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Journal of the Academy of Hospital Administration

Patient Attitude Towards Payment at Super Specialty Hospital in Hyderabad

Author(s): Nimma Satynarayana*, K Padma, G.Vijaya Kumar

Vol. 16, No. 2 (2004-07 - 2004-12)

Key Words:

Patients' attitude to payment, socio-economic status, Hospital billing services, Hospital economics.

Key Messages:

  • Rural based, employed and poor patient form the major clientele in this public sector hospital.
  • About 70% of patients are able to pay hospital charges, but are unwilling to pay them.

Abstract

In order to measure the patient's attitude towards payment on opinion survey was conducted through a structured questionnaire for a period of 2 months, with a total sample of 85 cases. The objectives were:

  • to study the socio-demographic profile of patients attending NIMS as inpatients, and
  • to measure the attitude of patients towards payment of hospital bills.

In our study we found that more number of rural patients, particularly from nuclear family with mean age of 36.35 + 18.8 and mean income of Rs. 3,102.56 with male preponderance (74%) attended the hospital. The study also showed that white card holder (income <6000 per annum) dominates (52%) the patient profile; and employed patients accounted for 61%. It is surprising to note that 70% patients are able to pay but unwilling to pay the hospital bills.

Introduction

The modern concepts, scope and philosophy of the hospital of today is far different from that of the past. The hospital of today is being recognized as a social institution. Hospitals are the most costly, part of the health services. They are expensive to build, operate and maintain. The common scenario in the billing section of any private hospital is patient asking for a reduction in their final bill.1 The patient carries an impression that the hospital has over charged him or he wants to use the facility given to the weaker section of society by the Government. This is the general perception and reality of the hospital economics.

The cost increases in the gross price of medical care are being transferred directly to the patients. Difficulty in paying for therapy is becoming an increasingly important problem due to the trend among physicians to order newer diagnostic modalities and changing prescription patterns where they prescribe newer costly drugs instead of the less expensive ones. With an increasing and ageing population, limited resources and absence of health insurance schemes; increased pressure on healthcare resources in developing countries is a ground reality.2 Limited resources, wide spread poverty and the absence of health insurance pose daily ethical problems for third world physicians, who must balance their roles as individual patients' advocates against desire to provide health care to the greatest number of patients.3

The NIMS is a super specialty hospital with approximately 966 beds and located in the central part of the city. The Institute is an autonomous, deemed University under the State Act. It caters to the needs of Andhra Pradesh and its neighboring states.

Aim and Objectives

In order to measure the patient's attitude towards payment on opinion survey was conducted with the following objectives.

• To study the socio-demographic profile of patients attending NIMS as inpatients.

• To measure the attitude of patients towards payment of hospital bills

Materials and Methods

The following methodology was adopted keeping in view the afore mentioned aim & objectives:

  • Record based study: This record based study was conducted to collect the data regarding patient oriented characteristics such as: age, sex, education, religion, profession, category of payments and monthly income.
  • Attitude survey: The patients and their relatives were interviewed to elicit their attitudes towards clearing the hospital bills. A structured questionnaire was used for a period for two months on a total of 85 respondents.

As expected cell frequencies are found to be less than 5, the first three columns cell frequencies were added and chi-square test is carried out. The formula of chi-square test is:4

= E (observed value-expected value)/(Expected Value)

Results and Discussion

The demographic parameters including socio- economic attributes of the respondents were analysed and tabulated as under:

Table I: Age-wise distribution

No. of respondents Mean age in year
85 36.45 ± 18.8

It is evident from the table that the respondents mean age was 36.45 years. The age distribution shows that age more number of younger patients are admitted into the hospital.

Table II : Sex-wise Distribution

No. of Respondents Percentage
Male 63 74.1
Female 22 25.9
Total 85 100

Sex wise distribution shows a male preponderance with approximately approximately three fourths of patients being males.

Table III: Religion wise-Distribution

No. of Respondents Percentage
Hindu 81 95.30
Muslims 04 4.70
Christians - -
Others - -
Total 85 100

Religion-wise distribution almost represents the population distribution of the community with Hindu preponderance.

Table IV: Domicile Rural/Urban Distribution

No. of Resondents Percentage
Urban 39 46.99
Rural 44 53.01
Total 83  

The domicile of the patients admitted in hospital with respect to urban & rural shows that more number of rural patients are admitted.

Table V: Types of family distribution

No. of Respondents Percentage
Nuclear Family 55 64.70
Joint family 30 35.30
Total 85 100

The sample was analyzed for type of family background under two headings (1) nuclear (2) joint. It shows the trend was towards nuclear family with almost two third of patients belonging to them.

Table VI: Distribution of Ration Card

No. of respondents Percentage
White 42 52.50
Pink 38 47.50
Total 80 100

The samples were analyzed for type of Ration Card under two headings

1. White card holders 2. Pink card holders

As per the rules of institution the white card holders having an income of Rs. 10,000/- per annum are given facility for concessions in outpatients and inpatient treatment. Previously patients with white cards visiting the institute were around 20-30% as inpatients. The present data shows a steep increase in the number of white card holder cases, which in turn infers that either they are referral cases or patient are aware of the benefit of State Illness Assistance Fund (SIAF), Chief Ministers' Relief Fund (CMRF) of State government.

Paying: Paying patients cases means patients who pay the costs in full.

White Card Holders: In the state of Andhra Pradesh, those people having an income of Rs. 10,000/- and below per annum are given a facility of white ration card for various subsidies and concessions from the government agencies in addition to regular ration.

