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LATEST NEWS UPDATES | How ‘surgical fraud’ counts vary-Ashutosh Bhardwaj

How ‘surgical fraud’ counts vary-Ashutosh Bhardwaj

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published Published on Jul 25, 2012   modified Modified on Jul 25, 2012

-The Indian Express

In Raipur hospitals, a joke doing the rounds these days is: “Soon, someone will file an RTI to know the number of uteruses left in Chhattisgarh.” What has prompted it is, however, no joke. If a series of media reports in the state is to be believed, the uteruses of thousands of women have been removed in unnecessary operations.

These reports talk of doctors cheating BPL families by encouraging women to undergo hysterectomy so that the surgeons can collect insurance amounts under the Rashtriya Swasthya Bima Yojna. The RSBY provides cashless insurance of Rs 30,000 yearly to a BPL family; for a hysterectomy, a doctor can charge Rs 12,500.

These “thousands” are not in black and white. The only official figure the government or any media report has so far is of prima facie “fraudulent” operations on 22 women in three Raipur villages and the nine doctors who did these. The rest is allegedly all extrapolation.

What may have been hit by such reports is the RSBY, which has actually changed the lives of many. Besides, hysterectomies comprise less than 3 per cent of all RSBY claims in Chhattisgarh since it was introduced in 2009.

Following a preliminary probe, the government has held the nine doctors “prima facie guilty” and suspended them as the women “seemingly underwent hysterectomy without proper procedure”. The final report has not yet been submitted. The government has also sought data on every operation under the RSBY in the past 30 months, though there is no plan yet to probe these as is being reported.

THE NOISE

It was Dainik Bhaskar’s story ‘Cancer ka bhay dikhakar nikale garbhashay’ (Uteruses removed invoking the fear of cancer) that triggered the first charges. The reporter, said the story, had visited Raipur villages Manikchauri, Dongitarai and Hasda and found “dozens of cases” of uterus removal, “many of whom were women under 30”. Only two “case studies” were cited — both from Dongitarai.

One of the two women, Dropadi Bai, told The Indian Express she had undergone the operation of her own free will. Her clinical records suggested she could have avoided it but in many cases, The Indian Express found, the patients knew this and still went ahead.

Dainik Bhaskar ran a series of stories on “taabadtod surgery” across Chhattisgarh and cited figures of operations on 7,000 women since the RSBY was introduced in June 2009. “We sent a reporter to the three villages. We verified the records with other doctors and found that the operations were not required,” said Rajeev Singh, Dainik Bhaskar’s state editor. “These three villages were our only case studies... It is the duty of the government to investigate, and they are. We have RSBY figures and the figures raise suspicions.”

Other papers and TV channels picked up the story, but most of their reports have been short on detail and without verification of medical reports. “Some reporters got a random sample of some women in those villages, and extrapolated the figures for entire Chhattisgarh,” additional CEO (RSBY) in Chhattisgarh Vijendra Katare said.

Prompted to act under pressure against the 22 known cases, director (health services) Kamalpreet Singh said: “We are now getting details of each of these patients. We have suspended the doctors, but a final decision will be taken only after the report (of a fact-finding committee) is submitted.” Among the 22 are many non-RSBY cases, indicating that not all uteruses were “removed for insurance”.

THE RUSH

A few nursing homes have conducted over 300 such operations each under the RSBY, and their names are routinely flashed by papers. “Yes, some new doctors are doing wrongs to earn quick money. Establish their guilt and punish them, but don’t blame all doctors. There are many reputable names also. Check their records, meet their patients before writing about them,” said Dr R S Thakur of Ojasvi Hospital in Dhamtari. The hospital is among those whose clinical records are being verified.

Among the hospitals that find themselves in the dock is Gupta Hospital in Dhamtari, which has recorded the highest number of hysterectomies under the RSBY in Chhattisgarh. A Dainik Bhaskar report noted that Gupta Hospital had 604 hysterectomies in 900 days. In comparison, it said, the government-run Ambedkar Hospital in Raipur had seven.

Says Dr Prabhat Gupta of Gupta Hospital: “Yes, we conducted the operations. As for why Ambedkar Hospital had fewer patients, please ask them. If patients trust private doctors more, is it our fault, or because of the services we provide?”

He acknowledged a massive intake of BPL families, who now constitute 80 per cent of their patients. His son Dr Sumit Gupta explained: “There is a backlog of illnesses in poor families. Once you introduce a scheme like this, there will always be a rush for treatment. It will subside in a few years.” Also, a family knows that if it does not avail of the insurance, the amount will lapse after a year.

Figures before the RSBY are not available, but all doctors agree that the scheme has led to an at least 50 per cent increase — some say 70 — in the number of BPL families going for better healthcare. “The RSBY has caused a boom in private sector healthcare. With cash in hand, poor families obviously prefer private hospitals,” says Dr Rakesh Gupta of Raipur.

