Citizens' Issues
How Patients are taken for a ‘test ride’
Billions of dollars are spent worldwide on health care through repetitive and cost enhancing tests. They only fatten the chain of doctors, labs and pharma companies. Some real life examples
 
A lot of money (billions of dollars worldwide annually) is spent on health care by countries, its citizens, governments and other stakeholders. In addition, some of it is merely repetitive and cost enhancing, without much (serious) addition in value.
 
During October-November 2011, a friend of mine came under a lot of stress and had to visit several doctors as part of this – from his corner family doctor to a local specialist as well as a top-notch diabetologist through a system of medical referrals. And each of them got him to repeat the same tests, over and over again within a space of hardly a few days, despite the fact that the tests were taken at accredited and well known labs.  But alas, the tests results and diagnosis were not hugely different from one another and I wondered what was the additionality that (to be) was gained by getting a patient to take the same tests within a short interval, especially when they (as professional doctors, perhaps) knew that it would hardly make a difference. 
 
‘Let me illustrate what I am saying with just one test glycated haemoglobin - HbA1c and much of what I argue here holds true for many other diagnostic tests, scans, magnetic resonance imaging (MRI)  and the like. For people with diabetes, the HbA1c test is important as the higher the HbA1c, the greater the risk of developing diabetes-related complications. The term HbA1c refers to glycated haemoglobin. It develops when haemoglobin, a protein within red blood cells that carries oxygen throughout the body, joins with glucose in the blood, becoming 'glycated'. By measuring glycated haemoglobin (HbA1c), doctors and other stakeholders are able to get an overall picture of what our average blood sugar levels have been over a period of say, three months or so, depending on the actual measurement and analysis process.’ This is what several sources including Mayo Clinic’s web articles say. 
 
Thus, it is clear that HbA1c will not have any significant change within a period of just a few days. That being the case, what is the great idea in doctors repeating it within a span of just few days and especially for someone who had not yet been declared as diabetic!
 
Today, when my friend is doing fine, I look back at these times and reflect back on the happenings, several things stand out: 
 
a) First, every doctor has a right to his diagnosis and therefore, a set of tests that go with it. That said, they can at least look at what the previous doctor has done and re-order ONLY those tests that are likely to have a significant change in values (and thereby impact diagnosis) in the time concerned. Tests like the HbA1c, which are unlikely to have significant changes in values within a space of few days, should NOT be repeated. The same principle must be applied for MRIs, computerised tomography (CT) scans and all other tests that afford very little opportunity for significant change in the underlying medical condition and diagnosis thereof! 
 
Of course, this decision of not repeating tests is also likely to be impacted by the actual health condition of the specific individual – whether he/ she is of normal health or has a serious critical illness and so on. That said, ceterus paribus tests (like the HbA1c), which are unlikely to have significant changes in values within a space of few days or MRIs, CT SCANS and all other tests that afford very little opportunity for significant change in the medical condition and diagnosis thereof, MUST not be repeated just for the sake of pleasing the whims and fancies of the new doctor. This will result in huge savings for the health care industry and the country as a whole!
 
b) Second, most often than not, this re-ordering of tests takes place primarily to enhance the business of a favoured laboratory. The practice of ordering the same tests from a (favoured) laboratory must stop, if it is being done just to provide enhanced business for the laboratory. I have heard many laboratory personnel as well as doctors remark on the practice of commissions/ incentives being provided to doctors for referrals. This is a wrong incentive and I would personally put such incentives or corruption as a major reason for tests being repeated. 
 
c) Third, apart from the corruption issues involved, there is a problem with the laboratories concerned. Let me give you an example. A few years ago, to better understand the calibration of the testing processes, I provided blood samples to three so-called top notch and reputed laboratories in Chennai (at the same time) and guess what, they landed up with totally different values for various parameters. Let me explain with the example of HDL cholesterol
 
Let me first explain the context of HDL Cholesterol and then proceed to outline the problem. According to (the highly reputed) Mayo Clinic documents, “Cholesterol is a waxy substance that's found in all of your cells and has several useful functions, including helping to build your body's cells. It's carried through your bloodstream attached to proteins. These proteins are called lipoproteins. 
 
