Resist healthcare's black market temptation
t is a cold, gray and rainy morning in a town somewhere in Central Europe. A vehicle speeds out from a huge complex of buildings into the main road. It seems to have priority over all other cars in the street at this early morning hour. The man sitting in the back looks pale. He has been informed about the purpose of his short journey in the afternoon of the previous day, but a clear explanation of the reason has not been given. He thinks: Why are the local facilities not being used, why must I put up with the added burden and stress?
A few minutes later the car stops in front of a building in the outskirts of the city. Driver and passenger have arrived at their destination: a radiologist’s private practice.
What sounds like the beginning of a cheap crime novel is a sad reality in some parts of Europe and the United States. Patients are the victims of villainous physicians who use their positions in hospitals or other institutions to extract money from colleagues through elaborate kickback schemes and abusive referral arrangements.
I am told that some neurologists, neurosurgeons, psychiatrists, as well as cardiologists and orthopedic surgeons believe that because the practice of referring patients creates business for others, they should be allowed to participate and augment their own income. Their main targets are the medical service disciplines, radiology being one of them.
The story usually follows the same pattern. Patients are sent to private clinics or practices for their radiological examinations, although the hospital in which they work has a department of radiology. This happens because the hospital radiologist does not want to share his income with the referring physician. Thus, patients are referred elsewhere – and, in many instances, undergo more studies than are necessary.
If a hospital radiologist does not play the game of his colleagues, they start moving other figures on the chessboard. If, in a smaller or even bigger hospital, there is only a department of general radiology servicing all clinical departments, they suddenly demand the creation of a department of neuroradiology or nuclear medicine, independent of general radiology, headed by a person of their confidence. This person, he or she, will pay a share of the income to them.
This is why some cardiologists prefer a separate department of nuclear medicine, why some neurologists, neurosurgeons, and psychiatrists push for a separate department of neuroradiology, or pediatricians for pediatric radiology.
"Political intrigue involves physicians, administrators, and local politicians."
Pressure can also be applied via research grants. Suddenly neurologists decide who gets imaging research grants – they are not awarded to radiologists or knowledgeable scientists, but rather to psychiatrists or neurosurgeons with little or no knowledge and background in imaging research. Often there is a spider web of political intrigues between physicians, administrators, and local politicians.
This Machiavellian behavior is outside social and medical norms, the norms that we are expected to adhere to by the people putting their trust in us. In many instances, this behavior is not only unethical and immoral, it is plain criminal.
Once involved in such a protection racket, there is hardly any way out. It is a vicious circle. Once you are inside, you have to conceal your movements, and you will get deeper and deeper involved. Additional crime is pre-programmed. It is like Mafia protection rackets selling “insurance” to restaurants or shops: it starts with simple blackmail, but you never know where it will end. If fraud and blackmail become public knowledge it will destroy your social standing and family. It is prone to become known, although in most cases there is a political cover-up to protect everybody compromised as well as hospitals, insurance companies, and medical organizations.
Blackmail and the creation of Mafia-like protection gang are too much for radiology (and medicine as such) to tolerate. The people involved should lose their medical license and go to jail.
To be frank, radiologists are not necessarily the good boys in this game. You also can play it the other way around: you offer a share of the patient cake to referring colleagues. This is a well-known scheme between laboratory physicians and customers sending test samples, but also known in radiology.
Self-referral is one rung lower on the ladder of irregular income enhancement. After Belgium and before Switzerland, Germany had the second highest number of imaging examinations in Europe per inhabitant and year. The number is 30% higher than in France, nearly 100% higher than in Italy, and 150% higher than in the Netherlands and Sweden.
In Germany, nearly 80% of all radiological examinations are performed by non-radiologists. Surgeons, orthopedists, and internists perform most of the x-ray studies of the thorax and skeleton in their own private practices. It is apparent that self-referral leads to millions of unnecessary x-ray and ultrasound examinations each year.
Let me just give you a hint of the amount of money we are talking about: German health insurance companies reimburse approximately one billion Euro per year for ultrasound examinations. If we assume that only one quarter of these examinations was superfluous and we could use this amount of money, then we could buy a bottle of nice Spanish red wine each for the entire population of Europe. Put them next to each other, this would give a line from Madrid via Basel, Warsaw, Moscow, through Siberia, Tibet, Shanghai, crossing the Pacific Ocean, America, all the way back to Madrid (this is an explanation of the magnitude of the problem for politicians – correct me if I am wrong).
Self-referral is not one of the topics widely discussed in Europe because too many physicians are deeply involved in it and too much money is at stake. The same is the case in the USA. In a recent statement in front of the US parliament, a spokesman for the American College of Radiology said:
“The practice of physicians referring patients to health care facilities in which they have a financial interest is not in the best interest of patients. The practice of self-referral may also serve as an improper economic incentive for the provision of unnecessary treatment of services. Even the appearance of such conflicts or incentives can compromise professional integrity.” 
Radiologists in Germany, but also in Scandinavia, Britain, or France usually repudiate any suspicion of possible corruption, even mental corruption: This cannot happen here. However, it happens. Everybody complains about a loss of values. Yet many of us think and act according to the following sentence: why should I love my neighbor if I can love myself a little more?
Corruption has always been part of our world. If you have connections you will be served faster and better – at least you believe that you are served better. Personally, I have the feeling and experience that very often patients using connections to get priority diagnosis and treatment pay more and die faster.
Building up and exploiting connections is called lobbying. It is an addition to continental European politics, although it too has been part of our world. Lobbying is just corruption turned into a business.
Last year, the World Health Organization summarized the failings of many health systems. Among them were:
In many countries, some if not most physicians work simultaneously for the public sector and in private practice. This means the public sector ends up subsidizing unofficial private practice.
Many governments fail to prevent a “black market” in health, where widespread corruption, bribery, “moonlighting” and other illegal practices flourish. The black markets, which themselves are caused by malfunctioning health systems, and low income of health workers, further undermine those systems.
Many health ministries fail to enforce regulations that they themselves have created or are supposed to implement in the public interest .
Earning a lot of money is attractive. However, the way a medical doctor makes money should be limited to legal and moral forms of earning it. Laws and moral can be stretched a little bit – but not too much.
Note and Disclaimer
Some people like to twist and turn sentences. Therefore, for the record, the following remark: I do not state that all neurologists, neurosurgeons, cardiologists, and, for that matter, radiologists are corrupt or criminal. On the contrary; I hope that all of us are honest, law-abiding, and following the Hippocratic oath. The rest is, hopefully, fiction; and the stories people tell are hopefully fairy tales.
I am also in favor of independent departments of pediatric radiology, neuroradiology, and nuclear medicine if there is enough competence and a solid infrastructure.
I have nothing against physicians of disciplines other than radiology performing imaging examinations – in those cases where it is professionally done and where it is necessary. Some non-radiologists are better radiologists than some radiologists.
1. Hauser, BJ: Testimony before the Subcommittee on Health of the House [of Representatives of the United States of America] Committee of Ways and Means. Hearing on Medicare “Self-Referral” Law. 13 May 1999.
2. World Health Organization: World Health Report 2000. WHO Geneva, Switzerland. Press Release. 21 June 2000.