In India can there be transparency around the financial relationships of manufacturers (pharma products and devices), physicians, and hospitals? Are the Indian physicians willing to disclose payments they receive from pharma and device manufacturers? Industry answers these tough questions By M Neelam Kachhap
From the time Open Payment database went online in the US, debates on the financial relationships among doctors and industry have erupted everywhere. In India, The Indian Medical Council (professional conduct, etiquette and ethics) regulations, 2002 guides the relationships of manufacturers (pharma & device), physicians and hospitals. Despite the blanket ban on accepting gifts, travel facilities and hospitality from pharma companies in lieu of promoting their products perpetrators find ways to flout the norms.
What is an Open Payment Database?
The Open Payments database is an implementation of the Physician Payment Sunshine Act (PPSA), passed as part of the Affordable Care Act in 2010, requires manufacturers of drugs, devices, biologics, and medical supplies to track and report “all transfers of value” to physicians or teaching hospitals.
MCI Guideline on Payments
The amendment to the “Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulation 2002” has brought out the code of conduct for doctors and professional association of doctors in their relationship with pharma and allied health sector industry which prohibit them from accepting any gifts, travel facility or hospitality, from any pharma company or the healthcare industry.
While the interaction among pharma and device manufacturers and medical practitioners have always been opaque in India, the industry is clearly rooting for greater transparency in its financial relationships. We asked the industry if there can be transparency around the financial relationships of manufacturers, physicians, and hospitals and almost everyone replied in an affirmative. But how can it be achieved and should it be made public is an idea the industry is grappling with.
Experts believe that greater transparency might influence patients’ trust in their doctors. It may also influence the patients’ perceptions of their doctor’s expertise and patient decision-making with regard to selection of a hospital might be affected. Like the issue of black money in India, the issue of transparency in financial dealings in the healthcare industry should be considered serious and dealt with an iron hand. The industry experts share their views.
– Anoop Misra, Chairman, Fortis-C-DOC Centre of Excellence for Diabetes, Metabolic Diseases and Endocrinology; Chairman, National Diabetes, Obesity and Cholesterol Foundation (N-DOC); Director, Diabetes and Metabolic Diseases, Diabetes Foundation (India) (DFI)
The only issue is its strict implementation. We in India are not allowed to accept any gift travel etc. from pharma companies, even sponsorship for conference is not permissible. So the only way pharma companies oblige physicians is by enrolling them as researcher/consultant for providing post usage inputs. We already have strong MCI guidelines but as in every country people find ways to manage the law.
– Dr Himanshu Bansal, Scientist Spinal Cord Neurodegenerative Disorders & Stem Cell research Mothercell-StemCell Research & Solution, Uttrakhand
Manufacturers use medical representatives to try to influence doctors to prescribe their products. Sadly, because so many of the products are “me-too” products, they are forced to resort to bribes in order to persuade the doctor to prescribe their brand. Rather than spending money on innovation, the companies find it much easier and more lucrative to bribe doctors for prescriptions. Targets are set for medical representatives, who believe that the only way they can succeed is by giving the doctor whatever he demands.
Companies are extremely smart and they are very clever at disguising these bribes as “educational grants” or “payment for travelling abroad to attend medical conferences.” They manipulate doctors and these payments lead to unethical behaviour on the part of medical professionals.
The ones who are ashamed of the money they receive will refuse to disclose these payments. They know that they are guilty and their conscience pinches them, but they are smart and are able to rationalise their behaviour. A common justification is – “After all, if the senior doctors do it, why shouldn’t I ? I’d be a fool to refuse this easy money.”
Yes, there is scope for a law like the US Physician Payment Sunshine Act (PPSA) in India and because medical corruption is so much more prevalent in India, we should implement a similar measure to encourage honesty. Good doctors will appreciate a law like this.
If a database of payments were created in India what would show that often it’s the most respected doctors – the “KOLs or knowledge opinion leaders” – who are the ones who take the most money from pharma. After all, they have the most clout, which is why pharma wants to pander to them. This list would literally be a “ Who’s Who” of Indian doctors – and would feature many who are extremely influential, and are considered to be the leading lights of the medical profession.
The Indian healthcare system has become sick and openness and transparency can be powerful healing measures. Indian patients deserve a better deal!
