 implantations, while government hospitals did just 448.
Hospital-wise data for the 1,200 implantations done between the beginning of the scheme in late 2012 and the end of 2014 was not made available by the TN government. But estimates suggest government hospitals did about 5% of total implantations till 2013 and about 10% in 2014, adding up to roughly 100 out of the total 1,200.
Thus, private hospitals have so far done around 80% of all the implantations under the scheme.
Why does this matter and why should the government try and change it? The implants themselves are just a part of the cost of the process of restoring hearing and speech to a deaf child using cochlear implants. Besides this, there is the cost of the surgery and the speech therapy and mapping (programming of the implant’s processor). The surgery costs about Rs 60,000 in a private hospital and the speech therapy and mapping accounts for almost Rs 2 lakh out of the Rs 6.39 lakh the TN government pays for each implantation under its revised package, which reimburses Rs 3.8 lakh for the implant.
Though many government hospitals have started implantation, they are largely dependent on private AVT (audio-verbal therapy) centres for the one-year post-surgery speech therapy (Rs 1.3 lakh) and another Rs 64,000 for switching on and mapping. If the government were to do everything on its own, the cost of the package could drop to the implant cost. At that rate, the government could have done over 1,200 implantations in 2016, when it actually did 720. But for this, the government would also have to provide speech therapy and mapping at every district hospital, as it plans to do. That wouldn’t just save costs. Every district hospital providing speech therapy would bring it closer home for parents of children undergoing therapy. Of course, there would be the initial cost of setting up the facilities and the salaries to be paid to the personnel, but in the long run these would obviously be a fraction of what it costs to pay private hospitals to do the procedure.
Government officials told TOI that they were conscious of the domination of private hospitals and were working to ensure that more government hospitals started doing the implantations. The number of surgeries done in government hospitals is indeed going up, but perhaps not fast enough.
Let’s look at the record so far. Senior ENT surgeon Dr Mohan Kameswaran of Madras ENT Research Foundation (MERF) is credited with persuading the state government to start the cochlear implantation scheme for poor children as the state has a higher incidence of deafness among children because of the prevalence of marriages within close relatives. The scheme had started with just three private hospitals, MERF, KKR ENT Hospital and Institute, Chennai and Vikram ENT Hospital and Research Centre in Coimbatore. The government decided to reimburse Rs 5.3 lakh per implant, the same as was being paid in Kerala, which too started its programme in 2012.
Data for the 2015 to June 2017 period shows that MERF had done 457 implantations and KKR Hospital 479. In the same period, all eight empanelled government hospitals put together had done only 448. Seven other empanelled private hospitals had done only 272 in the same period. Coimbatore Medical College was the first government institution to be included in August 2013. Which hospitals did the 1,000 plus implants in 2012, 2013 and 2014 that were not done by public hospitals? We really don’t know, but chances are the bulk was done by the early movers.
While MERF and KKR Hospital put together have certainly done over a thousand implants under the government scheme so far, Vikram ENT Hospital’s numbers are falling steadily. Incidentally, government hospitals are termed as ‘sub-centres’ of MERF as they are being mentored (trained by senior surgeons or mentors) by MERF.
In May this year, the Tamil Nadu government discovered that implants were being supplied to the Kerala government for just Rs 3.8 lakh while TN was paying Rs 5.3 lakh. The empanelled hospitals were informed about the revised rate for implants in a letter dated July 27. This raises the question of who was getting the extra Rs 1.51 lakh till now.
Many ENT surgeons have alleged that hospitals or surgeons doing the implantation actually get the implant at Rs 3.8 lakh or even lower. Whether this is true or not, what we do know is that the industry was indeed supplying the implants to neighbouring Kerala at that price. Such a practice is hardly unknown in the devices trade. It would be in keeping with what was happening in the purchase of other devices like cardiac stents or knee implants. Hospitals got devices at huge discounts to the marked price while charging patients the full price. During the price capping process, hospitals showed inflated procurement bills provided by the distributor/company to justify the high price to patients.
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