. Eminent citizens across India are unified in their opinion that corporate hospitals, diagnostic & imaging centres, pharmaceutical and equipment suppliers play a key role in “the kickbacks and bribes that oil every part of the healthcare machinery”. How does an endoscopy/ Colonoscopy cost Rs.1200 in Non NABH hospital, Rs.1360 in NABH hospital but Rs.23600 in a corporate super-specialty hospital in the same city probably done by the same doctor? A Drug which needs to be used only once daily has been known to be billed for 24 times in a single day to inflate bill in a corporate hospital. Why? This speaks of corruption with all parties being aware of what is going on, officials demanding their pound of flesh and leading to spiraling costs. Can universal health insurance succeed in this scenario? Can individual doctors resist the pressures from all sides?

Sometime ago a Hospital in Mumbai acknowledged, in a letter to the Maharashtra Medical Council, that it offered “incentives to doctors” to refer patients to the hospital. The complaint before MMC stated that the hospital had been sending out forms to various doctors to enroll in a forum promising a reward of Rs 1 lakh for 40 admissions per annum, Rs 1.5 lakh for 50 admissions and Rs 2.5 lakh for 75 admissions. Ultimately from whose pocket this money goes out? “In many of our five-star corporate hospitals, where the only motive seems to be profit for the stakeholders, there is a system of so called ‘facilitation charges’ or fees for ‘diagnostic help’ given to physicians who refer patients regularly and for expensive procedures like organ transplants, which may reach Rs 1-2 lakh,” said one medical expert, adding that doctors are confronted by financial officers of hospitals asking them to justify whether they deserved their salaries especially when the revenue they generated for the hospital from investigations and operations fell short of set goals. The “temptation” to do “unnecessary investigations like CT scans and MRI” and “unnecessary procedures like caesarean sections and hyterectomies” was “hard to resist”, he commented. Another expert from Apollo Hospital Chennai, told TOI that the practice of doctors getting kickbacks from any expensive operation or diagnostic procedure was pervasive and openly done. “In the case of doctors who have pointedly refused to take such ‘cuts’, it is given back to the patients as discounts. How many are strong diehards to kick the ‘Ghar Aai Lakshmi’. So the hospitals have not stopped this practice and doctors who take such cuts continue to do so. “It is a common practice for institutions running high tech and high cost investigations and treatments to offer inducements to doctors who refer patients to them for investigation or treatment. I believe this practice is reprehensible, and is detrimental to the interests of the patient.”

The routine advice of 130 different medical screenings and tests, being advertised in the media, are often unnecessary and should be given a go by. Only specified test should be advised that may be relevant and expedient to the health situation. Plethora of tests advised casually to diagnose all ailments is a mockery of clinical acumen and waste of national resource besides financial loss to the patient. Use of expensive and often unnecessary imaging tests, such as early use of magnetic resonance imaging (MRI) or computed tomography scan (CT) for complaints that are likely go away on their own are avoidable.  American Academy of Family Physicians (AAFP) recommends that unless red flags are present, doctors should wait six weeks to order imaging for low back pain. The scans do not affect treatment or improve outcomes any faster for patients—but it can lead to radiation exposure and unnecessary surgery. A study found that  mammography use is responsible for about 20 percent of the cases of over-diagnosis of breast cancer. It goes without saying that unneeded care can be hazardous to your health—and your wallet. For example, X-rays and CT scans expose you to potentially cancer-causing radiation, and can lead to follow-up tests and treatment with additional risks. And the costs can be substantial.  Same is true for TMT test for heart function. This may lead to avoidable follow up tests. Those follow-up tests can include CT angiograms, which expose you to a radiation dose equal to 600 to 800 chest X-rays, and coronary angiography, which exposes you to further radiation. Inappropriate testing can also lead to overtreatment with drugs or even surgery. Exercise stress test should only be ordered if you have chest pain, an irregular heartbeat, or other symptoms of heart disease. They can also make sense for people with diabetes or other coronary risk factors who are just starting to exercise. Similarly, patients should avoid scheduling non-medically indicated labor inductions or cesarean sections before 39 weeks.

Besides money and other favors, even academic excellence is being auctioned/ misappropriated. A survey published in an issue of Indian Journal of Medical Ethics points out that doctors are now being gifted authorship in journals of repute to enhance their stature in the eyes of the public and medical community, even if they have made no contribution to the research. Gifting authorship is one of the most prevalent misconduct in biomedical publication among researchers, and nearly 65% of doctors admitted they were witness to it. More than half the doctors surveyed said they had seen falsification of data and plagiarism. It’s unfair to give authorship to anyone who has not made a contribution. Most senior researchers say that ethics of science writing should be a part of undergraduate education and stringent action should be initiated if someone is found guilty of misconduct.

November 28, 2015

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