Physicians and other healthcare professionals are in a position to refer business to a variety of individuals and entities: specialists, companies, home health agencies, and others. But what criteria are used when deciding where patient referrals should go? Is it always what is in the best interest of the patient? Are there other motivating factors? How ethical are those 'motivating' factors?
This, we will dissect in this week's edition of our digest.
Have you ever reported sick to a clinic and found yourself being refered to another clinic for a particular procedure, be it diagnostic or curative? Chances are high that someone has made thousands off your coffers by that referral, as an inducement called 'kickback.'
What is a Kickback?
A kickback is the payment to a recipient as compensation or reward for providing favorable treatment or services to another party. A kickback in the form of money, gifts, credit or anything of value may be viewed as a corrupt practice that interferes with an employee's or official’s ability to make unbiased decisions.
In medical and healthcare practices, kickback is the underhand reward by a healthcare provider for anyone (mostly his/her colleagues) that refers a patient/client to patronize his/her facility/services.
Some pilot studies (including many other unreported incidences) exposed the unsettling fact that most healthcare businesses in Nigeria are sullied by the evil of kickbacks. And few consistent reports I had personally seen shows that these health practitioners who are approached to refer patients or order services or products frequently demand some benefit in exchange for their patient referrals.
On September 24, 2020, Premium Times published an exposé on the evil of kickbacks in Nigeria's health care system.
Despite efforts to educate clinicians that any payment for referrals is illegal, kickbacks continue to be paid as evidenced by the growing number of disgruntled patients who lament unsatisfactory referrals which were found to have been done for pecuniary purposes and against the patient's interest.
More practical explanation is in this illustration:
Mr. Pharmacist opened a Drug store in a particular town. He deemed it fit to visit all hospitals, laboratories, maternity homes, physiotherapy clinics, Radiography/Radiology centres in the town, to intimate them of his new pharmacy shop. He would go further than that, to solicit their patronage, by making an offer of a percentage cut from the total sum of the patient/client's bill that will be given to referring professional(s) as a "thank you" token.
This token, as said above will not come from the Pharmacist's pocket, but from the patient/client's pocket (without his/her knowledge). Thereby increasing the financial burden of someone who is seeking relief, having already been afflicted by the burden of illness.
If Mr. Pharmacist choose to avoid such underhand incongruency, Mr. Radiographer, Mr. Physiotherapist, Mr. Physician, etc may individually ask him, "how much is my share?"
Such inducement is what influences most referrals in our health care practice. And the overall bills of the patients/clients are reviewed upwards to accommodate such unholy indulgence.
There are threefold demerits of kickback.
First, it runs against the Hippocratic oath, by increasing the burden of the patient, akin to the adage of "curing someone with pills and killing him with bills."
Second, it leads to compromise in the treatment the patient receives. The accuracy, precision and merits of the choice of reference are questionable. For instance, patients will not be refered to the Laboratory facility that gives the best in service delivery, but doesn't offer kickback, but will be deceived (or prevailed upon) to patronize the one that may not meet the patient's health care demands, just because it played the underhand game of inducement.
Third, competence and professional integrity is at risk of fading and the general public is at the receiving end of such mediocrity and illegitimacy.
It is also a dehumanizing aspect of healthcare practice to use a patient like a commodity (a slave) to satisfy pecuniary interests.
And most importantly, the clinical decisions will, unduly be influenced by the hidden interest of the referrer.
It is the more reason why there is much clamour for ISO accreditation of all public and private healthcare facilities in the country, because kickback is outlawed in the ISO scheme.
In all, it is unethical to engage in kickbacks, whether as a receiver or giver.
However, one thing that is ironical is that when you go in for the best, they (the practitioners) refer to you to where their interest resides. But when they need the best result, when they want a sincere and trusted cure/diagnosis, they will patronize those facilities that give the best, and play by the professional cum ethical rules of no kickbacks.
How do we track and stop such unethical practice?
The best approach is through whistleblowing.
But Nigeria lacked a legal and socio political system that encourages whistleblower policy, unlike in the U.S (that world of free men), where it has helped put the monster in check. Since Premium Times released their findings two years ago, no one has been subjected to justice.
The insincerity of law enforcement agents on one part, and lack of professional integrity by the practitioners on the other part, are also two major factors against it. Even in the political scene it couldn't serve the Buhari regime few years ago, when they initiated it.
But in climes like the West, it works well in check-mating the monster.
The essence of referrals is to send a patient to another facility or expert where his/her need will be better taken care of. So inasmuch as it is unethical to retain a patient in your facility that could not effectively help the patient reach his/her health goal, it is more unethical to demand inducement in referring him/her for appropriate treatment.
In all, it takes integrity to resist the charms of kickback and maintain moral probity in this life-saving profession.