Low-density lipoproteins. These lipoproteins carry cholesterol throughout your body, delivering it to different organs and tissues. But if your body has more cholesterol than it needs, the excess keeps circulating in your blood. Over time, circulating LDL cholesterol can enter your blood vessel walls and start to build up under the vessel lining. Deposits of LDL cholesterol particles within the vessel walls are called plaques, and they begin to narrow your blood vessels. Eventually, plaques can narrow the vessels to the point of blocking blood flow, causing coronary artery disease. This is why LDL cholesterol is often referred to as "bad" cholesterol.
 
High-density lipoproteins. These lipoproteins are often referred to as HDL, or "good," cholesterol. They act as cholesterol scavengers, picking up excess cholesterol in your blood and taking it back to your liver where it's broken down. The higher your HDL level, the less "bad" cholesterol you'll have in your blood.
 
Cholesterol levels are measured in milligrams (mg) of cholesterol per deciliter (dL) of blood or millimoles (mmol) per liter (L). When it comes to HDL cholesterol, aim for a higher number. 
 
 
 
If your HDL cholesterol level falls between the at-risk and desirable levels, you should keep trying to increase your HDL level to reduce your risk of heart disease. If you do not know your HDL level, ask your doctor for a baseline cholesterol test. If your HDL value is not within a desirable range, your doctor may recommend lifestyle changes to boost your HDL cholesterol.”
 
Having set the context let me get to the problem. As noted earlier, I got my HDL 
Cholesterol and entire lipid profile done with three reputed laboratories in Chennai – all on the same day. And LO behold, they came up with the following values:   
 
 
I then went to visit a very senior general practitioner (GP of medicine) and showed him the three reports and he was terrified that I had done what I had done. He advised me not to test simultaneously at three labs and after some arguments, he did accept the fact that, calibration and standardisation of the entire medical testing process was HUGELY suspect. I would urge people to try this out now and do not be surprised if you land up with very different values for different key health parameters. 
 
The problem in the above case was that, the same individual, when tested at almost similar times, across three laboratories, reported very different values of HDL Cholesterol. That posed a huge problem to him in terms of what to advise me, the patient. If he took the values from LAB #1, he would have perhaps recommended serious life style changes and also further investigations. If he took the values from LAB # 2, he would have advised me some life style changes as I had HDL values that bordered risk. If he took the values from LAB #3, he would have perhaps advised me to continue doing what I did. 
 
Let us not get bogged down with HDL Cholesterol but look at the larger picture. 
 
When reputed laboratories give you as diverse values as they do, then how reliable and valid are the laboratory tests? That is the critical issue that needs focus here! And it goes without saying that there is an urgent and immediate need for quality control in standardisation of tests and laboratory processes in India! The problems are often compounded by the system of laboratories and testing/ scan centres incentivising doctors for referrals and doctors in turn having ‘favourite’ laboratories and testing/ scan centres for patient referrals. All in all, this indeed leads to a vicious cycle of wrong incentivisation and corruption as “eminent doctors across India are unified in their opinion that doctors play a key role in "the kickbacks and bribes that oil every part of the healthcare machinery.”
 
In fact, corruption in the health care system is very deep rooted and exists from ‘the cradle to the grave’ through the entire life cycle process for a range of aspects – i.e., from the medical college (e.g., Vyapam etc) to testing (laboratories, scan centres etc) to actual health care (with doctors, at hospitals and so on).  
 
Therefore, without question, we URGENTLY need a clear policy on health care in India, which is deep rooted in corruption from cradle to grave. Whether it is the large Vyapam scam or the equally notorious previous medical college accreditation scam, the state of health care in India is at best called dismal. And this policy must outline health care reforms that will address the above and other crucial issues such as the exclusion of millions of Indian’s (the poor, both urban and rural) from the ambit of affordable, high quality and timely health care services. Whether, at all, we, as a country, can do this is something, that only time will tell.       
 
