The Dying Nobility of Present-Day Doctors

Anil Maheshwari, TIR, 17 July 2014: With advancing scientific development and emphasis on clinical diagnosis as well as more medical consciousness among the people, the expenditure under the head of medicines and medical facilities in a family budget is on a rise. However, amidst the unabated price rise in all commodities and service, the cost of medical care too pinches the common man.

To add to the pot of miseries, the condition of the primary health care infrastructure is in shambles in the country except in states such as Tamil Nadu. The medical profession is no longer a noble one. The Hippocratic Oath, historically taken by physicians and other healthcare professionals swearing to practice medicine honestly, is observed in breach with impunity.

The cancer of corruption and greed that has eroded most of the institutions in the society has travelled to the medical profession too. The MCI has amended the Indian Medical Council (Professional conduct, Etiquette and Ethics) Regulations, 2002. The amendment prohibits the doctors from accepting gifts, travel facility, hospitality, cash or monetary grants or any other favors from any pharmaceutical and allied health sector industry for self or family members.

The Government through various means like Drug price control order, MCI guideline etc., have tried to keep the cost of drugs in check. Yet, in healthcare, medicines account for only 15 % of the total expenditure. Other heads like diagnostics, hospitals, Doctor’s fees etc account for the rest. These are all in unorganized sector and there are virtually no price controls and guidelines for these.

Most patients would have their own story to narrate about how many tests they or their family member had to undergo before the doctor pronounced his diagnosis. On many occasions an expensive MRI or a CAT scan was done but the doctor did not even spend a minute reading the report. Up to 50 % kickbacks to the referring doctors by the diagnostic centre is the norm in most metros.  The high rates of tests are not only to recover the investment the promoter has made in the equipment but also for the expenditure to cultivate a network of doctors who refer their patients to the centre.

Private sector hospitals particularly the tertiary care centers, often under a corporate structure, are a law unto themselves. The malpractices in pricing and dispensation of medical devices like stents or heart valves are many. Under the veneer of computerised efficiency and courteous patient care, over billing and cheating the unsuspecting patient is rampant.

Kickbacks at every level of private practice

The malpractice of kickbacks started off with kickbacks for high cost diagnostics but today it has percolated to almost every level – kickbacks to village level unqualified (quake) providers who act as a tout for private hospitals, kickbacks paid to qualified doctors for specialist referrals, kickbacks paid for referrals between specialists. Kickbacks are also paid by diagnostic laboratories, by radio-diagnostic centres and pharmacies to doctors and specialists who prescribe drugs and diagnostics. There are a number of “successful” businessmodels, for both primary care and for hospital care that are built around such unethical commissions.

Unfortunately, measures curbing kickbacks and commissions were not included as main elements in the Clinical Establishments Act though in most of the developed nations of the world, including the US, the leader in privatized care, such kickbacks are illegal. There is a need to legislate against these kickbacks, and to insist that professional councils outlaw such commission payments. There is also a need to raise public and provider awareness against this practice.

Corruption in Government Health Insurance Cover Schemes

With much fanfare, the Government launched the Rashtriya Swasthya Bima Yojna (RSBY) in April 2008, designed to provide health insurance cover for Below Poverty Line (BPL) families with a limit of Rs. 30,000. But this laudatory scheme too fell prey to the machinations of corruption plaguing the health sector. The very design of the RSBY promotes corruption. Many providers in these schemes routinely double charge – both patient and the government, when in most instances the services should be provided free. They convert primary care cases into secondary and tertiary care opportunities and add on prescriptions and other charges so that the sum assured is fully exhausted. They cherry pick cases that have higher profit margins and refuse services for cases that have lower margins. Many studies have shown that insurance companies and private providers collude to inflate treatment costs, with the costs being borne by both the poor patient and the government. The design flaws are expressive of the reality that the political clout and vested interests of sections of the private sector providers shape these schemes.

The Jan Swasthya Abhiyan (JSA) Haryana has urged the Union Health Minister Dr. Harsh Vardhan to

• Declare all payments of kickbacks and commissions at every level as illegal and monitor compliance to this through citizens committees and tax audits. This would need legal as well as administrative measures. The Clinical Establishments Act must incorporate a ban on kickbacks in its rules. Persuade MCI and other professional bodies also to act against such kickbacks as an ethical issue.
• Enforce ban on capitation fee for medical education courses and take over or close down colleges that refuse to comply.
• Redesign all publicly financed health insurance programmes including the RSBY to eliminate corrupt practices.

The malaise is not restricted alone to the private hospitals and doctors. Even the doctors serving in the government establishments are not immune to these inhumane and corrupt practices. If you operate in a government (civil) hospital, there are no fees but if you refer the case to a private hospital and don’t operate, you will get kickbacks for referral. It means “to operate means no money and not to operate means money”.

In a well-reputed British Medical Journal (BMJ) in May this year, Dr. David Berger wrote, “Kickbacks and bribes oil every part of the country’s healthcare machinery and if India’s authorities cannot make improvements, international agencies should act.”

The author reiterated the much known facts that the latest in technological medicine is available only to those people who can pay for its high price. However, the vast majority of the population has little or no access to healthcare, and whatever access they have is mostly limited to substandard government care or to quacks, which seem to operate with near impunity. He further points out that “Corruption is rife at all levels, from the richest to the poorest”. It is a common complaint both from the poor and the middle class that they don’t trust their doctors from the core of hearts. They don’t trust them to be competent or to be honest, and live in fear of having to consult them, which results in high levels of doctor shopping.

Dr. Berger also deliberated on the widespread corruption in the pharmaceutical industry, with doctors bribed to prescribe particular drugs. Common stories usually doing the rounds that the decision makers in the hospitals are being given top of the range cars and other inducements when their hospitals sign contracts to prescribe particular expensive drugs preferentially.

The article does not fail to mention that many Indian doctors do have huge expertise, are honorable and treat their patients well. However, as a group, doctors generally have a poor reputation these days.

But many international pharmaceutical trade associations, which are primarily the lobbying bodies, are the strong votaries of self-regulations by the industry. They have also created many documents in these regards since quite some time and displayed those in their respective websites. Despite all these, the charted path of well-hyped self-regulation by the industry to stop this malaise is not working.

If the new Modi government too does not swing into visible action forthwith, this saga of international disrepute, corruption and collusion in the healthcare space of India would continue in India with increasing vigour and probably in perpetuity. This would, undoubtedly, sacrifice the interest of patients at the altar of excessive greed and want of the vested interests.

This new government, in which most people have reposed faith, has both the will and wherewithal to hold this raging mad bull of pharma malpractices by the horn, ensuring a great relief and long awaited justice for all.

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