JOIN USIt is unfortunate that the medical profession has been unable to resist the insidious habit of referral commission and fee splitting that has become a regular feature of clinical practice.
An excuse offered is that it is symptomatic of a widespread malaise of corruption and greed that has gripped society. However, we cannot afford to be so blasé about such transactions that directly and negatively impacts the patient within the healthcare setting.
Doctors are not unaware that fee splitting and receiving of commissions is unethical and provides grounds for action under the Medical Council of India (MCI) Regulations 2002. In fact, the regulation was amended in 2009 to specifically address this misconduct as well as the act of receiving gifts and incentives from the pharmaceutical industry.
In spite of this, there have been no convictions or reduction in this notorious practice. In fact, the medical industry has found creative ways to profit and offers lucrative incentives in the booming private health sector.
The modus operandi is simple. On referral of a patient to a laboratory, diagnostic clinic or scan centre, the referring doctor receives a percentage of the fee charged to the patient at the centre. Some hospitals too, routinely reward practitioners for referrals. The patient thus pays twice for the same consultation, called ‘self-referral’ in other systems.
This manner of kickbacks is unworthy of the profession and gravely affects patient care. It can result in over-prescription and unnecessary testing which drives up the cost of care and health insurance.
Unhealthy competition
There could be compromise in quality and choice of diagnostics, laboratories and referred doctors. Another fallout is that hospitals may create policies of patient care in self-interest. This could lead to rigid loops of referral, denying patients’ access to other new, skilled and worthy consultants within the healthcare space. It could also lead to unhealthy competition between industry stakeholders to corner a larger share of the market.
The fiduciary nature of the doctor patient relationship demands that the doctor place the good of the patient above all other consideration. Diagnostic tests need to be prescribed according to protocols of care and evidence based medicine.Fee splitting results in a conflict of interest that is unacceptable, as it introduces the lure of financial gain, making it unethical.
Although patients are aware of fee splitting, they express helplessness against this entrenched practice and have no idea of the actual size of the commission. Those who are skeptical tend to seek second opinions. Most patients, however, have faith in the doctor’s intentions and believe he will do what is best. But, for whom?
The burden of the increase in cost of care that results from this practice falls squarely on the shoulders of the patient with all other stakeholders emerging ‘winners’ in this deplorable scenario. In an over-burdened, under-resourced healthcare sector it is an injustice to poorer patients, as their only other option is often the substandard or absent care in Government clinics.
The World Medical Association and Governing Medical Councils have condemned the practice worldwide.The US, for example, introduced the Stark laws against self-referral that are related to ‘Kick-back’ laws of that country. Violations attract substantial fines and punishment including suspension of licence.
These laws are directed at medical industry as well individual doctors and are strictly enforced. As the MCI has failed to rein in this deplorable practice, there is need for a broader solution. Hospitals, diagnostic clinics, scan centres and laboratories may need to be covered by specific laws and audits that discourage commissions and link this compliance to licensing and accreditation.
In India, there are some service-oriented hospitals and practitioners that denounce and resist this practice, and are recognised by patients and rewarded with over-filled Out-Patient (OP) rooms. Some doctors even refuse commissions and negotiate with service providers to pass on the cost benefit to the patients. Is it possible to publicly recognise and incentivise ethical behaviour?
We would also require more whistleblowers and ways to protect them. Building public awareness, along with stricter laws, is one way to drive change in this area and encourage accountability, thereby restoring faith in the vital healthcare industry.