India turns spotlight on kickbacks for referrals
BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g5265 (Published 27 August 2014) Cite this as: BMJ 2014;349:g5265All rapid responses
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“…We are forced to become businessmen by society. If others like property dealers and lawyers can charge their percentage, then why can’t we?” These words of Dr Nitin Bhagali, quoted in the recent news article by Vidya Krishnan in this Journal, draw the eye. (1)
Corruption, defined as the extraction of excessive profits from the vulnerable, is of course, to be decried.
From providers, the naked exercise of business principles such as caveat emptor and maximisation of profit as a prime corporate goal, seem to impose unreasonable burdens on those most vulnerable in the population at a time when they are most in need. Further, in a true free market the option to deny delivery of the good or service if the price is not met remains open.
Amar Jesani, once again quoted by Vidya Krishnan declares “Corruption is, indeed, only a symptom of an iniquitous and unregulated system dominated by business interests.” (1) The point is that business goals are overriding where there is insufficient regulation or transparency.
A key question arises in this country from the perspective of providers. With the introduction of the reforms flowing from the Health and Social Care Act 2012, should business entities who provide health care services in a profit driven manner have their profits regarded as being derived corruptly? (2)
I would argue that the answer is no. The NHS purchasers are not a vulnerable entity, there is no lack of regulation or transparency and, the only question of denial of delivery of a potentially required healthcare good or service arises from the rationing decisions flowing from the National Institute for Health and Care Excellence (NICE) or the clinical commissioning groups.
If a private business entity can deliver a service with better quality or efficiency than an NHS provider for the same price then the profits taken by the private provider would not seem a loss to the patient or to the NHS. From the perspective of the NHS and the patient the same funds would have otherwise fallen into the hands of an NHS provider for the same or lesser service provision. Thus it is not the existence of profits alone that seems to be the problem.
From this we can conclude, with Dr Bhagali, that there seems to be no reason why doctors cannot be business-like. There is an ethical gloss however. Health care cannot be regarded quite the same way as any other commodity. Personal physical well-being is a core interest upon which all of the other goods in life are contingent. Extracting more than fair profit from the weak when they are most vulnerable with the threat of denial of treatment is an attack upon this critical interest and as such is more than distasteful. That is why doctors cannot be like property dealers. Lawyers must speak for themselves.
1. Krishnan V. India turns spotlight on kickbacks for referrals. BMJ 2014;349:g5265
2. See e.g. http://www.bmj.com/content/348/bmj.g4184/rr/761181
Competing interests: No competing interests
Re: India turns spotlight on kickbacks for referrals
Clinical decision making has been plagued by unethical practices for a long time. Guidelines on ethical practices for promotion of drugs exist but are hardly followed as many cases of unethical practices by MNC pharmaceutical companies have come to light. Most prominent of them were by GSK and Pfizer. GSK was fined $ 3 bn in fraud settlement for its antidepressant drugs in 2012 (1). Despite paying heavy penalty in the past, GSK has fresh accusations against it for alleged bribery to doctors in Poland (2).
In India, the pharmaceutical industry is under fire for its unethical practices. Despite regulations governing practice of ethical promotion of medicines, many pharmaceutical companies are involved in unethical promotion of medicines. The culture is deep rooted due to extreme competition among Indian pharmaceutical companies to have business from the same set of customers. The industry has adopted strict measures to bring in transparency in clinical drug trials and ban gifts to doctors, which are in line with MCI regulations (3). This is a welcome sign by pharmaceutical companies.
One of the most overlooked aspects of unethical practices in the medical field, which significantly lightens patients’ pockets, includes expenditure on carrying out diagnostic tests in laboratories. The system of referral by a physician to diagnostic center or laboratory to carry out tests for better (rational) decision making is well understood and justified. However, when referral is for profit rather than rational decision making, it becomes a menace, which is in the form of specifying a particular diagnostic center and/or laboratory to carry out the tests. This menace, which came to light and became a matter of debate and discussion, is known to people. But people have not questioned these practices as doctors in India are considered demi-Gods, whose word about patients’ treatment is final. Many doctors even do not have time to discuss clinical condition of patients, do not encourage patients to ask questions related to their health and are defensive when tough questions are asked by patients. Unlike in the developed countries’ where patients can ask as many questions as needed to doctors, in India doctors spend very little time with patients explaining to them the condition, treatment options and rationale for their decision. When a doctor prescribes a diagnostic test, the patient diligently follows the orders and goes to the particular center where the doctor has asked him or her to go. If a patient goes to carry out a test at another diagnostic center, the results are not considered valid and the patient is asked to repeat the test at a specific diagnostic center, from where a physician gets a share of the profit. This is purely business as doctors who have asked to go to a particular diagnostic center get a share of the profit. Diagnostic centers charge exorbitant fees in order to provide a share of profit (in crude language “Commission”) to the doctor who has referred. This is more prominent in villages and small towns; this does not mean it doesn’t happen in cities and metros. The nine diagnostic centers in Delhi that were caught (4) through a sting operation are just the tip of the iceberg.
The diagnostic centers run by MD Radiologists do appear to be pure business as a doctor has to pay approximately 1.5 crore rupees, which is a whopping amount, to acquire the degree itself, leave alone the cost of establishing a diagnostic center (5). This situation points to a rat race among the diagnostic centers to break even as early as possible.
Though there is no dearth of honest doctors, the entire profession is maligned and the image of a noble profession is tarnished because of a select few.
The growing demand for stringent laws to curb unethical practices will serve no purpose unless concrete and concerted steps are taken in this direction. When a sting operation is carried out, there is a huge hullaballoo and over time the focus is lost and the same routine (unethical) practices continue and flourish. The laws, regulations and guidelines will serve no purpose unless they are implemented in such a way so as to act as a deterrent for others to indulge in such unethical practices. When diagnosis becomes a business it is the government which has to pitch in and implement a strong control on the pricing done by diagnostic centers for essential tests much like drug price control carried out for essential drugs. More importantly, public participation and an awareness campaign for common men to avoid falling into such traps is required. A campaign like “Jaago Grahak Jaago” (Wake up Customer, Wake Up) in India should make people aware of not falling prey to such a nexus.
References
1. http://www.nytimes.com/2012/07/03/business/glaxosmithkline-agrees-to-pay...
2. GSK faces accusations of bribing doctors in Poland. BMJ 2014; 348. doi: http://dx.doi.org/10.1136/bmj.g2768 (Published 14 April 2014)
3. http://timesofindia.indiatimes.com/business/india-business/Pharma-compan...
4. Krishnan V. India turns spotlight on kickbacks for referrals. BMJ 2014;349:g5265 doi: 10.1136/bmj.g5265 (Published 27 August 2014).
5. Bandopadhyaya I. Millionaire radiology. Indian J Radiol Imaging. 2011;21:70–1.
Competing interests: No competing interests