Ethical Care’s Post

If you're a person who's been anywhere in healthcare, you know everyone who refers patients to specialty hospitals gets paid. This is a fixed percentage of the bill patients are charged at the hospital. Suppose you have a patient come to you and you happen to be a general practitioner. You see that they have some atherosclerosis of the coronary arteries (fat deposition with inflammation and stiffening of blood vessels). An old school doctor might advise statins (cholesterol-lowering drugs) if the lipid profile (fats in blood) is adverse and lifestyle changes, in the hopes it becomes nothing serious and the vessel doesn't become almost fully blocked. But you, the modern doctor, know the patient will not adhere to your lifestyle prescription, and you need the referral fee. You know they will suffer a cardiac event ten years down the line, but you need the money now. So you advise the patient a coronary angiogram followed by an angioplasty because that's the only solution that's best for you. If one patient generating a bill of 200,000 pays 20,000, referring 15 patients a month means you've got that new sport bike you've always wanted. And only one patient dies during the procedure every 10 months. You can always convince their family they would've died anyway. If not, the cool money you've made and the indemnity insurance you've purchased will reimburse damages when taken to court. 149 patients feel better that their blood vessels are now cleansed (before the stent clogs up and leads to a certain death in 5-10 years) and 1 patient is at peace, relieved of their mortal coil, with their family paid off. The doctor is on a vacation in Dubai, sponsored by the specialty hospital. All's well that ends well. Healthcare is all about creating win-win situations.

A few months ago, there was some outrage about foreign nationals flouting regulations to undergo transplantation in India. Even though this didn't involve Indian organ donors and the foreigners were gracious enough to traffic organs from their own countrymen they brought along, there was a fair amount of controversy surrounding the issue. A pioneering healthcare firm knowing for transforming healthcare over and over again, led by a nonagenarian holding aloft its torch, got caught in the crosshairs (it rhymes with polo). While everyone scrambled to cover up on the firm's behalf, nobody paid much attention to how this healthcare company and others handle domestic transplants. Fun fact - This healthcare company and others pay over 100,000 rupees to anyone who gets them a patient desirous of getting a transplant. This is the referral fee, paid under the table. Yet, no one seems interested in this activity that's been going on quite unchecked. The ones getting the transplant do not know this happens and are happy they get to live (for a year but their doctor didn't tell them that). The donors couldn't care less, as long as they get paid the few lakhs they were promised on a phone call (just kidding, for legal reasons that's a joke). The transplant surgeon is flush with money and goes on a pleasure trip. Hospital fat cats can now post this in the press for a few lakhs and get more suckers ready to receive organs. Healthcare is all about creating win-win situations.

You can accuse hospitals of many things, but not being innovative ain't one. Hospitals operate with stiff margins and the successful ones practice radical innovation to realize obscene profits that are more vulgar than the words mouthed by expectant mothers in the labor room (words of appreciation for their husbands). Here's an example of how hospital leaders innovate. Suppose you go to a doctor for a mild cold. What do you get? Maybe a prescription for paracetamol and an outsized bill for wasting the doctor's time. But the hospital has a CT machine lying around, unused. And the hospital has a bronchoscope that happens to be lying around too. These aren't free. The CT scanner is in an air-conditioned room. People tend to it. The bronchoscope cost money. Now a brilliant executive comes up with a plan. You go to the doctor with a mild cold. And you get prescribed a high-resolution CT scan for 15000 rupees and a bronchoscopy for 10000 rupees because there's a 1 in a billion chance it's cancer. The doctor tells you he wants to rule out cancer and you are a dummy dumb who doesn't know better. That evening, the brilliant hospital executive carries a suitcase with 200,000 rupees to the doctor's chamber. There's 100,000 in consultation fee, 30,000 for the lab tests ordered, 40,000 incentive for referring patients to bronchoscopy services, and 30,000 for CT scans. Everyone's happy. The doctor is happy about the money, the executive is happy their assets generate revenue, the patient is happy they don't have cancer. If you want to thrive in healthcare, create win-win situations.

