Kickbacks for Doctors

The unholy nexus between doctors and diagnostic centres is presently being probed by Income Tax department sleuths in Bengaluru, but as a countrywide unethical practice, it bears implications for Assam as well. Last week, IT raids were conducted in two fertility clinics and five medical diagnostic centres in the Kartaka capital city. Over hundred crore rupees in cash, gold bullion and foreign exchange were seized; the damaging revelations showed how doctors were being paid in various ways for referring medical tests to these ‘preferred’ labs. “The commission varied from laboratory to laboratory, but the median range of normal cuts or commission for doctors is 35% in case of MRI tests and 20% in case of CT scans and other lab tests,” said the IT department. Further, the raids revealed that some of the labs employ commission agents “whose job is to distribute money to doctors in envelopes” — while handing the envelops to doctors, the agents insert chits containing details like mes of patients referred by the doctor concerned, tests performed, amounts billed as well as the cut/commission amounts being paid to the doctor. Reportedly, the diagnostic centres and the doctors will be booked under the Black Money Act, and therein hangs a tale. The Medical Council of India (MCI) in its 2012 code of ethics had taken a clear stand against the long-standing practice of commissions (or cuts/kickbacks) being paid to doctors for referrals, stating that such ‘fee splitting’ is unethical. “A physician shall not give, solicit, or receive nor shall he offer to give solicit or receive, any gift, gratuity, commission or bonus in consideration of or return for the referring, recommending or procuring of any patient for medical, surgical or other treatment. A physician shall not directly or indirectly, participate in or be a party to act of division, transference, assignment, subordition, rebating, splitting or refunding of any fee for medical, surgical or other treatment,” so decreed the MCI. But the practice has continued ubated.

Matters came to a head in 2013, when a senior medical practitioner of Mahad city in Maharashtra, Dr Himmatrao Bawaskar, received an unsolicited cheque from a diagnostic chain asking him to refer patients for MRI scans to their labs. An incensed Dr Bawaskar filed a complaint with the Maharashtra Medical Council. This incident of corruption in medical practice in India also found mention in the reputed intertiol medical jourl The Lancet. Soon thereafter, another article appeared in the British Medical Jourl (BMJ), written by Dr David Berger, an Australian doctor who had volunteered to serve in a charitable hospital in the Himalayan region. He wrote about a patient “with no apparent structural heart disease and uncomplicated essential hypertension” who had been advised an echocardiogram every 3 months. Calling it “a totally unnecessary investigation”, Dr Berger alleged that an ECG or other investigation at a private clinic “attracted 10-15% kickback to the referring doctor”. On this topic, Dr Bawaskar has blamed the cut-throat competition among laboratories by pointing out: “If you own machinery worth crores, you will do anything to make money to pay for it”. Resolving to stamp out this practice, the Maharashtra government has set up a nine-member panel including Dr Bawaskar. The draft ‘Maharashtra Prevention of Cut Practices Act, 2017’ is almost ready for tabling in the Assembly soon, aiming to make it a crimil offence to accept or offer commissions for referral of patients by any healthcare provider. Fine to the tune of Rs 50,000 and jail term up to five years or both are being envisaged in the draft Act. The Maharashtra branch of Indian Medical Association (IMA) is opposing this proposed law tooth and il, arguing that there are already laws to prevent corruption in medical fraternity, and use of anti-corruption bureau to probe complaints will result in “harassment” of medical practitioners.

Across the country, doctors new to the profession have to pay commissions to more established doctors to refer patients to them. Many private hospitals are known to browbeat doctors to suggest extra tests to patients ‘to justify paying their salaries’. Lately, commissions are even being paid to non-doctors like medical agents, tourism agencies and websites for bringing in more patients! When the NDA took over reins at the Centre in 2014, newly appointed Union Health Minister Harsh Vardhan had minced no words in Parliament when he spoke of doctors being drawn by the “lucre of commissions” offered by diagnostic centres. He had then promised to write to the MCI against such “racket” and “cartelization”, underlined the need to codify laws relating to clinical/diagnostic tests, and promised to constitute a panel of medical practitioners and consumer law experts to suggest means to bring about greater transparency and accountability in medical practices. Since then, there has been little progress, which is hardly surprising in a country where a parliamentary committee last year surmised the doctor-patient ratio could be as low as one doctor per 2,000 of population. Given this scerio, there is not much governments can do. In Assam, Health Minister Himanta Biswa Sarma has made no secret of his displeasure with doctors getting sizeable commissions from diagnostic centres; he has hinted at a law to curb such practices, but that is very much in the air. In Guwahati Medical College and Hospital (GMCH) itself, the notification forbidding doctors referring patients outside for tests at private labs, has had little effect so far.

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