Thin line between ethical and unethical acts

Dr KK Aggarwal
Padma Shri and Dr B C Roy National Awardee
President, Heart Care Foundation of India

1. Giving commissions and cut is an unfair trade practice in terms of section 2(r) (6) of the Consumer Protection Act, 1986. It is also violation of regulation no. 6.4 and 6.5 of the MCI, 2002, regulations.
“6.4 Rebates and Commission:

6.4.1 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.

6.4.2 Provisions of Para 6.4.1 shall apply with equal force to the referring, recommending or procuring by a physician or any person, specimen or material for diagnostic purposes or other study / work. Nothing in this section, however, shall prohibit payment of salaries by a qualified physician to other duly qualified person rendering medical care under his supervision.”

2. A treating physician, a path lab, an imaging centre and a surgeon – are all service providers and provide service under a contract of service against service charges. The contract of service, whether written or unwritten or implied, does not include a term of contract that the service provider, in addition to providing service against payment received in cash, will also obtain from or give further payment to another service provider. (Dr M C Gupta)

Doctor is next to GOD
3. A physician is not a businessman or a trader. He is a service provider. It is legal to charge a commission in many trades. The sellers of stocks and debentures and even the government organizations like the LIC and the PPF organization give commission to their agents. But the LIC agent gives a service to the person who gets his life insured and, as a service provider; it is illegal for him to pass on a part of the commission received to the beneficiary of his services. (Dr M C Gupta)

4. A doctor purchases drugs from the stockist at concession rates and dispenses it at MRP. This cannot come under cut, commission or an unethical act. But the doctor cannot bill the drug separately. It has to be a part of dispensing service. Many GPs buy generic drugs and charge for the drugs as part of service fee.

5. Most doctors run a lab collection centre and collect the charges and pay 75% to the labs. They are providing the service.

6. Most hospitals are buying the services of full time doctors and selling it for a premium to the patients.

7. In the United States, for every imaging test (for example CT scan) there are establishment charges, operator charges and reading charges. The referring doctor often gets trained in reading and interpretation imaging tests and can charge money for the same. The service provider only sends the CD and does not report the test.

8. For charging any money it has to be established that a service has been provided. A service is said to be provided if:

Doctor Symbol
If you accompany a patient for CT scan or MRI test
If you discuss with the reporting doctors about the clinical condition and share all the reports
If the patient comes to you with the report and you give your opinion.
If you order for a test after seeing a patient.
If you are present in OT when surgery is being done to your patient.
If you visit your patient daily while he is admitted in a hospital.
If you make a referral note with all the details.
If you make a summary of a case.
If you are involved in the interpretation of any test.
A pharma representative comes and consults you about the efficacy of their molecule.
If a pharma company invites you to an industry symposium and wants you to listen and react to the molecule.
If a CRO representative comes and wants you to be a part of a survey.
If you are a panelist, speaker or a chairperson in any symposia whether by an association or pharma sponsored.
If you issue a medical certificate
If the patient wants a second opinion and wants you to discuss with the treating doctor.
If you assist in any procedure in a health care setting.

For any service if you are paid, it’s ethical and legal. But the client must know about the same and it should be legal and accounted for. The following come under the purview of what is unethical or when is it a cut and not a service.

1. When you do not provide any service and you charge for it.
2. When you are not entitled to private practice and you charge for the services provided.