You make your hospital sick with worry when you are about to pass away and the bills haven’t been paid yet. Jokes aside, there’s this urban myth that hospitals intubate the dead and maintain life support to make some extra money. While this might have happened someplace sometime, what’s more commonplace is hospitals prolonging the lives of terminally ill patients who are suffering with little to no hope of recovery. The person might be on the verge of death with no hopes of meaningful recovery. Think of an 80-year-old with stage 4 cancer (where it has spread to distant sites in the body) and the doctor draws up a plan of aggressive chemotherapy (medication) coupled with surgery and radiotherapy (irradiation to destroy the tumor). The treatment, if it doesn’t kill the old person, will keep them in suspended animation for some time before they die. But the hospital and doctor make a cool crore or two delaying the inevitable, so why care? Of course, there’s a 1 in a billion chance granny will make a full recovery and your doctor is fully betting on that happening (not for the money, *wink*). Imagine resuscitating a 90-year-old with end-stage renal disease. If this example seems far-fetched, it is. But a lot of similar events as these do happen. Because healthcare has an agent-host problem. The doctor gets paid for the stuff they do. The hospital gets paid for the stuff their doctors do. Nobody gets paid to make sure you do not suffer, especially when you can’t speak and are half comatose. This is why we need hospital ethics committees which convene once a month and where participants eat cake from little saucers with floral designs while pondering over your dying gran’pa. Nope, forget that. What we’re coming to here is that medical professionals are bound to advise patients or their representatives, usually families, on the choices available to them and what each decision entails. The doctor can also tell patients what they would choose if they were in their place and explain why they would make that decision if the patient is undecided and seeks the doctor’s advice on what is best for them. Anyway, if the hospital has a new palliative care unit (where the sick are given loads of morphine and other narcotics Mexican cartels can only dream of, to make you trippy before you die), you know for a certainty your doctor will recommend palliative treatment for you. Also, the only thing that makes hospitals sicker than a dying patient who won’t settle their bills is a dying patient who avails of palliative services elsewhere. Until next time, stay safe, stay away from your friendly neighborhood hospital run by professional investors 😁. 

🏥 Healthcare in India is a scam 💀. Why? Here's what you need to know - Way too many doctors 👨🏻⚕️👩🏻⚕️ and labs 🔬 competing for patients means the ones who bribe 🤑 for referrals are the only ones that thrive. - This practice has become well-established in cities and towns. A general practitioner or specialist refers 💬 to another specialist or a lab who then pays kickbacks 💫 as a percentage % of the bill 📃 - The going rates for lab 🔬 tests, including CT/MRI scans are 20% - 40% and the going rates for referrals to a hospital 🏥 or doctor 👨⚕️ are 10% - 50% of the total bill. - The hidden preference of doctors 👨⚕️ and others to send patients to the entity providing the greatest commissions 🤑 means it's a race to the bottom 💀. - The ones providing top money 🔝 are the ones who get enough patients 👨👩👧👦 to realize economies of scale ✨ and make profits 💲💲💲. The rest perish 😢. - As a result, few ruthless, cut-throat, and unethical players dominate the market 👔. Prices are sky-high 💹, go up all the time by a lot ⏫, and incorporate so many hidden, illegal charges that you never get to see 🙈. - Patients 👨👩👧👦 are not the only ones affected. Conscientious doctors 👨🏻⚕️👩🏻⚕️ and lab service providers 👩🏻🔬👨🏻🔬 also suffer. There are some doctors who are reluctant 😓 but forced by peer pressure and family expectations 🧐 into complicity 🙈 or eager participation 😈. - The government needs to come down hard ⚖ on this malaise before it leads to the demise of Indian healthcare 🕯️. Currently, the government is turning a blind eye 🙈 to the colossal corruption happening right underneath its nose 👃🏻. Please add your comments and suggestions below 🔽