18 Why a 'cut' for what you can't do

The Wolf and the Horse:A wandering wolf walked through a field of well grown oats. Since wolves do not eat oats, he gave it no further thought until he came across a majestic looking horse. The wolf, wanting to ingratiate itself with the horse, said, "Look, my friend, here is a field of fine oats. I knew you would like to eat them. I haven't touched even a single grain. Let me have the pleasure of watching you munch it all.” But the horse was unmoved and said, "If you wolves could eat oats, my friend, you would have hardly indulged in comraderie at the expense of your belly."

Dr Abu was a physician with a busy practice in a polyclinic. Dr Babu joined there as a surgical consultant. "Welcome aboard" said Abu, "My ward has plenty of cases who need surgery. I have kept them just for you. I would like to see your fine work on my cases.” Dr Babu grinned wryly and thought to himself, "If only you could operate, my friend, you would not have kept your cases waiting just to see my fine work."

Comments

Absence of such horse sense makes a referee feel obliged to the referrer, and leads to the practice of kickbacks and 'cut-practice'. Unlike the consumer market, where competition reduces prices, in health care, the cost to a consumer goes up. This anomaly occurs because consumers have no direct access to health care services; they have to go through a health care provider. When competition gets hot, the industry offers more

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inducements to the care providers to entice them to refer more clients. The enhanced inducement costs are ultimately paid by the clients without being aware of it. Ten to sixty percent of the collected charges are paid by diagnostic centres and referral hospitals to the referring doctors (and other providers) as 'cuts'.

The practice of collection of fees and splitting it with the referring doctor has become commonplace. It is euphemistically called as 'professional fee', 'follow-up fee', 'professional service charges, ' etc. The rationale offered is that the referring doctor has to 'correlate the laboratory data with the clinical picture' and 'follow up the case after the specialised treatment'.

However, the real picture is scandalous. The provider-seeker relationship, based upon trust and fiduciary norms, gets corrupted by this vicious process. Just look at the facts:

 The patient has already paid and will continue to pay the referring doctor.  The fee splitting is concealed from the client.  The 'cut' for the referrer is an incentive to refer more cases for specialist service.  It abets and entices a doctor to forget the fiduciary nature of provider-seeker relationship.  The professional is reduced to being a prescribing robotic arm of the health care industry; the doctor's role is vulgarised to being a vendor-solicitor rather than a trustworthy friend, philosopher and guide (see Chapter2).

Do you feel I am exaggerating? Just read the following extract from the Journal of Medical Ethics: "I saw a friend of mine, a consultant, earning a hundred rupees from a patient. He gave sixty rupees to the family doctor who brought the patient. My friend subjected the patient to a host of tests that were not needed and removed his healthy appendix. Twenty-six years of honesty, integrity and self-respect were washed down the drain in just a day. He has joined the rat race to earn a living." (Muralidhar V, 1993)

In the same journal, Dr MK Mani, the famous nephrologist of India, has published his correspondence with the Medical Council of India (MCI). The MCI is the watchdog

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body that regulates allopathic medical practice in India. Dr Mani had sent them proof of fee splitting, in this case a sum of Rs 2,000/-, for referring a patient with renal stones for ultrasonic treatment. He had implored the referee to stop offering such incentives and to reduce the patient's charges instead of "bribing the doctors to send more patients.” Many letters were exchanged with the MCI but to no avail. As the title of his article says, 'Our watchdog sleeps, and will not be awakened'. (Mani MK, 1996)

Bernard Shaw had cautioned us in 1933 when he wrote, "Until the Medical Council is composed of hard working representatives of suffering public, with doctors who live by private practice rigidly excluded except as assessors, we shall be decimated by the vested interest of the private side of the profession in disease.” These are no doubt strong words but none the less, entirely applicable to the current Indian scene.

Will the profession ever get the 'horse sense' to follow an ethical path? When?

Does the public realise that up to 60% of the health care cost is spent on kickbacks and bribes to solicit more health care business? Does it care? How can these concerns be converted to effective actions?

Meanwhile, a conscientious professional can use the following self-test: "Would I like the arrangements between myself and the referee known to my patient?” If the answer is 'No', then the arrangement is unethical and is to be abhorred.

I know some ethical physicians who give the 'professional fee' back to their patients, saying that they were eligible for a special discount. There are others who use the 'Robin Hood principle' and get free service for the poor in lieu of the kickback.

Until we get truly emancipated from the curse of cut-practice, our society needs more of such unsung heroes.

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