Chhattisgarh has seen 2,34,215 claims under the scheme so far, of which only 6,938 are hysterectomies. “If doctors cheat patients in this relatively complicated operation, they are more likely to cheat in simpler cases. Going by media accounts, the entire scheme should be marred by fraud,” an RSBY officer said.

Dr Rakesh Gupta, however, agreed the ratio of hysterectomies to all surgeries is suspicious. Of the 6,672 RSBY claims coming to Gupta Hospital, nearly 2,500 involved operations, one-fourth of these hysterectomies. The 341 hysterectomies at Ojasvi form around one-third of its surgeries. “If a hospital conducts one-third or one-fourth of its operations only of one kind, then it raises suspicions,” Dr Gupta said.

Insurance companies also seem to have had their doubts. RSBY officers in Raipur said Oriental Insurance Company and TAP Medsave had visited Gupta Hospital and inspected its records on several occasions, but found nothing dubious. Some alleged these hospitals had reached a deal with insurance agents and they are also part of the “racket”.

NEEDED OR NOT...

The doubts about the operations emerged largely because the patients concerned did not undergo proper tests before or after. Doctors admitted some tests were dispensed with and they exercised their “personal discretion”. “We largely go by clinical judgment,” said Dr Prajwal Soni of Soni Multispecialty Hospital in Razim, Gariaband. Two branches of this hospital together saw 409 hysterectomies.

Dr Soni is among those suspended. So is Dr Pankaj Jaiswal of Sewa Sadan Mata Rani Hospital in Gariband that recorded 513 hysterectomies. These two hospitals rank second and third, behind only Gupta Hospital, in terms of hysterectomies covered by the RSBY.

The Indian Express visited some patients of the two hospitals, including among the 22 whose cases are now being probed, got copies of their clinical records, and verified them with independent doctors in Raipur. The latter said hysterectomy had not been necessary in any of the cases and medication or other treatment could have worked.

Said Dr Rakesh Gupta: “Removing such a vital organ without proper tests, and when a primary clinical examination clearly suggests it need not be removed, is not just medical negligence but criminal.”

There is another side to it. As Health Minister Amar Agarwal said, “There is no complaint so far from anywhere in the state.” The patients The Indian Express met, including those in the reproductive age between 30 and 45, confirmed this and added they had not been coerced.

In many cases, a village quack refers the woman to a pathologist or sonography centre, which then advises surgery. “There is a nexus working from village to city that pushes patients to doctors,” said endocrinologist Dr Biplab Bandyopadhyaya.

...THEY WANTED IT

There is another reason why women, especially in rural areas, opt willingly for hysterectomy. For them, the uterus is nothing but a “pouch for holding babies”, a “troublesome organ” associated with an often unwanted pregnancy and also the discomfort of menstruation. As many women of the ages 30-55 in villages and hospitals told this reporter, menstruation can be an extremely trying period, living as they do in houses without a toilet, where a shared pond is used for bathing, where sanitary pads are unavailable or rarely used, and where many taboos are associated with the process.

With husbands shying away from vasectomy or contraceptives, the women also live under a recurring fear of pregnancy. The sentiment is, “Get rid of the ‘burden’ once the family is complete”.

Devki Bai, 37, of Dongitarai had a pain in the abdomen and irregular periods for four or five years before she went in for the operation in April. Hers is among the cases being probed.

Armed with a smart card under the RSBY, Sonia Chelak of Hasda village too found it an easy option. In her early thirties, she has already had five children, including four daughters. Her husband is a labourer. She says she saw neighbourhood women opting for the operation and decided to have one too.

However, no one explains to these women the side-effects of uterus removal, such as hormonal disorders. Women confirm a gradual weakness after the operation, but would rather live with it than “suffer” the complications of having a uterus.

Dr Rakesh Gupta says that it’s the doctor’s duty to make women aware of these side-effects and to counsel them. “Let her insist. The doctor should never remove an organ when it’s not necessary," he said.

In fact, at least one major research paper on hysterectomies among women members of NGO SEWA had similar findings. As per the May 2011 paper in the international journal Reproductive Health Matters, nearly one-third of the insured women undergoing hysterectomy were younger than 35, and for them the operation was a way out of difficulties with menstruation and a range of gynaecological problems. Others didn’t want more children. “Women’s attitude towards menstruation was a significant driver in seeking hysterectomy,” said the paper.

It also found that many of the medical conditions mentioned in case of women who underwent hysterectomy were amenable to noninvasive, less expensive treatment options.

Incidentally the report covered not women in hinterland villages but Ahmedabad, among India’s most developed cities, and the insurance scheme was not a government one but that of SEWA.

The Indian Express, 25 July, 2012, http://www.indianexpress.com/news/how-surgical-fraud-counts-vary/978884/0


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