Doctor-diagnostic centre unholy nexus

Dr. Dharmakanta Kumbhakar

(The comments made in this article are of the writer. He can be reached at drkdharmakanta1@gmail.com)

Patients blindly trust doctors and do whatever is prescribed for them. But it seems some doctors are allegedly sucking patients' hard-earned money by some unethical means. Many doctors allegedly prescribe profitable unnecessary costly tests to get hefty commissions from hospitals and diagnostic centres. Greed of a few doctors, lack of firm laws and regulations, lack of accountability and a lenient society have allowed an unholy nexus among some doctors, hospitals and diagnostic centres.

It is an open secret that diagnostic centres survive allegedly on doctors' prescriptions. The Indian diagnostic centres are currently driven mainly by doctor referrals and the user has very little choice in the whole process. Some questions over suspected nexus between doctors and diagnostic centres are always present in India. A few years back, a private TV channel exposed the nexus between doctors and diagnostic centres in Delhi. The sting highlighted the nexus between the two to fleece the patients by suggesting unnecessary investigations. The sting exposed that doctors collect 30-50% commissions from diagnostic centres by cash every week or on a monthly basis on magnetic resonance imaging (MRI), CT scans, ultrasound and other routine pathological tests. In quite a few part of the sting operation, the staff of the diagnostic centres revealed that they pay referring doctors as much as 50% commissions on expensive tests like MRI. Following the sting, there was an uproar in the parliament, which compelled the Union Health Minister to set up a high-powered committee to enquire into the alleged nexus in July 2014. The committee found clean evidence of unethical practice and unfair trade practice by both.

The tacit understanding between diagnostic centres and a large pool of doctors for referring patients for a variety of diagnostic tests has been a standard practice in Assam. The referring doctors allegedly get hefty commissions from these diagnostic centres. According to a survey carried out by CUTS International (Subject-Collusive behaviour in health care and impact on consumers: Evidence from Assam) in Kamrup (metro) and Nagaon districts of Assam in 2010, they found that some doctors earn 40-50% commission on the tests prescribed by them and many a time, suggest unnecessary tests for patients to improve business of diagnostic centres. The main issue here is the percentage receivable, rather than what is necessary for the patient. The fact that only a third of these diagnostic tests ever revealed a serious illness bearing testament that on most occasions these tests might not have necessary. Thanks to the mushrooming of diagnostic centres in the State, there is intense competition among them to win over a doctor. Typically, super-speciality doctors command 40-50% cut in an overall bill, charged to the patient by the diagnostic centres. Some diagnostic centres of Guwahati offer Rs. 1 lakh every month to super-speciality doctors. If the doctor prefers to go bill-by-bill commission, they give Rs. 1,000 for CT scan, Rs. 1,500 for MRI and Rs. 3, 000 for PET scan. Sometimes even up to 50% commission is involved in MRI. Similarly, radiology tests like X-ray, pathological tests and bone density tests being around 35-40% to the doctors on each bill. There are instances where doctors demand advance payments from diagnostic centres. It is found that a few diagnostic centres give cars, air-conditioners and equated monthly installments for home appliances, cars and life insurance premiums to some doctors to get frequent and costly investigations. Sometimes, the owners of diagnostic centres host weekend parties to the families of the doctors. Of course, the doctors ensure that the centres get the patients.

Some doctors even allow collection centres to be set up in their chambers, where personnel from the referral diagnostic centres collect patients' samples. Sometimes, doctors invest money together with a diagnostic centre and then send long lists of investigations for kickbacks and incentives. Some doctors refer patients to technician-run laboratories to get high percentage of commission. They even refer peripheral blood smear, cytology and histopathology samples to these laboratories. Nobody cares about the quality of reports that these laboratories have to offer. Even top consultants accept these reports (sometimes even unsigned one) from technicians. The flip side is that when it comes to the consultants' own relatives or friends they always come to a pathologist even for the simplest of tests. What is good enough for other patients is not so for the doctors' kith and kin. Due to the nexus that exists between the doctors and diagnostic centres, unless a patient comes back with a report from a particular centre, he is subjected to another battery of tests with the explanation, 'these tests are wrong; why haven't you go to other centre?' The poor patient fears the wrath of doctor and does as he is told, in the process compromising his right to choose where he wants to go. The racket is leading to unjustified profit margins. As the diagnostic centres pay the commissions in cash, so the referral doctors never pay income tax on these amounts. The government loses huge amounts of taxes. Even after paying the hefty amount of commission, these diagnostic centres report good profit. If somehow the government can stop this unethical practice, the patients will be able to get the investigations done by spending less amounts.

In Assam, though the infrastructure of almost all types of clinical tests is available in the government hospitals, some government doctors refer patients to particular private laboratories for tests. Patients, who consult a government doctor because of free consultation fee, are unaware of the facts that many such doctors make up for the 'free' consultation fee by advising unnecessary tests, to be done in private diagnostic centres. A few government doctors allow private laboratory technicians to visit wards for collecting samples of the patients. Despite a set-up of modern radiology room, doctors prescribe patients to get their ultra-sounds and CT scans done by a private radiologist, which raises questions over some suspected nexus between government doctors and diagnostic centre. For this, the patients and their attendants have been facing heat as they are made to pay hefty amounts for clinical tests, which are available in government hospital laboratories at nominal rates. The common clinical tests, which are generally charged from Rs.100-200, cost from Rs.800-1000 onwards at private laboratories. The ultrasound at government institution cost from Rs.300-500, while private radiologists charge from Rs.1000-1500. A CT scan costs around Rs. 6000 outside, while in hospital it costs Rs.1000. Similarly for an X-ray, a patient has to pay Rs. 300-500 to private laboratory while in the hospital it costs Rs. 100. Such malpractices affect the financial position of the government hospital.

No doubt, modern medical practice is dominated by sophisticated and often expensive investigations, but judicious use of investigations is necessary. Indeed, a test should only be advised ordered if it is clear that the result will influence the patient management and the perceived value of the resulting information exceeds the anticipated discomfort, risk and cost of the procedure.