A leading hospital in Mumbai announced that it offered medical opinions without any ‘commissions’. The advertisement displayed prominently outside the Mumbai airport invited significant commentary from people within and outside the medical fraternity. The Indian Medical Association called for the hoarding to be taken down. The hospital respectfully declined and urged the IMA to take steps to address the pernicious practice of cuts. It calls for a discussion about ‘doctors integrity badge’ as a differentiator.
Over the last few decades, cuts and commissions have become an entrenched part of India’s private healthcare system, that serves over 80% of the healthcare needs. These cuts refer to fees paid to doctors when they refer patients for an opinion to another doctor, or for testing to a diagnostic laboratory or for surgical intervention to another hospital. Despite the Medical Council of India explicitly prohibiting this practice, commissions have become a part of the healthcare supply chain. Several authors have written about this practice, and the Indian Journal of Medical Ethics has called it a “Pernicious practice, here to stay”.
Commissions have come to be demonised for two main reasons – they add to the total cost of healthcare and more seriously, it taints the medical opinion provided by doctors. It is estimated that commissions between two parties may range from 20-40% and the patients inevitably end up bearing this additional cost out of their own pockets. On the other hand, patients start thinking – Do I really need another opinion, do I need that additional test or the surgery, or are these being advised to share the increased cost amongst this cabal of doctors…Ultimately, it undermines the trust that patients should place in the opinions provided by their doctors.
The recent advertisement by the cardiology hospital is a bold move to call out the practice and also position itself as an honest provider of services. The medical community (including many of my own doctor friends) reacted strongly, taking umbrage over the suggestion that other doctors indulge in these practices. In painting themselves as the white sheep, did the hospital paint the other doctors as the black sheep?
Many other doctors have applauded the willingness of the hospital to fight the practice of commissions. Their contention is that the practice exists, so it’s fair to place it under the spotlight in an attempt to eradicate it. The hospital itself has called for the Indian Medical Association and other doctors to join their campaign in eliminating the practice.
I conducted a brief Twitter poll which showed that the integrity of the treating doctor was important to majority of patients. Only a small fraction of respondents said they had never thought about integrity as an attribute for their doctors.
In undergoing treatment for a serious medical condition, how important is integrity of the doctor as a factor to consider?
— aakashganju (@aakashganju) June 15, 2017
Patients are also increasingly seeing themselves as healthcare consumers and so doctors are increasingly having to market themselves, as other businesses would. What is interesting is the choice of the messaging. The hospital could have chosen to differentiate itself based on the quality or the cost of treatment, the post-operative recovery time, the superior experience they provide, their low cost, or a variety of other attributes on which healthcare businesses usually differentiate themselves. By choosing to call out integrity as a differentiator, this advertisement has for the first time, perhaps, called out physician/ hospital integrity as a key attribute that patients value highly in their healthcare transactions.
Patients are increasingly treating their experiences as they would any other service. We do have to be careful though of not reducing healthcare to the transactional status other consumer businesses can afford to be, healthcare is not like other businesses!
I remain ambivalent about the entire episode, even as I mull through its pros and cons. Mainly, I feel a sense of sadness that doctors have to proclaim their integrity before offering a medical opinion. Having said that, it’s up to all of us to rebuild the trust between patients and doctors. Next time we go looking for a doctor to save a life, we shouldn’t find ourselves looking for an integrity badge.
Dr Aakash Ganju is a healthcare consultant and entrepreneur, focused on increasing transparency, access, and convenience to health providers and consumers. He is the CEO of Avegen and lives in Mumbai, India.