(Ramesh S Arunachalam has over two decades of strong grass-roots and institutional experience in rural finance, MSME development, agriculture and rural livelihood systems, rural and urban development and urban poverty alleviation across Asia, Africa, North America and Europe. He has worked with national and state governments and multilateral agencies. His book—Indian Microfinance, The Way Forward—is the first authentic compendium on the history of microfinance in India and its possible future.)
 

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COMMENTS

captainjohann

2 years ago

Even Government hospitals are repeating the tests in their own labs. Why? Quality control is required for all Nationaly accredited labs and the body which is supposed to conduct the quality control must be held responsible if labs are found to be wanting.

manhar kothari

2 years ago

whom to held responsible ? for corruption at all levels.first of all we as a individual also responsible.

Anand Vaidya

2 years ago

One of my relative was getting treatment in a hospital (OPD) and the hospital did a blood test, we also did a test in a lab outside. The two results were off by 50% (Haemoglobin - within a day). When I confronted them with these strange results, the hospital refused to provide any explanation and re-did the test at their end with repeat numbers. Case closed.

The lab refused to entertain any complaint and refused comments

This is how "healthcare" is.

Neelam Kundani

2 years ago

Very true, almost all.docs advises referrals to partucular labs and docs, saying tht.quality of tht lab and machineries.are.trustworthy, and we don't trust other labs results

Narendra Doshi

2 years ago

Well said and it is the most common & correct experience received.

Narendra Doshi

2 years ago

Well said and it is the most common & correct experience received.

Will: Why it is important to write and register a Will
Adv Bapoo Malcolm, while speaking at a workshop organised by Moneylife Foundation, discussed mechanics of preparing a Will, registration and explained litigation possibilities, witnesses, executors, intestate problems, adoption problems
 
In an interactive session at Moneylife Foundation, Advocate Bapoo Malcolm explained to a packed house the practical aspects of making a will and importance of registering your own Will. This was Adv Malcolm's fifth session on Wills at Moneylife Foundation. 
 
Mr Malcolm, advocate, Bombay High Court, a man of many interests and the speaker for the workshop, covered issues related to Wills, like registration, litigation possibilities, witnesses, executors, intestate problems and adoption. He also discussed types of wills, including privileged wills, joint wills and holographic wills.
 
Talking about Wills, the well-experienced lawyer in both civil and criminal matters, said, “A Will can be made by any person who is not a minor and who is of sound mind. You need two witnesses, preferably independent of each other. The Will must list all the immovable and movable properties you own, and who you wish to will them to after your death. However, remember, you can only bequeath what belongs to you and what is self-earned; otherwise the distribution is governed by various Succession Acts."
 

Adv Malcolm, then explained the technicality of the subject - testators, codicils, executors, probates, administrators and the various succession acts - with real-life examples that elucidated the complicated topic of wills to the audience. 
 
Explaining the simplicity of creating a Will, Adv Malcolm said, “A Will is a simple document to be written in simple language. Preferably, avoid legalese. You simply have to give specific instructions about what has to be done with the movable and immovable properties you own and the property you might acquire in future. It would be best if it reads like a balance sheet. Just specify the property and the person. A Will should be legible and clear to understand."
 
The religion of an individual matters for succession under the Hindu Succession Act, Muslim personal law, Parsi personal law, Christian law and for others by default under the Indian Succession Act. Each category has different tables for arriving at legal heirs in the absence of a will. 'Hindu' has a broad meaning because anyone who is not Muslim, Christian or Parsi is categorised under the 'Hindu' category, he added.
 
A Will needs to be clear and concise, leaving no room for misinterpretation. “A Will would be interpreted according to the word of the law, which may not assign the same meaning as you intended.” 
 
For example, while mentioning names it is important to specify the relationship along with the date of birth of the person, as there could be common names. In addition, if you wish to intentionally leave someone out of your Will, especially, if it is a close family member, it is better to mention the name in the Will. If not, the person may contest the Will by saying you have forgotten his/ her name, Adv Malcolm explained.
 
