Doctors-pharma nexus: Do you have to go round pharmacies to find the medicine prescribed by your doctor?

Syed Akbar 

A middle-aged man visits a doctor with a complaint of mild food poisoning. The doctor examines him and prescribes certain medicine. The man goes to at least a dozen medical stores with the prescription, only to be told that the medicine is not available. He then approaches the doctor to inform him about the non-availability of the drug. The doctor then directs him to a particular pharmacy, and presto! the patient finds the prescribed medicine.

Many patients silently make rounds to a number of medical stores before they finally get the drug prescribed. It is not that the drug is exclusive, restrictive  or of high curative value. It is because the doctor does want the pharmaceutical company to stock the drug only with a limited number of chemists. And what does the doctor get in return by restricting the sale of the drug?

Restricting the sale of drug to a medical store or a group of pharmacies is part of the larger game plan, what insiders in the medical field prefer to call, "cut practice". By restricting the sale of the particular drug, the pharma firm jacks up the MRP by almost 100 per cent. A commission ranging between 20 and 40 per cent of the MRP is then passed on to the doctor concerned. The loser, as always, is the patient. He pays, for instance, Rs 10 for a tablet or capsule that normally costs Rs 5 or Rs 6.

"Cut practice" is a term that encompasses everything unethical that a person or firm in the medical or pharma industry indulges it. It ranges from simply restricting the sale of drugs to certain medical stores, to garnering costly gifts by doctors from pharmaceutical companies for prescribing their drugs, and from sponsored luxury foreign visits to commission in diagnostic tests.

According to insiders, an ordinary doctor gets anything upward of Rs 2 lakh a year from pharmaceutical companies and diagnostic centres. In the case of specialist doctors/superspeciality hospitals, the commission and gifts touch even Rs 50 lakh a year. The price, patients pay in India thanks to the system of cut practice, is estimated at a whopping Rs 2,000 crore a year. This is patients' money, which otherwise they would have saved.

The recent guidelines, issued by the Medical Council of India prohibiting doctors from taking commissions from diagnostic centres and gifts from pharmaceutical companies, have kicked off a debate in the pharmaco-medical industry in the country on this nasty cut practice. All doctors, though openly support the new medical ethics, they do not want to come out of the cut practice, as it cuts their income drastically.

"Doctors get more than what you pay as consultation fee every time you visit them. They get commission from pharmaceutical companies for prescribing their products, including those which are classified as irrational medicines,"
says cancer specialist Dr P Raghuram.

According to a study by the Indian National Commission on Macroeconomics and Health, doctors prescribe drugs that are "irrational or non-essential or (even) hazardous." After a study of 25 top-selling medicines in the country, the Commission came out with a report saying that 10 of the 25 fell in the irrational or non-essential drugs  category.

"The drug industry, immensely powerful and profitable, spends more than 11 billion US dollars each year in promotion and marketing. It has succeeded in tightening its grip over the medical community over the last two decades. It tempts doctors by such offers as expensive gifts and foreign junkets, which often leads to the unscientific, costly and irrational use of drugs," points out Dr SP Kalantri, associate editor of the Indian Journal of Medical Ethics.

Dr Raghu Ram, who is also the director of KIMS-Ushalakshmi Centre for Breast Diseases, argues "cut practice is common in every segment of medical
and health care industry across the country. Taking money from the manufacturers and distributors for prescribing medicines, for obtaining diagnostic tests some of which may be unnecessary, doctors employing people with the sole purpose of luring patients is now a part and parcel of Indian practice. Faith, which is the principal link between the doctor
and patient, is fast losing its relevance and the practice of medicine is no longer considered to be noble".

The modus operandi of pharma companies and distributors to lure medical
practitioners is quite interesting. Most of the multinational and big
Indian pharma companies has specialist doctors on their payrolls.

Says Dr MN Khaja "the quality of drug is often compromised and patients have to shed more from their pockets as the drug was insisted by the doctor.
For instance, medical oncologist can only prescribe medicines for
cancer patients. However, the common practice is that the surgical
oncologists prescribe chemotherapy medicines."

Another vicious web involving doctors and diagnostic centres is that
the patients are forced to take the tests which are unnecessary. Even some doctors prescribe the tests on the letterhead of the diagnostic centres.
Inquiries revealed that the software of the diagnostic centres has a
names of the doctors who are on their pay list and when each and every patient comes them it is noted down in the database.

At the end of the month the doctors get the pay pack from the
diagnostic centre The propaganda-cum-distribution system in pharma sales is a big business where the branded drugs of promoted companies are prescribed for the patients by doctors.

A senior official in the drug control department said manipulating things with the Drug Price Control Order is another major aberration in the
industry. There are 74 drugs in the price control order and it has not been reviewed after 1995. The government fixed MRP for all these drugs in the order.

AP Medical Council member Dr K Ramesh Reddy makes it clear that the code of medical ethics prevent doctors from accepting gifts or favours from any company. "This kind of practice is more rampant in the medical disposable. These are the synthetic products used in human body for implantation and replacement," said Dr Ramesh Reddy.

The pharma companies add an ingredient and make it a combination and
sell it under different brand which will not be under price control order and they fix the MRP of their own. Even the recent high end drugs like retroviral, TB and Cancer drugs, stents and implants used in cardiovascular and orthopaedic surgeries do not fall under the price control order category.

All India Drug Control Officers Federation General Secretary Mr R Uday
Bhaskar says "the proposal to see that the MRP shall not cross more than 50 to 100 per cent of the manufacturing cost of the drugs has to be worked out."

For instance, Streptokinase costs only Rs 800 but the MRP is
around Rs 2400. "This shows that Rs 1600 on injection is shared by the doctor, distributor and the pharma company. There is no margin to this level in general products," said the official.

In many Western countries generic drugs are prescribed rather
than the brands. The Andhra Pradesh State government earlier issued GOs in 2002 and 2007 asking the government doctors to prescribe the generic drugs and the same are not implemented.

Federation of Drug Traders of Andhra Pradesh president Mr Peddi
Jagadeeswar says that there are around 45,000 retailers and wholesalers in drug trade in the State and they do ethical promotion. He puts the blame on the MNCs and Big companies. He says the presence of substandard drugs have come down in the State and there can only be three percent in circulation.