Medical ethics

Patients pay a heavy price as India’s doctors continue with the corrupt ‘cut practice’

Many doctors are lured or scared into paying commissions to other doctors in return for having patients referred to them.

Psychiatrist Dr Shyam Shastri (name changed) routinely visits general medical practitioners near his clinics in South Mumbai to hand them envelopes of cash. Shastri, who has been struggling to establish his medical practice for the past three years, has finally decided to offers “cuts” to his colleagues from the fees that his patients pay him. By handing over these cash envelopes, Shastri has ensured that the general practitioners will recommend and refer his services to their patients.

The current rate of such commissions, Shastri said, is between 40% and 60%, which means that if a patient paid Rs 1,000 to Shastri, he will have to pay between Rs 400 and Rs 600 to the doctor who referred the patient to him.

“I never thought I will have to indulge in such unethical practice,” said Shastri. “This cut-practice is just like how somebody pays premiums to politicians for clearing a project.”

He hopes to be able to stop paying commissions once he has enough patients and a practice robust enough to pay his bills.

Shastri’s senior colleagues also say that they have had to offer incentives to other doctors, particularly general practitioners, at least once over their years of practice. A senior doctor who works with a well-known hospital in Mumbai said that at one point he was paying at least 10 doctors to refer patients to him.

“I had decided to never get into cut-practice,” he said. “But, my practice was so poor that my family asked me to do it.”

Eventually he established himself enough to be able to stopped paying cuts.

A decade ago, when Tamara Zweck, a sports and orthopaedic physiotherapist, shifted her practice to Mumbai from Australia, her well-wishers and patients told her to “connect with doctors” to improve her practice.

“For me, the patient comes first and I decided to rely on word of mouth instead of offering or taking cuts,” said Zweck. She added that fitness trainers, yoga teachers also accept cuts to refer patients to doctors.

Cardiac surgeon Dr Ramakant Panda from Mumbai has started a campaign with several doctors to end to cut-practice. Panda regularly comes across patients who are advised angioplasties – a procedure in which catheters are guided through narrowing arteries to widen them or remove plaque – when they do not really require one. He estimates that 30% of angioplasties performed are unnecessary. “[Doctors] are advising getting the procedure because they get cuts,” he said.

A sign at a conference at the Asian Heart Hospital in Mumbai, which has started a campaign against cut-practice. (Photo: Priyanka Vora)
A sign at a conference at the Asian Heart Hospital in Mumbai, which has started a campaign against cut-practice. (Photo: Priyanka Vora)

A network of agents

Several doctors hire public relations officers to work as agents. “These agents go to general practitioners introducing the doctor he works for and offer incentives for sending patients,” said Dr Jeevan Rajput, a neurosurgeon in Aurangabad.

When Rajput launched his private practice in Aurangabad four years ago, other doctors suggested that he hire a public relations officer and offer kickbacks in return for patient referrals. “I wanted to start my own hospital and initially it was tough as I didn’t even belong to a family of doctors,” he said.

Rajput decided to visit doctors personally and request them to send him patients for his skills. Some obliged, others did not. “Instead of offering kickbacks, I offered discounts to patients and never insisted on a deposit, which worked for me.” Some clinics ask patients to pay a certain amount as deposit upfront, even before treatment or hospitalisation.

Sometimes, an agent works for multiple doctors simultaneously, said Shastri. These agents either get paid monthly salaries or on the basis of the number of patients they bring in.

Shastri had also hired an agent for some time but later decided to approach doctors personally instead. “It is then that I realised that some doctors are ethical and don’t ask for kickbacks,” he said.

“Doctors cannot self-advertise,” said Dr Milind Balakrishnan, a psychiatrist and a member of the Association of Medical Consultants. “Young doctors have to rely on word of mouth and other doctors to send them patients.”

Doctors trying to establish their practice are given the impression that if they do not pay commissions, their practice will not survive. Moreover, corporate hospitals often set targets for doctors on how many patients they should treat and how many medical procedures they must perform in a given timeframe. If a doctor cannot achieve the targets, he could lose his affiliation with the hospital. Students of private medical colleges then pay donations that can range anywhere between Rs 30 lakh and Rs 1 crore, putting great pressure on them to start earning well early in their careers.

This combination of factors alarms doctors into paying commissions for referrals.

All-pervasive cut practice

In 2013, Dr Himmatrao Bawaskar, a senior medical professional from Mahad city in Maharashtra received an unsolicited cheque from a popular diagnostic chain asking him to refer patients who needed Magnetic Resonance Imaging or MRI scans to their laboratories. A shocked Bawaskar filed a complaint with the Maharashtra Medical Council against the diagnostic chain. The incident found mention in the international medical journal The Lancet bringing much needed attention to the corruption in medical practice in India.

Bawaskar blamed the cut-throat competition among doctors and laboratories for the culture of kickbacks. “If you own machinery worth crores, you will do anything to make money to pay for it,” he said, referring to the huge cost involved in setting up diagnostic centers especially those with MRI and computed tomography or CT scan facilities.