– Dr Aniruddha Malpani, Medical Director, HELP – Health Education Library for People
It is highly unlikely that Indian physicians will be willing to disclose payments they receive from pharmaceutical and device manufacturers? Yes there must be scope for a law like the us physician payment sunshine act (PPSA) in India. Significant transactions of monumental size across India would be revealed if a database of payments were created in India
– Dr Alok Roy, Chairman, Medica Group
– Samar Khan, Managing Director, Brainlab India
However, currently the cut-practice is so rampant that the protocols can be implemented only through laws, constant monitoring and penalties. It will be a long drawn process.
To begin with, Association of Healthcare Providers (India) is working on a code of ethics which will be promoted as self-regulating code, which will require them to desist from taking any cuts or commission. The practice is so deep rooted that physicians’ willingness or acceptance could be implemented only through law. AHPI is making members conscious of the growing perception among society that the healthcare sector is prone to unethical practices and is urging the industry to take proactive measures against it. There is certainly scope for a law like the US Physician Payment Sunshine Act (PPSA) in India. It is probably the only means to clean up the system.
– Dr Girdhar Gyani, Founder Director General Association of Healthcare Providers (India)
There seems to be good paper work with Western organisation since they follow their global policies and try to enforce the same in India. I am not really aware of the practices followed by local manufacturers. But again, since there is a ambiguity in law. It may be hard to measure the effectiveness.
I don’t think there is any system where public can see payments doctors’ receive from manufacturers. There is hardly any transparency. But for an Indian patient to decide on the treatment or doctor based on their ethical behaviour may be a little futuristic at the moment.
Yes. There is scope for a law like the US Physician Payment Sunshine Act (PPSA) in India. If a database of payments were created in India it would reveal payer, receiver and amount and what is the reason for payment at a minimum. There is further need to frame new rules to deal with other corrupt unethical practices like cuts/ commissions to doctors for referring cases.
– Kuldeep Tyagi, Global Head of Medical Practice, Cyient
Sponsorship by pharma industry towards achieving improvement in skills, and knowledge of physicians can only help improve patient care, however malpractice can be garbed and misuse of such financing is and will be rampant. Therefore disclosure to regulatory authorities, authorities at work and patients is the best solution.
Stringent measures to ensure that disclosures are complete and unrestricted; powerful punitive action for failed disclosures are obviously a corollary.
Some percentage of Indian physicians would be willing to disclose payments they receive from pharma and device manufacturers, the rest would be unwilling. But that should not be a deciding factor; mandating such disclosures is the need of the hour.
Absolutely, there is a scope for a law like the US Physician Payment Sunshine Act (PPSA) in India. There is a huge opportunity to clean up the system by introducing such laws with due modifications for the Indian context.
If a database of payments were created in India it would differentiate ‘clean’ from ‘unclean’. I can assure you there is a sect of providers and doctors who are clean, however there is equally a group that is not. Exposing the latter is necessary and will only do good to all concerned.
– Dr Nandakumar Jairam, Chairman and Group Medical Director, Columbia Asia Hospitals, India
Can we do this in India? Yes. There is nothing that can stop this. Ethical business rules find their place in every ecosystem – provided there is political will for the same. Will they get enforced in the true form is the real question.
Pros: Will make it difficult to break the rules – will not stop until a more holistic multi-pronged approach is adopted.
Cons: It may add to the cost of doing business in India and may lead to more cost being passed on to the customer.
Supplier-provider/ physician interactions follow a similar pattern across the world. But like the traffic on the road, more developed the healthcare ecosystem, it has more rules that make it more organised with lesser tolerance for breaking the rules. Scope for breaking the rules is higher in emerging markets due to possibilities of breaches in accountability in the overall business environment – black money (cash dealings) being a key area to state in this case in India. This is aided by the unorganised channel of small dealers to go to market, who bridge the compliance requirements of the foreign parent (FCPA or the like) and the local realities to serve the needs of customer relationships. Currently, compared to Indian regulators, there is more enforcement in India due to compliance requirements like FCPA (or similar) of the MNCs doing business in India.
