Bhupesh Bhandari: Too much investigation

Cardiologists of the All India Institute of Medical Sciences, or AIIMS, have launched an initiative called the Society for Less Investigative Medicine to reduce unnecessary medical tests, The Times of India has reported. This is acknowledgment from within the community that doctors often recommend tests that serve no useful purpose. Annual general health check-ups fall in this category. Studies have shown that these yield no tangible benefits, the report said. And it is not just individuals who fall victim to this misdemeanor: companies spend decent money to organise annual health check-ups for their employees and the government offers such check-ups to employees of a certain category. It is a well-oiled racket that has duped almost everybody.

In the absence of investigation guidelines and low awareness of medical processes, most people are left with no option but to go through all the tests suggested by the doctor, even if some are not necessary. The AIIMS cardiologists want to draw up guidelines so that patients know the situations that require the various tests. Any other test need not be carried out. Once this exercise gets completed, the group plans to reach out to doctors in other disciplines in order to curb the menace of over-investigation. I think there are a large number of honest doctors in the country who are worried that their profession is rapidly earning a bad name, and they would be more than willing to join hands with the AIIMS cardiologists.

Harsh Vardhan, the Union health minister who is also a doctor, should know why this malpractice abounds. Putting up a hospital is expensive. So the hospital needs to max the revenue out of patients. One way out is to write more and more diagnostic tests. Some health activists say that leading hospitals draw up to 25 or even more of their revenues from their diagnostic clinics. Doctors who practice privately – and even some in government hospitals – get a cut from the diagnostic clinics for sending people for tests. The commission paid by clinics to doctors can vary from five per cent for a simple blood test to 10 per cent for the more sophisticated tests.

The diagnostic sector is fragmented and, therefore, highly competitive. Thus, the smaller clinics offer higher commissions to survive. As reported by Business Standard in April, there are over 100,000 clinics across the country (given the country’s population of 1.21 billion, it works out to one clinic for 11,210 people), of which up to 90 per cent are small unorganised ones. There are only a handful of national chains such as Dr Lal Pathlabs and SRL Diagnostics. (A related problem is that there are no quality benchmarks for the sector; less than one per cent of the clinics are known to be accredited.)

In the United States, in a vast majority of the cases, the healthcare bill is picked up by the insurance companies. They put the treatment records under serious scrutiny and demand explanations for any test, procedure or medication that they think was unnecessary. Doctors who they find are prone to over-investigation or over-prescription are axed from their panel, and their practice plummets. A similar system exists in the United Kingdom where the bills are analysed threadbare by the National Health Service, and errant doctors get blacklisted. Compare this to India where only 15 per cent of the patients buy medical insurance (the insurance companies have started to take third-party advice on treatments but the scrutiny is far less intense when compared to the United States or the United Kingdom) and where there is no regulator for healthcare.

In the absence of an effective monitoring mechanism, what the new health minister can do is put together standard procedures for ailments and other medical conditions, and then publicise them. People ought to know that if they need a cataract removal, what are the tests required and procedures involved. It would also help if he can specify what the treatment can cost in various categories of hospitals.

The commission system works in more ways than one. For instance, it is possible that the general physician who has referred you to a specialist may have done so for a commission. Then there is the nexus between doctors and drug makers. There are thousands and thousands of generic drug makers in the country. Every molecule is available under dozens of brands in the market. Since they cannot advertise, the only option they have is to get doctors to prescribe their medicine. They do this by offering them incentives. These can range from innocuous notepads and calendars to overseas junkets, exotic pets and even cars. The bigger the reputation of the doctor, the larger is the incentive. This has led to serious problems. One, there is over-medication. The indiscriminate use of antibiotics has made India home for several superbugs. And two, doctors at times prescribe expensive medicine and the patient, in a bid to save money, reduces the dosage, which results in under-medication. There are no ethical guidelines for doctors. Though most hospitals have a code of conduct in place for their doctors, these are openly flouted.

All this shows that healthcare in India is grossly under-regulated. The health ministry lacks the bandwidth to do the job. This is an issue that Mr Vardhan needs to address in his tenure.