Cut practice


What is a cut practice?
All doctors qualified to practice modern medicine take the classical Hippocratic Oath before beginning their professional career. However, when they start practicing in real life, they start making so called ‘practical’ adjustments during his clinical and therapeutic decisions. Sometimes they get open offers of referral of patients for a predetermined and regularized practice of fee-sharing (‘cut practice’).

In this blog I have tried to highlight different aspects of cut-practice.

As the name cut practice itself suggest that there is something fishy. In fact, this is one of the several reasons for the increase in health care costs. As a Kid, I was always wondering that the Doctor to whom I am being referred must be the best doctor in the area and I never doubted that there could be any ‘practical adjustments’ involved in it.

While in general doctors at village level (or clinics with lesser facility/expertise) recommends you to visit some doctor in a city as there will be better medical facility and expertise available at the referred doctor’s facility, sometimes you feel really bad when you realize that you ended us visiting a doctor who you would not have liked to see, if you could have taken an independent decision. Thus hurts even more when referring doctor’s charge usually get added on to the referred specialist’s fees and are paid unknowingly by the patient.

How often do you realize that you must have bought medicine near to Doctor’s clinic? Well, specially, if you are not living close to the doctor’s clinic then it becomes a real pain. You are usually left with two options
1) Either go back near to Doctor’s clinic and get the medicine or
2) Rely on pharmacists near your house to provide you a right substitute

I am sure, you would like to avoid both these scenarios.

Cut practice occurs in many forms:
• Giving a share of fees to the referring doctor.
• Referring patients for unnecessary consultations or tests to ensure a kickback from the consultant or laboratory.
• Giving expensive gifts periodically to the referring doctor.
• Appointing junior specialists to a super specialty hospital so that procedural work is always referred by them to you.
• Unnecessary admissions in nursing homes/hospitals.
• Sponsoring of a conference or payment of travel expenses by a company in return for the use of its equipment or prescription of its drugs.

Ugh, while this may sound completely unethical in health care business, people find it perfectly fine in other businesses. Have you ever thought about how one can offer 75% discounts on cloths? Well, doesn’t that say that the actual cost is not even 10 % of the overall price that the customer is being asked to pay for? Well, yes, here you justify that price by using technical terms like transportation, distribution, storage and marketing costs.

However, in case of health care, the similar practice look really bad. Remember that doctor’s are still being seen next only to god as they save life of the people. Hence, when the same people come to know about their involvement in such practices, they get hurt even more. The basic problem is that, that the patients are neither aware of their rights in getting information nor do they take any action against the doctors if they know that the doctors are involved in malpractice.

Recently, one of my Colleague’s mother suffered multiple fracture. The doctor was prescribing a very costly medicine (approximately INR 2500/- per tablet) without writing the medicine name and he was asking to deposit that money so that he can order for the medicine. Although there is a substitute for same medicine at the cost of INR 40/- per tablet, doctor forced the patient to buy the costly medicine. Interestingly, this medicine was to strengthen the brittle bones and it was not something very urgently needed for the treatment. This definitely hurts the credibility of health care business. However, this is kind of thing where it is extremely difficult for the patient or his/her relatives to call wrong because doctor can always justify his action and he can always prove that he is doing things for the better health of the patient. However, patient must be given choices and allowed to take an informed decision.

While so far it looked like some of the doctor’s are really messing up the good efforts by many other doctors, the situation has improved quite a lot in recent pasts:
1) Although every doctor determines his/her professional fees on the basis of experience, wisdom and self perceptionof the level of skills required for a particular treatment, they have started quoting same price for all the patients. Hence, patient is not charged more because doctor has to share fees with someone else as well.
2) Also, as long as the patient is aware of the sum to be paid before the service is rendered it should not be considered as bad as cut practice term make it look.
3) Many times you can compare and calculate the referred doctor’s fee and service cost with other competitive doctors and take more informed decisions

Unfortunately, these improvement in health care practices are not yet used effectively by the patients.

How we can control this cut practice
1) Public Education or awareness on such cut practices is the first step of controlling.
2) We must have strong local or national medical association or federations, with the strong code of ethics.
3) Themselves medical doctors should talk and conduct meetings to prohibit and condemn the cut practice.
4) Consumer protection act needs to be implemented in order to stop this cut practice.
5) The monthly salary and other benefits of full time doctors especially in teaching hospitals should be such that they are able to maintain a decent standard of living
6) Each general practitioner must charge a publicly stated fee from the patient for the act of medical examination, making a diagnosis and recommending appropriate treatment or referral to an appropriate consultant or hospital
7) A body of government appointed experts should monitor the performance of various procedures to ensure that they are based on scientifically valid indications

Having said that, any controlling steps will work only when patient increases its own awareness and doctors involved in such practices decide to lower down the overall cost of health care.

