The unethical practice of commissions in private healthcare requires an open debate since it leads to expensive and hazardous healthcare. Doctors are accused of being sales agents and law breakers, private hospitals resemble luxury hotels, the consumer has become fair game whenever he/she has money, and our profession and society are rendered insensitive to human suffering. At the root of this malaise is the unplanned promotion of healthcare as a free market product. This very complex product, which is required in times of stress and vulnerability, has been institutionalized as a business for profiteering in the absence of adequate checks and balances. The product is inherently unsuited for the free market because the consumer cannot be king unless he is empowered to choose wisely. Not enough has been done to address this deficiency. Efforts are required to strengthen non-profit health facilities; to make the consumer wise and minimize her/his exposure to doctored health information. The present unethical practices of our profession are not the fault of doctors or the Medical Council of India, and punitive measures would be inappropriate. We should start with the creation of a government health website which educates the public about modern healthcare, and by regulating advertisement of health products. Since health personnel, officials and news media are directly benefited by the present malpractices, corrective will require consumer participation.

Natl Med J India 2007;20:147–9

It is dangerous to have a system in which the doctor obtains pecuniary benefits by cutting off your leg.                                                                                               —george bernard shaw

INTRODUCTION

A news item reporting on commercially run diagnostic laboratories1 alleges ‘most (are) indulging in giving commissions to doctors and medical establishments for referring patients to their centres, a patient may be paying as much as 25–50 per cent extra of the actual cost for any test… (and)… patients are in some cases even encouraged to go in for tests that they don’t require and pay for the same’. The news item further mentions that ‘MCI rules prohibit physicians from indulging in giving or taking gifts, gratuity, commission or bonus in consideration of or return for the referring, recommending or procuring for any patient for medical, surgical or other treatment, the rule is often flouted.’ This news item criticizes health professionals, alleges that they deliberately put to harm their patients for profits, and that the Medical Council of India (MCI) has been ineffective. Medical forums should not ignore such criticisms. The allegations are serious, and we have an obligation to society to be responsive to its concerns, as much as we need to defend ourselves against unfair criticism.

ARE COMMISSIONS PAID?
The newspaper report may not surprise readers; people regard covert commissions as fait accompli. Any widespread practice cannot remain hidden from the public. Numerous agents are required to generate business and deliver commissions. In the past few years, India’s leading business houses have entered the hospital business, and are knowledgeable about commissions.1

DOES IT CONSTITUTE A PROBLEM?
Such commissions are detrimental to health and society for various reasons, which include the following.

1. They increase healthcare costs. When 50% of the test charges are spent on marketing and commissions, the patient pays double the price. Unnecessary tests increase costs many fold.

2. The consumer is deprived of an unbiased medical opinion when monetary considerations influence recommendations. The referring party recommends an expensive medical product that she does not fully understand, and the recommendation is based on monetary reasons. The specialist provider cannot be expected to offer a fair second opinion, because of covert commitments made to the referring party. In such a scenario if the specialist provider does not conduct the test (procedure) for which the patient is referred and sends the patient back, the contract with the referring doctor has been broken, and further referrals will not occur.

3. Even the best medical care will have some deaths and bad results, and any compromise in intentions and conduct are therefore at the expense of increased risk to life and well-being of the client. In modern medicine, management of patients is often based on statistical evidence of benefit. Extensive management protocols such as angiographies, angio-plasties, bypass surgeries, major operations and chemotherapy regimens are recommended because they can improve outcome typically by about 5%–10% over less expensive and simpler treatments. For example, coronary angioplasty,2use of
   GpIIb–IIIa inhibitors,3and drug-eluting stents3are modalities which may reduce infarctions/deaths by 1%–2% over less expensive therapies. When they are offered to patients in whom they are not indicated, the risk–benefit ratio of a procedure can tip from net benefit to net harm. It can tip a health facility from being a provider of health to the net deliverer of iatrogenic disease.

4. It makes the public suspicious of healthcare, and reluctant to use it in times of genuine need.

5. Commission-based services make the providers focus on commerce at the expense of science, skills and knowledge, leading to a commensurate fall in standards.

6. Such practices make the health industry personnel callous and insensitive to human suffering.

GENESIS OF CHEATING
Such commissions are possible only if patients and the public
are expected to purchase health products from the free market. It does not exist in countries where healthcare is provided by the state, and is hard to contain when delivery of healthcare is left to businesses.
   A free market functions effectively when the consumer understands the product and can choose wisely. Healthcare is a very specialized product. Even medical professionals cannot, with certainty, be expected to choose the right test or decide the need for a complex procedure. The average patient has little knowledge of the tests and treatments she needs and is dependent on the supplier for advice regarding the quality and quantity of products to be purchased. It is unreasonable to evolve a delivery system that relies on the consumer to buy efficiently a product that is too complex for her to evaluate. Preventive healthcare is even more difficult to assess. Clients are encouraged to purchase health products before they fall sick. Consumption of preventive health products requires an unbiased health provider, because the consumer has no disease, and has no way of knowing whether the product has made her better.
   Private healthcare facilities are expected to be profitable, to pay back bank loans, create value for shareholders, generate funds for updating and expanding facilities to remain competitive. It is natural for them to focus on selling profitable products to those who have money (hence the burgeoning of dubious preventive products such as lipid profile, prostate specific antigen and mammogram). It is naive to expect businesses to focus on unprofitable activities such as caring for the sick and needy.

