A doctor in rural Maharashtra has highlighted one of the worst-kept secrets in Indian public life: that doctors across the country, with a small minority of exceptions, routinely expect and receive commissions or cuts on what patients pay for diagnostic tests recommend by the doctors to whom the patients come for clinical consultations.
Dr H S Bawaskar of Raigad district recommended a CT scan to a patient of his from "anywhere" and thereafter received a payment of Rs 1,200 from a medical centre for referring the patient. He sent the money back to the centre, which refunded the amount to the patient. He also lodged a complaint with the Maharashtra Medical Council. Dr Bawaskar is aware of this practice, and has objected to it in the past. As a result, patients referred by him have been charged less for diagnostic tests.
This practice is, expectedly, not limited to diagnostic tests; it extends to medical equipment such as stents and pacemakers implanted in patients and to general physician-specialist referrals. The commission on tests and implants is now fairly standardised in the 30-40 per cent range.
The commission paid to doctors who recommend diagnostic tests has another dimension. Over the years, there has been a general decline in clinical skills. Half a century ago, a doctor's diagnosis mostly relied on physically examining his patient, using the stethoscope and feeling the pulse. With the advancement of medical science and the compulsion on the part of doctors to specialise, their willingness and ability to diagnose a patient through clinical examination have declined. It is routine for doctors today to advise a patient to first undergo an array of tests and come back with the reports before a proper diagnosis is offered. Doctors have become intellectually helpless without first finding out what the tests say. Also, as they rely more and more on diagnostic tests, the practice of taking a commission on what the patient has to pay for the tests has increased considerably.
What is remarkable is that the code of ethics for doctors, laid down by the Medical Council of India, forbids accepting commissions; and the MCI, through its state branches, is the keeper of those ethics. The MCI's code of ethics regulations says in clause 6.4.2 under "unethical acts" that a physician shall not offer or receive any commission or bonus or split any fee for referring a patient or recommending a diagnostic test. The code has in recent years been amended to make more stringent the rules against doctors receiving benefits in any form from drug and implant makers and also to better regulate the way drug and implant makers can fund research whose findings are beneficial to them.
The commission that medical device makers are used to paying doctors is now often secured by private hospitals, which negotiate bulk discounts with suppliers. While that may be legitimate business practice, these hospitals routinely lay down clear financial targets that consultants have to meet in terms of business they bring in. Part of that business is generated through devices implanted and diagnostic tests conducted in house. Specialists also liberally refer inpatients to other specialists. As a result, patients usually end up paying for a plethora of tests and consultations, some of them clearly unnecessary.
While there is a regulation that prohibits doctors from receiving commissions for patients referred from other doctors or diagnostic laboratories, this regulation does not cover private hospitals. They are, thus, free to pay doctors by cheque and even secure doctors' PAN numbers so as to treat such payments as business expenses for income tax purposes. As to why the MCI acts rarely, if at all, on payment of commissions to doctors, a 2011 news report quotes Dr Kishor Taori, president of the Maharashtra Medical Council, as saying, "We are not a policing agency. We act on complaints by agencies and try to find the truth." The MCI had not received any complaints regarding "fee splitting", whereby a specialist pays a general physician for referring patients to him.
The rules of the marketplace appear to be at the root of the practice of paying and receiving commissions. A young specialist seeking to establish a practice, or a new diagnostic laboratory trying to get going, pays in order to secure a foothold. And once the practice has become the norm, as is the case, even an established laboratory pays to remain in business. As the few ethical private practitioners readily agree in private conversation, there seems to be no end to the greed of many doctors and private hospitals.
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