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4 comments on “Cut practice
  1. darshan says:

    very important information_ i am victim of cut practice*

  2. While i agree to most of what has been mentioned under the Cut Practice and i also see the indication towards Doctor’s involvement as a stake holder in the overall game. But let me ask a few straight questions :
    a) How many individuals in a developing country like India invest in their health on a proactive basis ( buying insurance, maintaining societies, keeping balanced habits ) ?
    b) How many government agencies would look at the Health of Individuals as the Health of the country ? Countless schemes from government have been initiated and how many of them have really benefitted the intended ones ?
    c) Did we not hear the government say more than once that the Medical services ( including medicines ) are overpriced and un-regulated ? How about the revenue that government earns from the pharmaceuticals ?
    d) Is the quality education for qualifying somebody as a specialist Medical Practitioner is in reach of individuals who are willing to do a better job ?

    There can be countless questions which would coverge to the same point of increasing/exisitng irregularties in the industry. Given the environment, i would not single out the “cut practice” and blame all on it. Not to say, that it is justified, but to say that it an offshoot of a much bigger problem. Even if i was able to get rid of cut practice, there would be enough which would deprive me of the health care that i deserve.
    – Regulations and their implementations from the Government Agencies
    – Focus on Health Care for the countrymen as an overall goal, with individuals having a feeling of inclusion
    – Since Health Care services are already in the Basic Servies category, defining the right to Healthcare for every individual
    – Bringing in more efficiency in the Government operated healthcare centres so that they are able to compete with the private centres and give them a run for the money.

  3. Sula says:

    It was indeed an interesting article from TOI. However, I personally feel that cost of the medicine must also be a criteria to certify a drug. Because, the pharam companies, frankly speaking, are only interested in increasing their market share which inturn translates into maximisation of their profit. And, in order to do so they tend to push the medicine/drug on which they have higher margin (remember the motivation factor of a sales person). So, effectively, they push those drugs by sponsoring a family trip for the doctor, giving him gifts, commission, etc. so that the doctor starts recommending those drugs in their prescriptions. So, at the end, the company is happy because they are making profit, the doctor is happy because he got his share and it is the poor patient who needs to bear the cost to keep these two “stakeholders in their health” happy. Idea is that people must make money in order to be able to grow the business, invest in R&D, but at the same time they must have a vision of bringing down the overall cost of the drugs and using innovative ways to get around the cut practice.

    For the patient to get out of this trap, I see a “Family Doctor” or “Community Doctor” concept more appropriate to stop this cut practice and unnecessary expense on the drugs.

  4. wtcindia says:

    TOI had a new on front page, “Doc bribing: Pharma cos asked to self-regulate”. In fact, TOI has also used a very good phrase “Giving the fox the job of guarding the henhouse”. In a country where everyone has its own interpretation (usually backed by some reasons) of what is good values, if government is asking pharmaceutical companies to self-regulate without associating the regulation with some legislative rules then I wonder, what is the point in issuing such statements? This is definitely one of the great contributor in cut practice, where less appropriate drugs gets prescribed by a doctor and patient will never ever have a reason to argue with the doctor about why he is prescribing so-n-so drugs. Interestingly, government also knows that bodies like Organization of Pharmaceutical Producers of India (OPPI) and Indian Drug Manufacturer Association (IDMA) already has some sort of codes to prevent these malpractice and these codes are hardly enforced, still we want them to self-regulate. Hmm .. doesn’t look convincing at all.

    So what do we do in such scenario? Probably, one thing we can do is to verify whether Food and Drug Administration (FDA) department has approved the prescribed drug or not. Well, if it is a new drug then you may also check if it is allowed to market in India or not by going to http://www.indiaoppi.com/regulatory.asp. I wonder, there should be a database where all the pharmaceutical companies should be asked to put following information:
    1) Drugs Name
    2) What is meant for
    3) Any side effect or risks involved in taking that drug
    4) Any other optional information??

    Personally, I think, 50% problem in health care is due to lack of appropriate knowledge or unavailability of correct information. May be FDA should do something about this as well.

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