Wednesday, September 15, 2010

Is there anything wrong with specialists giving referring doctors a kickback ?


Cuts and kickbacks have become the norm in medical practise in India today. In public forums, most doctors frown on this practise as being unethical and unprofessional ( even though they continue giving cuts in their own practise). This is hypocritical and just adds more dishonour to the medical profession.

Let's take a fresh look at the subject. The question we need to ask ourselves is - Is there anything wrong with doctors giving cuts ? Is this really such a bad thing ?

Cuts and kickbacks are pretty much standard practise in many areas of life today, such as politics and commerce. Greasing palms is considered established practise if you want your file to move in the government office , and if it's okay to give bribes and kickbacks in other fields, what's wrong when doctors do the same ?

Let's see why the practise evolved in the first place - after all, the fact that it has spread like a cancer means it must have some plus points ! Rather than turn a blind eye to these , let's look at some of the benefits this offers.

The advantages to the family physician ( primary care doctor ) are obvious ! It's a fact that family physicians are underpaid as compared to specialists. Doctors who do procedures command an unfair premium and these kickbacks helps to reduce the disparity in their incomes.

Also, primary care doctors play a very useful complementary role to the specialist, but this is often not explicitly acknowledged or reimbursed . They don't just refer the patient to the specialist and then walk off after collecting their commission ! They help to identify the "best specialist"; help the patient to get a timely appointment; counsel and handhold the patient
( something which most specialists just don't have the time or energy to do !) ; explain what the specialist is saying ; and demystify the medical journey for the family. They are always available for assistance ( for example , in the middle of the night, when the specialist has disappeared) ; and because they have an ongoing long-term relationship with the family, they are able to provide emotional support much more effectively than the specialist . Equally important, they are better at taking a holistic view of the medical problem, as compared to specialists, who have a very narrow viewpoint - and who may know a lot about the technical minutiae of their specialty , but know precious little about the person who has the disease !

Family physicians act as a useful bridge between the specialist and the patient - how are they going to reimbursed for their efforts in a fair fashion ? In my opinion, the cut which the specialist gives for the referral is their reimbursement. Taking a share of the spoils is the most effective way for them to earn money.

So it all hunky-dory ? No ! There are major disadvantages to this system ( which is why we do not give cuts in our private practise !). For one, this system increases the cost to the patient. It also promotes malpractise , because family physicians will often pressurise specialists to do surgery in order to maximise their revenue, which means that procedures are done which are not always in the patient's best interests. Also, because this is unaccounted for black money , which is paid in cash, under the table, it encourages a parallel underground economy.

Because this practise is hidden, it's never discussed openly , and this creates a lot of resentment amongst patients. The fact that doctors indulge in giving kickbacks is an open secret - and hiding this reality creates a lot of suspicion in the patient's mind. This is one of the major reasons patients do not trust their doctors , and why the reputation of entire medical profession has taken such a beating in recent years.

So what's the solution ? Can we ban kickbacks ? While the Code of Medical Ethics explicitly bans cuts, unfortunately this does not work in real life. We need to find a realistic solution !

I feel the major danger with the kickback is the fact that is done in an underhand secretive fashion. Because the doctor hides the fact that he is giving a kickback to the referring family , he has to be dishonest - and this damages the doctor-patient relationship, which should ideally be based on trust !

Large corporate hospitals routinely give referral fees to doctors. This is considered to be part of the "cost of doing business" and is usually given as a cheque payment. If we accept this practise
( because a hospital is a business and needs to fill its bed), then why not level the playing field and allow doctors to give referring doctors a commission as well ( which can be claimed as a tax-deductible expense ? ) Similarly, doctors give referral / commission fees to medical tourism companies which refer patients to them. What's wrong if they give this to the family doctors who send patients to them ?

I feel it's far better to make this an open and transparent system, so the patient knows what the truth is ! The specialist can add a " surcharge" to his fees, and this can be paid to the family physician by cheque , as a "patient management fee" . This transparency will keep everyone honest and help to align the doctor's interests with that of the patient !





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