Hence, to start, absolute enforcement may be challenging in the Indian context – as a large part of this will either escape reporting or be masked under alternate expense heads. But either ways, it will be a welcoming step. Counter controls can be set-up by strengthening the healthcare supply chain to correlate patronage of drugs and devices with possible financial relationships between suppliers and providers.
– Vineet Kapoor, MD, Inhx Indian Healthcare Exchange
The pharma and device manufacturers are in a very competitive sector and are sales/ revenue driven organisations. In their quests to ensure top/bottom lines, many a times due to pressure the companies or employees acting independently may have turned to gift distribution/ cheque distribution to put it very mildly. On the other hand poor pay/ income and no proper standardisation of the healthcare practitioners/ sector in the country may have driven the physicians to accept/ demand such relationships. Minimal or no regulations regarding such relationships may be another contributing factor.
I am not sure if Indian physicians will come out clean to disclose all payments received directly or indirectly.
Proper regulations and standardisation will be required before implementation of such laws (like the US Physician Payment Sunshine Act) in the Indian setting. Also proper implementation and ensuring control to prevent misuse of the law need to be in place.
If a database of payments were created in India it would it reveal a Pandora’s box and better left at that. For creation of such a database we need to ensure proper legislation and ensure bringing physicians, physician associations, pharma/ device industry, hospitals and healthcare institutions, insurers/ TPAs/ Payors under one department/ ministry. Currently each of them function under different structures which gives rise to ambiguity of regulations which may be one of many loopholes to the functioning of physician-industry interactions.
Current tightening of certain regulations/ guidances – e.g. clinical trial participation, video recording of consent, MCI guidance on accepting gifts, foreign travel by physicians, OPPI guidance etc., may have been deterrents but these need to be consolidated.
– Dr Karen Marlyn Syiem, Principal Consultant, Integra Ventures, Guwahati
I can’t really speak for all physicians. Presumably if there was a law requiring discloser of payments then Indian physicians would be willing to disclose payments they receive from pharmaceutical and device manufacturers.
There is always a scope for regulation, however what ultimately matters is how the regulation is enforced.
– Dr Arjun Kalyanpur, CEO, Teleradiology Solutions
I am sure only a small section of people accept unethical norms and they can be brought back to the main stream and government can make strict guidelines for ethical trade practices and value based medical business.
I think eventually we need to make a law very similar to what US is doing and it will slowly but surely pick up momentum. Common man wants a system corrupt free and ethical dealings and any civil society will eventually accept it as the best form to have an equal justice honest system.
If a database of payments were created in India. It can be the same effect like Income Tax Department reveals the names or deals which requires explanation or legal action but revealing such information do not generalise a system or point out everyone is part of such unethical system.
– Som Panicker, VP, MRI Division, Sanrad Medical Systems
It is difficult to generalise how pharma and device manufacturers interact with physicians, as many companies follow stringent ethical norms while there are others who compromise and offer incentives to the HCPs as quid pro quo for favourable recommendations/ purchase decisions.
Very much doubt that Indian physicians would be willing to disclose, but if there is strict regulations then suppliers can be mandated to disclose. Problem is most of these transactions happen in cash, hence difficult to trace.
There is not only scope for a law like the US Physician Payment Sunshine Act (PPSA) in India, but dire need to have one if we have to weed out corruption from the healthcare space. It should however not be limited to interactions between vendors and HCPs but also extended to interactions between say HCPs and diagnostic centres or clinics/ nursing homes/ hospitals etc. There is lot of internal referral that goes on within the HCP community which also hikes patient charges.
It is impossible to create a database given mostly these are cash payments or benefits passed on in terms of free international trips etc. But one thing is sure, if this malpractice is curtailed it can bring down the price of drugs, medical devices and patient diagnostics and treatment costs.
– Ashok K Kakkar, Senior MD, Varian Medical Systems International India
– Dr Purshotam Lal, Chairman and Director, Interventional Cardiology, Metro Group of Hospitals
If the Government has the will, there is scope for a law like the US Physician Payment Sunshine Act (PPSA) in India. If a database of payments were created in India, firstly there needs to be a statute that the disclosure is compulsory like IT return. Then it would be very effective. But till then it’s wishful thinking.
– Dr Sujit Chatterjee, CEO, Dr L H Hiranandani Hospital