A senior doctor from Mumbai said: “[Independent] doctors are small fish in the pond. The real culprits are charitable and corporate hospitals who do organised corruption.”

In 2014, Kokilaben Dhirubhai Ambani Hospital was pulled up by the Maharashtra Medical Council for offering incentives to doctors for referrals to the hospital. A report in the Times of India, said that the hospital was offering doctors the chance to be a part of an “elite forum”. The doctors would be rewarded Rs 1 lakh for 40 admissions in a year, Rs 1.5 lakh for 50 admissions and Rs 2.5 lakh for 75 admissions.

Commenting on both Bawaskar’s case and the Kokilaben Dhirubhai Ambani Hospital case, Dr Sanjay Nagral wrote in Economic and Political Weekly: “In the current brouhaha, however, some novel points have emerged. The first, as illustrated by the Ambani hospital case, is that we are now poised to see sophisticated, structured, and even transparent forms of corruption where kickbacks are offered in the guise of well-designed schemes… In this, individual doctors working in such hospitals may actually be pawns in a larger game. Thus ‘underground’ corruption may change to ‘open’ corruption, even acquiring a certain transparency.”

Meanwhile, the surge in medical tourism is boosting the practice of referrals for commissions. “[Corporate] hospitals pay a large cut to private companies that are medical tourism agencies for bringing them patients,” said Dr Prince Surana who runs a private hospital in the eastern suburbs of Mumbai. “This is the newest form of cut-practice, where non-doctors are being paid for referring or bringing patients to the hospital.”

Another problem with referral fees is that it helps quack doctors. While most quacks charge a nominal patient fee, they rake in plenty of money from specialists who pay them for referrals. “There are quacks who only survive on referral fees by just referring patients to specialists,” said radiologist Dr Ramnath Ghute. A quack is a person pretending to have medical skills without undergoing any formal training in medicine.

More people now are looking online to find good doctors but commissions play a big role even on online healthcare appointment fora. Surana said that doctors usually have to buy a registration package with such fora to ensure that their names appear the top of the list of doctors during a search.

“I was surprised when I was told that I would have to pay an annual fee to be registered on the website,” he said. “Another service these platforms offer is that they give you the contact details of the patients who are searching and give you a lead by sharing the number with you first, so you can convert the patient before anyone else does.”

By “convert”, Surana is referring to turning a potential client into an actual one.

Patients pay the price

Rajput, who has studied the problem closely, estimates that at least 20% of head-injury patients do not reach the right hospital and doctor because of cut-practice. “Instead of referring to a hospital which is well equipped, we have seen that patients are sent to smaller hospitals because there is money involved,” he claimed.

In rural areas, Rajput observed, doctors also pay off ambulance drivers. “Many times patients, who might have been saved, die because they went to a wrong doctor or a hospital which is not equipped well enough,” he said.

Balakrishnan agrees. “The patient is actually paying for the cuts,” he said.

Cut-practice has eroded trust between doctors and patients. “My relatives call me to check which doctor they should go to because they fear that their general practitioner may send them to a not-so-good doctor just to get kickbacks,” said Balakrishnan.

The Maharashtra government has instituted a nine-member committee to draft legislation to end cut-practice. The Medical Council of India’s code of ethics clearly states that:

“A physician shall not give, solicit, or receive nor shall he offer to give solicit or receive, any gift, gratuity, commission or bonus in consideration of or return for the referring, recommending or procuring of any patient for medical, surgical or other treatment. A physician shall not directly or indirectly, participate in or be a party to act of division, transference, assignment, subordination, rebating, splitting or refunding of any fee for medical, surgical or other treatment.”

— Code of Ethics Regulations, Medical Council of India

However, a law can make the act of giving or offering a commission a criminal offence. “The committee is looking at recommending a legislation which can stop cut-practice, which is practiced under different names such as ‘split fee’ and ‘sharing fee’,” said Dr Avinash Supe, director of major civic hospitals in Mumbai and member of the committee.

Supe said that the committee is closely studying laws in the United States and United Kingdom that have already made cut-practice a criminal offence. For instance, the anti-kickback statute in the US “includes fines of up to $25,000 per violation, felony conviction punishable by imprisonment up to five years, or both, as well as possible exclusion from participation in Federal Healthcare Programs.”

Such legislation will go a long way in protecting patients’ interests. As Balakrishnan said: “In medicine, the patient should be the brand ambassador (for the doctor).”

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Swara Bhasker: Sharp objects has to be on the radar of every woman who is tired of being “nice”

The actress weighs in on what she loves about the show.

This article has been written by award-winning actor Swara Bhasker.

All women growing up in India, South Asia, or anywhere in the world frankly; will remember in some form or the other that gentle girlhood admonishing, “Nice girls don’t do that.” I kept recalling that gently reasoned reproach as I watched Sharp Objects (you can catch it on Hotstar Premium). Adapted from the author of Gone Girl, Gillian Flynn’s debut novel Sharp Objects has been directed by Jean-Marc Vallée, who has my heart since he gave us Big Little Lies. It stars the multiple-Oscar nominee Amy Adams, who delivers a searing performance as Camille Preaker; and Patricia Clarkson, who is magnetic as the dominating and dark Adora Crellin. As an actress myself, it felt great to watch a show driven by its female performers.

