In June, as the southwest monsoon rolled into Mumbai, strange hoardings at prominent sites sponsored by a well-known cardiac hospital made big news. In contrast to the usual claims of “cutting edge” medicine, these advertisements ads announced: “Honest opinion; no commission to doctors.” What was being attacked was the practice of cuts and commissions in the referral of patients in Indian health care. Predictably, this raised the hackles of doctors and medical associations who demanded that they be pulled down. Dr. Ramakant Panda, the founder of the hospital, (who had operated on former Prime Minister Dr. Manmohan Singh) defended them and upped the ante by holding a press conference with other doctors where a campaign against this practice was launched. With uncharacteristic efficiency the State government appointed a committee with a brief to draft a law to curb commissions in health care.
As this episode in the very old saga of “cut practice” awaits its outcome, it’s important to dissect what lies beneath. What needs to be uncovered has repercussions for something all of us will inevitably need — decent, trustworthy health care.
Around two decades ago when I joined private practice, friends warned that if I was too “idealistic” I would not survive. In the early years, colleagues would refer a patient and after I had offered advice, would call and say curious things such as “Do you believe in keeping your colleagues happy?” I knew what they were alluding to and nipped it in the bud. I suspect my reputation spread and the suggestions stopped. Today the largest numbers of patients I see are referred to me by other patients. My well-wishers were partly right. If I had chosen to play along, I could have been doing much more work and maybe earned more money. But I have survived on my own terms. And also have the time to write such pieces!
A ‘normal’ now
My insider view of two decades tells me that the phenomenon of commissions, though secretive, is now normalised as the main way to refer patients from one player to another, be it family doctors, specialists, laboratories or hospitals. This practice is adding to the cost of care as kickbacks are factored into the charges. Also, if referrals are made based on commissions, it intuitively means a compromise on quality. Thus as citizens seeking health care it’s biting you in more ways than you can imagine. But, interestingly, it is also making many doctors uncomfortable and restless. If this is so, why are bright, idealistic, young doctors getting sucked en masse into such practices which are not only deemed unethical by the Medical Council but also patently illegal as they involve the exchange of money? There is obviously more to it.
A decline sets in
Post-Independence, Indian medicine, which was largely based in public hospitals and around family practice, gradually morphed into a giant entrepreneurial industry. The state, by underfunding and with benign neglect, weakened public medicine, thus vacating space for an unprecedented growth of the private sector, now one of the largest in the world. Soon private medicine, which delivered friendly, efficient and sophisticated care, became the desired destination of not only the rich but also the emerging middle class. It also caught the imagination of medical professionals. The goal posts of young doctors shifted from teaching, research and serving in public medicine to the glamour of the private sector. When I left a reputed teaching hospital to join a large private hospital, I received many congratulatory messages from friends and family as if it was an achievement. Private medicine had acquired a higher status even in the eyes of society. Unlike other countries where commerce is partly negated by strong moorings in science and research, Indian medicine veered to a trade, with its measures of success.
The booming private sector soon experienced intense saturation and cut-throat competition. So whether it was individual practices or large hospitals ensuring returns on investments became vital. Soon, marketing tactics had to be employed to keep the flow of patients going. There was another emerging fault line. Specialist doctors, by the power of hierarchy, were making more money than family physicians. So rather than increase their charges, commissions were a surreptitious strategy adopted by those lower in the hierarchy to extract their pound of flesh.
Thus, “cut” practice is not only a sinister plot by the health-care industry but also has many complicit actors — the state by undermining public health and allowing the unregulated growth of the private sector, the profession by lapping up the logic of market medicine and failing to self-regulate, and citizens, especially the emerging middle class, who have given tacit support to the growth of private medicine. Unlike many astute countries, we failed to shield health care from market economics.
While a law to curb it may have some impact and the breaking of ranks by senior doctors is a good sign, I am afraid that unless there is deep collective rethinking on the trajectory of health care, we will see symptoms in other forms. As we say in infections affecting the human body, immunity is as important as shotgun antibiotics.
Sanjay Nagral is a surgeon practising in Mumbai. He is also the publisher of the Indian Journal of Medical Ethics
