Refer a patient, get a hefty commission: The murky world of rural healthcare

Your pharmacist-cum-village doctor refers you to a specialist or hospital for better treatment or a diagnostic centre for some tests. What do you think? Your health requires it and you would think it is in your best interests. And, the people you are being referred to are best-equipped to help you. 

But in reality, your "doctor" may have a vested interest in referring you to another doctor or treatment facility – he may earn a portion of the money that you spend on these treatments and tests as commission. 

Such a commission that even goes up to 50% for a referral has now become commonplace in Lakshmipur – in most cases, patients are being advised unnecessary treatment under a false sense of health security.  

There is often a close nexus among doctors, private hospitals, clinics, diagnostic centres and middlemen, even relatives of patients, who indulge in such exercise in exchange for commissions between 20% and 50% of what a patient spends on their treatments and tests.   

Local sufferers say many doctors recommend different unnecessary tests and surgeries in some cases only to get commissions, causing patients not only to spend a lot of money but also so much time for treatment. 

When they move from one doctor to another, they have to have the same tests done again and again, they allege.  

Local people claim that they are falling prey to a section of greedy doctors and substandard private hospitals as the government-run healthcare facilities are riddled with a shortage of physicians and necessary equipment and various other problems.  

Md Zakir Hossain, 25, a pharmacist at Lakshmipur Sadar upazila, when a village man catches a disease, he goes to a nearby pharmacist for help. The pharmacist sends them to private hospitals and clinics that will give the highest commissions, irrespective of the quality of these services. 

Almost all village doctors are involved in this illegal practice where the referee of a patient pays out to the referrer for sending him or her "business", which is called cut practice, he also said, adding that  in this way, they get up to 50% of a patient's treatment cost.

"What could be a bigger deception than this?" he regretfully questioned.

For example, Shipon Kuri (not real name) took his five-year-old son who developed something like an allergy in his body to a medicine shop in Bashikpur Bazar of Lakshmipur Sadar upazila. The pharmacist referred his son to a private hospital in Noakhali, 60 kilometres off his house. 

The doctor at that hospital advised him to undergo 11 tests that cost him around Tk10,000. Shipon stayed in Noakhali for the whole day and returned home at night after completing all the medical tests on his son. After all the tests, the doctor prescribed only 2 allergy medicines, he narrated while talking to The Business Standard. 

He returned home and came to know from another person in his village that the pharmacy owner got half of the money he spent on the tests, Shipon said.

Shipon Kuri alleged that three out of 10 pharmacists in his village market have amassed a lot of money by engaging in such an illegal practice of referral business in exchange for hefty commissions. 

They also have shares in some private hospitals, he also said.

Didar, manager of a private hospital, said they cannot charge patients coming to them with pharmacy reference lower even if they want because half the hospital bills go to the pharmacy owners' pockets.

Abdur Rahman Tuhin, owner of Matrichaya Hospital in Raipur, said now ambulance drivers, CNG-run auto-rickshaw drivers, and even patients' relatives also take commissions. 

If all private hospitals stop paying commissions, patients will get good and necessary treatment at lower costs.

On the condition of anonymity, some owners of several private diagnostic centres and hospitals said it is possible to reduce medical expenses by half if the commission business is stopped.

Talking to this correspondent, the managers of five private hospitals in the district town said unnecessary tests are sometimes done under the pressure of pharmacy owners, seasonal brokers and some doctors.

A housewife named Fatema Akhter said her little child underwent three tests at the Upokul Diagnostic Centre only because of having fever on the advice of a doctor of Kamalnagar Upazila Health Complex. 

After seeing his report, the doctor referred the child to a paediatrician at Fair Diagnostic Centre in Lakhsmipur. But the doctor made her repeat the same tests in the diagnostic facility of his chamber, she claimed.

Professor JM Farooqui, president of Sushasoner Jonno Nagorik, Lakshmipur, said many patients are turning to private hospitals for not getting necessary treatment in government hospitals for various reasons and are falling prey to agents and middlemen for their ignorance. 

Many private unregistered clinics and diagnostic centres have sprung up, making a way for the practice of giving commission in exchange for patient referrals, he noted. 

Only 2-3 general tests of blood and urine are conducted in one district hospital and four upazila health complexes. There is also a lack of technicians and equipment, according to sources.  

Locals said a strong syndicate has intentionally created such a situation in the government-run healthcare facilities for driving patients to private facilities. 

JM Farooqui said the medical system of the entire district has become hostage to village doctors and brokers of substandard diagnostic centres and private hospitals.

Lakshmipur Civil Surgeon Dr Ahmed Kabir said behind the commission business is the lack of awareness of the patients. Besides, middlemen nudge them towards private hospitals in the absence of security personnel in the government hospitals. 

They cannot render proper treatment to patients due to the lack of doctors and lab technicians in the hospitals. That is why many are referring patients to private clinics and diagnostic centres and getting good commissions, he also said.