REMEDIES

Punitive measures
To demand punishment for such ‘business’ healthcare ventures would be understandable. However, such a knee-jerk reaction will not suffice. The practice is widespread and it will be difficult to punish everybody, especially the powerful. Officials responsible for scrutinizing are often the beneficiaries of commissions. Correcting deficiencies in the system is far more worthwhile.

Alternative healthcare facilities
We need to augment healthcare facilities and research outside the free market system, to encourage competition. Wherever voluntary and government health facilities are functioning well, private healthcare is forced to remain competitive and fair. Government and private health facilities should by law have public representatives from the local area on the board of management. Methods have to be developed to bring in genuine representatives and make them accountable.

Public education
Independent and government websites and printed material that provide clear information on high cost healthcare products are required. They should give useful details such as which patients benefit, to what extent, how the product is rated by past clients, the rate of product failure (false-negative and false-positive rates, 5-year survival curves, etc.), the cost per quality life-year gained, results of alternative low cost products, etc. The sites should not glamorize details of products such
as laser, robotics and genetic engineering. Consumers have to be educated to choose products on efficacy and cost, not on glitter.
   The consumer must be educated on how and when to ‘shop’ for doctors, tests, operations, specialists, second opinions, hospitals, etc; how to monitor the performance of the service provided, how to plan for and procure healthcare products. Consumers have to be educated to prevent them from being lured by marketing and advertisement strategies such as free health checks and subsidized initial charges.
   Attempts should be made to publicize fair prices of various medical products (excluding commissions). Information on the wholesale bulk prices of drugs, manufacturing costs of converting bulk drugs into formulations, estimates of fair prices of medicines and consumables minus the ‘marketing expenses’ should be made available. The consumer requires education on calculating the true charges of the care purchased. Fair prices of consultations as well as tips for estimating appropriate prices of products such as consultations and surgeon’s fees need to be publicized.

Legislation and guidelines
These are required on

1. Disclosing conflict of interest when health information that is paid for by sellers is presented as news by the media.

2. Industry sponsorship of medical conferences and jamborees. These lead to gross distortion of medical thinking. Modern science evolves through medical conferences. Most modern medical conferences are funded by the free market. Profitable products and industry-friendly doctors are projected. Sometimes conferences become trade fairs dressed as scientific forums. It has passed medical leadership from the hands of altruistic, socially committed and academically strong doctors to the hands of profit generators. It leads to doctors becoming sales agents of expensive products.

3. Very small and dubious benefits are magnified for promotion of expensive products. It is necessary to develop guidelines on the quantum of benefit and the quantum of proof required before any product can be legally recommended. The present recommendations that are publicized by health providers and ‘expert’ committees in the absence of such guidelines are mostly market-driven and based on dubious science.

4. Making health claims on any product should be regulated, requiring stipulated quanta of proof, adherence to stipulated norms, use of officially prescribed disclaimers, etc.

   Health information about food, consumer goods and lifestyle has been distorted to ridiculous extremes to promote business. Just as advertisement of financial products and tobacco products require legally prescribed warnings, health claims too should be regulated. It is not a product to be marketed by creating a demand. Baby milk formulations, tobacco and alcohol cannot be advertised, and the same should be extended to surgical procedures and all other medical products.
   Delivery of healthcare is woefully inadequate in India and the present emphasis on profit-based delivery is one deficiency that can be addressed. It is possible to deliver adequate healthcare with relatively limited funds, as has been achieved in Sri Lanka, and even in some parts of India such as Kerala. It is equally possible to have crippling costs and poor delivery as has occurred in ‘for profit’ healthcare. We need to reform the system and thereby direct the available infrastructure to focus on those in need, rather than those who will pay. This will help us to achieve our healthcare needs within our limited resources; it will help us to become a model for other countries, and not professionals who are criticized for indulging in illegal practices.

References

1.  Perappadan BS. Pathology labs flourishing in absence of Government regulation. The Hindu Delhi, 5 July 2005.

2.  Boden WE, O’Rourke RA, Teo KK, Hartigan PM, Maron DJ, Kostuk WJ, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007;356:1503–16.

3.  Guagliumi G, Stone GW, Cox DA, Stuckey T, Tcheng JE, Turco M, et al. Outcome in elderly patients undergoing primary coronary intervention for acute myocardial infarction: Results from the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial. Circulation 2004;110:1598–604.

4.  Moses JW, Leon MB, Popma JJ, Fitzgerald PJ, Holmes DR, O’Shaughnessy C, et al. Sirolimus-eluting stents versus standard stents in patients with stenosis in a native cornary artery. N Engl J Med 2003;349:1315–23.