Credit facilities: Organisation like public sectors and autonomous, undertakings which have entered an agreement with NIMS to extend treatment facilities on credit basis

Table VII: Average income per month

No. of respondents Mean income per month
78 Rs. 3,102.56

The mean income per month was Rs. 3,102.56 which means that more patients with lower income are attending the hospital.

Table VIII: Occupational status

No. of Respondents Percentage
Students 17 20
Unemployed 16 18.82
Employed 52 61.18
Total 85 100

The occupational status shows that more number of employees were being admitted.

Patient attitude towards hospital payment:

While analyzing the patient's ability to pay and willingness to pay, we applied the principles of johari window (one of the concepts of management) to the above sample groups. By transposing the sample on the johari window, we would classically get four different situations. They are as follows:

  1. Unable to pay and willing to pay
  2. Unable to pay and unwilling to pay
  3. Able to pay and willing to pay
  4. Able to pay but unwilling to pay

Table IX: Patient's attitude to hospital payments

Unable to pay and
willing to pay
Unable to pay and not willing to pay
Able to pay and willing to pay Able to pay and not willing to pay

Table X: Rural/urban patients score regarding ability to pay and willing to pay

Category Unable to pay
Unwilling to Pay
Able to pay
willing to Pay
Able to pay and
unwilling to Pay
Unable to pay and
willing to pay
Total
Rural 2 (2.53%) 7 (8.86%) 27 (34.17%) 9 (11.40%) 45
Urban --- --- 3 (3.80%) 28 (35.44%) 3 (3.80%) 34

Chi-square value: 3.16, P<0.05 Significant at 5% level

Table XI: Pink/white-card holder patients score regarding ability to pay and willing to pay

Category Unable to pay
Unwilling to Pay
Able to pay
willing to Pay
Able to pay and
unwilling to Pay
Unable to pay and
willing to pay
Total
Pink --- --- 2 (2.53%) 27 (34.17%) 9 (11.39%) 38
White 2 (2.53%) 8 (10.13%) 28 (35.44%) 3 (3.80%) 41
Total --- --- --- --- --- --- --- --- 79

Chi – Square Value: 7.15, P < 0.001 Significant at 1% level

Table XII: Income wise patients score regarding able to pay and unwilling to pay

Category Unable to pay
Unwilling to Pay
Able to pay
willing to Pay
Able to pay and
unwilling to Pay
Unable to pay and
willing to pay
Total
Less than 6000 2 (2.40%) 9 (10.85%) 47 (56.63%) 4 (4.83%) 62
6000 to 10000 --- --- -1 (1.20%) 11 (13.25%) 9 (10.84%) 21
Total                 83

Chi-Square Value 10.43, P<0.001 Significant at 1% level

Pie Diagram showing WHITE card holder patients

Pie chart 1

Pie diagram showing PINK card holder patients score regarding ability to pay and willing to pay score regarding ability to pay and willing to pay.

Pie Chart 2

It can be seen from the above that the group which falls in category No. 3 i.e., able to pay and unwilling to pay is the group on which the health/hospital administrators should concentrate, to minimize loop holes in money collection. The peculiarity of these groups are that the patients in comfortable positions to pay the hospital bill but with some ulterior motive/reasons is not willing to pay the total hospital bills.

This group either tries for concessions or will try to exploit the facilities offered by the government Institute for benefit of the weaker section in the society like State Illness Assistance Fund, Chief Minister Relief Fund, Prime Minister Relief Fund and the voluntary organizations. If the top management can concentrate on these groups and try to change their attitude/ towards hospital payments, it will result in substantial income gain to the Institute.

In our study we have seen that almost 70% of the patients in this group.

Recommendations

1. More number of rural patients are being admitted in Hospital. This required the services of public relation department and the emphasizes on good patient information system in the form of good reception/ medical social services etc.

2. From the point of quality patient care the groups covered under white card, PMRF, CMRF, SIAF may be placed at different wards for uniform patient care.

3. This study also stressed the importance of insisting on advance cash deposit prior to admission so as to restrict/ minimize the monetory loss to the institute in the form of concessions and non payments6.

4. At present the institute is not restricting to the statutory recommendation of 10% in patient admissions for white card holders which will indirectly affect the revenue (money) generation capacity.

5. The study also highlights the importance of scrutiny and elimination of pseudo white card holders and also tighten and plug the loopholes in the process of issual of white cards at government level (procedural change)

6. Another important finding in our study is that, contrary to our expectation of attracting paying (middle income group) patients, the Institute at present getting low income group/referral patients. In order to attract the paying patients medical insurance policy should be considered.

In our study we found that more number of rural patients, particularly from nuclear family with mean age of 36.45 + 18.8 and mean income of Rs. 3,102.56 with male preponderance 74% attended the hospital. The study also showed that white card holder (income <6000/per annum) dominates 52% and employed patients accounted for 61%. It is surprising to note that 70% patients are able to pay but unwilling to pay the hospital bills.

Reference

  1. Doctors Patients, and bills: What do you do when the patient doesn't pay, NC-Med.-J:50(5) 1989, 258-260.
  2. Pauly MV: ‘The changing Health Care Environment' Am J.Med 81(6c): 1986, PP: 3-8.
  3. Moazam F, Lakani M Ethical dilemmas of health care in developing nations J Pediatric-Surgery 25(4): 1990 438-441.
  4. Mahajan AK Text book of Biostatistics 1998.
  5. Blanchard H: Management of Organisational Behaviour, 1996, pp 294-304.
  6. Anderson HJ “CEOs say patients deposits improve flow hospitals, USI: 65(4): 1991,48.

* Associate Professor & Deputy Medical Superintendent,
Nizam Institute of Medical Sciences, Hyderabad

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