While preparing a Will people are often left confused about its registration. Clearing the doubts and misconceptions about Wills, Adv Malcolm, said, “The government does want to encourage people to make Wills, so they haven’t made it compulsory to register a Will. You can even make a Will on a serviette. So long as the basic requirements are fulfilled, the Will is legal. Registration is a grey area, mainly because if you then wish to make a second Will, you may not have the time to register it. If you realise the day you die that a relative is useless, you may not be able register this second Will. Then, does the unregistered Will have more value than the registered one? An unregistered Will could easily be lost; however, registration takes care of the safety issue. At least, if it is registered, you know that it is always in some government ward.”
 
He then explained about probate, which is validation of a Will by the Court. "Probate is required only in Presidency States of Bombay, Chennai, Kolkata and only within their jurisdiction only for immovable property. Companies prefer to recognize Wills that are registered or sometimes require a probate. In addition, transmission of immovable property also usually requires a probate," he added.
 
Adv Malcolm then explained Trust, which is used for complex bequests and special cases. He said, "A Trust can be registered under the Indian Trusts Act. You can transfer funds and property to the Trust, which becomes the holding vehicle. Trustees manage the Trust as per the Trust Deed. You can access and control assets while alive and decide on distribution too. A Trust protects your assets from probate."     
 
Citing several examples, Adv Malcolm also explained several things that need to be avoided while preparing a Will.
 
Adv Malcolm also answered the queries of Moneylife Foundation members who raised their doubts.

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Nifty, Sensex rally may pause – Weekly market report

Nifty uptrend may continue as long as it manages to stay above 8,355

 

We had mentioned in last week’s closing report that Nifty has to close above 8,390 for the first confirmation of a new upmove. Nifty stayed above this level throughout this week and closed at 8,609.85, up 2.98% from the last week’s closing. On Friday, Nifty opened at 8,623.65, touched a high of 8,642.95 and a low of 8,593.15 before closing at 8,609.85. The S & P BSE Sensex closed this week at 28,463.31, up 3.0%. The Sensex opened Friday at 28,480.92 and touched a high of 28,576.32 and a low of 28,417.46. The Bank Nifty closed this week at 19,094.70, up 2.0%. On Friday, Bank Nifty opened at 19,175.30 and touched a high of 19,229.05 and a low of 19,069.30. Over the week, the indices have performed, as fears about Greece’s exit from Eurozone and a crash of Chinese market, abated.  
 
On Monday, Greek Prime Minister Alexis Tsipras accepted a compromise on German-led demands for the sequestration of Greek state assets to be sold off to pay down debt. With the Greece deal being struck, indices were up by around 1% in Monday’s trading. European Council President Donald Tusk said that EU leaders had unanimously reached an agreement on a third bailout for the cash-strapped southern European country of Greece. This was positive news for stock markets worldwide.
 
On Tuesday, it was a listless day of trading with a flat close after lower-than-expected retail inflation data dampened hopes of an interest rate cut by Reserve Bank of India (RBI) next month. Rise in food and fuel prices propelled India's retail inflation to 5.40% in June from 5.01% in May, official data showed. Foreign funds were net sellers of $87 million on Tuesday. Good buying was observed in IT and healthcare sectors, while selling pressure was seen in auto and banking sectors.
 
In Wednesday’s trading, Nifty and Sensex closed with healthy gains while Bank Nifty was subdued. Expectations of a rate cut in August by the Reserve Bank of India and cheaper oil imports from Iran cheered investor sentiments which led the Sensex to gain more than 265 points on Wednesday. 
 
The uptrend continued in Thursday’s trading, as positive global and domestic cues lifted investors' sentiments. Sensex gained more than 247 points on Thursday.
 
On Friday, S & P BSE Sensex and CNX Nifty closed in the green, while Bank Nifty closed marginally in the red. 
 
Out of the 27 main sectors tracked by Moneylife, top five and the bottom five sectors for this week were:
 

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