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.
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.