The series is woven around a troubled, alcohol-dependent, self-harming, female journalist Camille (single and in her thirties incidentally) who returns to the small town of her birth and childhood, Wind Gap, Missouri, to report on two similarly gruesome murders of teenage girls. While the series is a murder mystery, it equally delves into the psychology, not just of the principal characters, but also of the town, and thus a culture as a whole.

There is a lot that impresses in Sharp Objects — the manner in which the storytelling gently unwraps a plot that is dark, disturbing and shocking, the stellar and crafty control that Jean-Marc Vallée exercises on his narrative, the cinematography that is fluid and still manages to suggest that something sinister lurks within Wind Gap, the editing which keeps this narrative languid yet sharp and consistently evokes a haunting sensation.

Sharp Objects is also liberating (apart from its positive performance on Bechdel parameters) as content — for female actors and for audiences in giving us female centric and female driven shows that do not bear the burden of providing either role-models or even uplifting messages. 

Instead, it presents a world where women are dangerous and dysfunctional but very real — a world where women are neither pure victims, nor pure aggressors. A world where they occupy the grey areas, complex and contradictory as agents in a power play, in which they control some reigns too.

But to me personally, and perhaps to many young women viewers across the world, what makes Sharp Objects particularly impactful, perhaps almost poignant, is the manner in which it unravels the whole idea, the culture, the entire psychology of that childhood admonishment “Nice girls don’t do that.” Sharp Objects explores the sinister and dark possibilities of what the corollary of that thinking could be.

“Nice girls don’t do that.”

“Who does?”

“Bad girls.”

“So I’m a bad girl.”

“You shouldn’t be a bad girl.”

“Why not?”

“Bad girls get in trouble.”

“What trouble? What happens to bad girls?”

“Bad things.”

“What bad things?”

“Very bad things.”

“How bad?”

“Terrible!!!”

“Like what?”

“Like….”

A point the show makes early on is that both the victims of the introductory brutal murders were not your typically nice girly-girls. Camille, the traumatised protagonist carrying a burden from her past was herself not a nice girl. Amma, her deceptive half-sister manipulates the nice girl act to defy her controlling mother. But perhaps the most incisive critique on the whole ‘Be a nice girl’ culture, in fact the whole ‘nice’ culture — nice folks, nice manners, nice homes, nice towns — comes in the form of Adora’s character and the manner in which beneath the whole veneer of nice, a whole town is complicit in damning secrets and not-so-nice acts. At one point early on in the show, Adora tells her firstborn Camille, with whom she has a strained relationship (to put it mildly), “I just want things to be nice with us but maybe I don’t know how..” Interestingly it is this very notion of ‘nice’ that becomes the most oppressive and deceptive experience of young Camille, and later Amma’s growing years.

This ‘Culture of Nice’ is in fact the pervasive ‘Culture of Silence’ that women all over the world, particularly in India, are all too familiar with. 

It takes different forms, but always towards the same goal — to silence the not-so-nice details of what the experiences; sometimes intimate experiences of women might be. This Culture of Silence is propagated from the child’s earliest experience of being parented by society in general. Amongst the values that girls receive in our early years — apart from those of being obedient, dutiful, respectful, homely — we also receive the twin headed Chimera in the form of shame and guilt.

“Have some shame!”

“Oh for shame!”

“Shameless!”

“Shameful!”

“Ashamed.”

“Do not bring shame upon…”

Different phrases in different languages, but always with the same implication. Shameful things happen to girls who are not nice and that brings ‘shame’ on the family or everyone associated with the girl. And nice folks do not talk about these things. Nice folks go on as if nothing has happened.

It is this culture of silence that women across the world today, are calling out in many different ways. Whether it is the #MeToo movement or a show like Sharp Objects; or on a lighter and happier note, even a film like Veere Di Wedding punctures this culture of silence, quite simply by refusing to be silenced and saying the not-nice things, or depicting the so called ‘unspeakable’ things that could happen to girls. By talking about the unspeakable, you rob it of the power to shame you; you disallow the ‘Culture of Nice’ to erase your experience. You stand up for yourself and you build your own identity.

And this to me is the most liberating aspect of being an actor, and even just a girl at a time when shows like Sharp Objects and Big Little Lies (another great show on Hotstar Premium), and films like Veere Di Wedding and Anaarkali Of Aarah are being made.

The next time I hear someone say, “Nice girls don’t do that!”, I know what I’m going to say — I don’t give a shit about nice. I’m just a girl! And that’s okay!

Swara is a an award winning actor of the Hindi film industry. Her last few films, including Veere Di Wedding, Anaarkali of Aaraah and Nil Battey Sannata have earned her both critical and commercial success. Swara is an occasional writer of articles and opinion pieces. The occasions are frequent :).

Watch the trailer of Sharp Objects here:

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This article was published by the Scroll marketing team with Swara Bhasker on behalf of Hotstar Premium and not by the Scroll editorial team.