What can be done about financial targets for doctors working in profit driven hospitals that lead to
expensive but unnecessary tests and surgery that also come with risk of harm, asks Meera Kay
Meera Kay
journalist, Bangalore
“For seven years I had to bear the burden of
doing unnecessary investigations and procedures, including angioplasty, under
pressure from the management of the hospital,” Gautam Mistry, a cardiologist in
Kolkata, told The BMJ.
What Mistry
is describing is one of the best kept secrets of India’s private healthcare
sector—consultants hired by private hospitals have to meet targets for
generating revenue by overprescribing diagnostic tests and avoidable surgeries.
No data
exist on the prevalence of such targets, and Mistry did not disclose details of
what targets he had been set.
“Significant numbers of patients must be
advised to be admitted for surgery or medical procedures that bring in real
financial profit for the hospital,” explained Kunal Saha, adjunct professor and
HIV/AIDS consultant in Ohio, United States, and president of People for Better
Treatment, a non-governmental organisation that promotes corruption free
healthcare in India.
Unnecessary risk, additional cost “Needless
surgery, even simple procedures like tonsillectomy or appendectomy, may cause
unexpected hazards for the patient,” he said.
Unnecessary
surgery not only comes with the risk of harm but also burdens patients and
their families financially, often directly. “In the absence of any effective
medical insurance system, most ordinary patients in India are forced to pay the
hefty hospital bills out of their own pockets,” Saha said.
Such
unethical practices are widely known about in medical circles but public discourse
has been lacking. “Doctors who face pressure from hospital management to
overprescribe surgeries or investigations fear for their livelihood,” Mistry
told The BMJ. “They also need to practise for a certain number of years, and by
complaining they would be jeopardising their career.”
Conscience
takes a back seat
Support for
Advocacy and Training to Health Initiatives (SATHI), a non-governmental
organisation based in Pune, documented the problem for the first time in its
recent report, Voices of Conscience from the Medical Profession.
The report
contains interviews that the gynaecologist Arun Gadre held with 78 doctors
throughout India.
1 More than
half of India’s hospital beds are in the private sector.
2 Gadre, an
associate coordinator at SATHI, told The BMJ that India has seen a rise in
multispecialty hospitals. “Some are run by corporates but most are run by
business minded professionals,” he said. “Their main aim is to generate revenue
and profits for their investors. In the race to earn higher profits, conscience
takes a back seat, and doctors are encouraged to indulge in unethical
practice.” Sharing the feedback of a surgeon from a metropolitan city, Gadre
recounted, “Corporate hospitals are not content unless there is some procedure or
operation done related to each bed in the hospital.”
Performance
targets raise efficiency.
Some doctors disagree about the ubiquity of
financial targets for doctors, including Devi Shetty, cardiac surgeon and
chairman of the Narayana Health Group, which runs 32 hospitals for profit in 20
locations in India and abroad.
“We often hear about revenue targets for doctors
in private hospitals; I know it is a very rare phenomenon,” he told The BMJ. He
said that Narayana’s hospitals do not set financial targets for doctors but do
set performance targets to raise efficiency. “Hospitals like ours will
definitely expect doctors to work long hours to serve the needs of thousands of
outpatients. We can’t afford to have doctors spending more than an hour with a
single patient. But setting financial goals for a doctor is not a common
practice in India,” he said
Regulating
doctors’ practice
In taking the Hippocratic oath every doctor
pledges to uphold ethical standards. Yet allegations such as these indicate an
inability of some doctors to regulate themselves.
The Medical
Council of India (MCI) is responsible for institutional regulation of medical
services. But its reputation is in tatters—its inability to collect data on
alleged medical negligence and general failure to bring prosecutions do not
instill confidence.
3 The cry
for transparency at all levels of the MCI is growing ever louder in India.
4 Saha said
that the MCI had unequivocal and stringent provisions against unethical medical
practice by registered physicians, which clearly encompass the deliberate
referral for unnecessary medical or surgical procedures. But, “such medical
laws are hardly enforced by the Machiavellian MCI and other state medical
councils that have always worked only to maintain the hitherto ‘untouchable’
status of the Indian medical community,” he said.
“A radical change in the structure and
functioning of the MCI is the need of the hour,” Gadre told The BMJ. “The
elected members are all doctors, which could result in a biased outlook.” He
said that the Clinical Establishments (Registration and Regulation) Act 2010,
which is not uniformly implemented in India, should be enforced by the
government, because it has provisions to check the prescription of surgeries
and investigation. He said that all practice should be evidence based, with
standard treatment guidelines.
People for
Better Treatment and SATHI are among a handful of organisations in India
voicing concerns over revenue targets for doctors at corporate hospitals.
People for Better Treatment is trying to tackle unethical practice by recourse
to the law, through public interest litigation in the Supreme Court of India,
for example, to allow the public to challenge complaints that the MCI drops.
The Society for Less Investigative Medicine, which was initiated last year by
cardiologists at the All India Institute of Medical Sciences in Delhi, hopes to
raise awareness of evidence based recommendations for medical care.6 7
Second
opinions India now has several internet portals that offer a second medical opinion,
such as mediangels.com and apkadoctor.com, which run on the premise that
surgical interventions in India are overprescribed. One report showed that
second opinions about surgery reversed the recommendation in 44% of 12 500
patients.
However,
these companies are for-profit ventures and charge patients for second opinion
consultations. “Honest and well minded doctors must stand up and speak out loud
against their corrupt medical colleagues,” said Saha. The public “must also
raise their voices to mount pressure to force the inept government to take
exemplary action against the unprincipled doctors and avaricious private
hospitals,” he said.
The BMJ
contacted the MCI and the Association of Healthcare Providers (India), the
trade body for private hospitals, but had not received responses by the time
this article was published.
Competing
interests:
I have read
and understood BMJ policy on declaration of interests and have no relevant
interests to declare.
Do you have
a story to tell about how financial targets have affected your practice as a
doctor? Let us know by sending a rapid response to this article or by emailing
rhurley@bmj.com in confidence.
Provenance
and peer review:
Commissioned;
not externally peer reviewed.
1 Gadre A.
India’s private healthcare sector treats patients as revenue generators. BMJ
2015;350:h826.
2 Edacherian S. Financial growth of private players in Indian
hospital sector. Frost and Sullivan. 14 Feb 2014. www.frost.com/sublib/display-market-insight.do?id=289119345.
3 Nagarajan
R. Clean slate for doctors on medical negligence. Times of India 2013 Dec 15.
http://timesofindia.indiatimes.com/india/Clean-slate-for-doctors-on-medical-negligence/
articleshow/27394151.cms.
4 Pandya
SK. The Medical Council of India: need for total overhaul. Indian J Med Ethics
2014;11:68-71.
5 Francis
PA. States and clinical establishments. Pharmabiz 2015 Apr 29. www.pharmabiz.
com/ArticleDetails.aspx?aid=87988&sid=3.
6 Travasso
C. Indian cardiologists plan campaign to reduce unnecessary investigations. BMJ
2014;349:g4740.
7 Nagarajan
R. Doctors across India join hands to stop practice of unwanted tests. Times of
India 2015 May 17. http://timesofindia.indiatimes.com/india/Doctors-across-India-joinhands-to-stop-practice-of-unwanted-tests/articleshow/47313607.cms.
8 Iyer M.
44% advised unnecessary surgery: 2nd opinion-givers. Times of India 2015 Jan 4.
http://timesofindia.indiatimes.com/india/44-advised-unnecessary-surgery-2nd-opiniongivers/articleshow/45746903.cms.
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