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Doctors Consider Informal Payments Normal

Many patients are dissatisfied with the health services they receive, but prepared to pay doctors extra for quality care. Doctors, in turn, consider it normal to receive cash or gifts from grateful patients. However, the line can be very thin between gratitude and extortion, according to a study by Alla Chirikova, Senior Research Fellow of the RAS Institute of Sociology, and Sergei Shishkin, Academic Supervisor of the HSE's Institute for Health Economics, published in the Universe of Russia journal

Public expectations of healthcare quality have grown in the past decade, but the reality often lags behind. In addition to this, the public is increasingly concerned about informal payments to health care providers.

In their paper 'Interaction Between Doctors and Patients in Russia: Vectors of Change', Alla Chirikova and Sergei Shishkin identify two main challenges in the doctor-patient relationship, namely

  • how treatment decisions are made, and
  • how patients pay for their care.

The authors identify some of the key trends in these two areas, based on in-depth interviews with 57 health professionals, including medical specialists and regional health care administrators, conducted in the city of Moscow and in the Kaluga and Vologda Regions in 2012.

Self-diagnosis via Internet

Widely covered in western literature, informed consent is a concept that requires medical providers to fully inform every patient about their disease and available treatment options and to involve patients into decisions about medical intervention. Even where the patient's choice is different from the doctor's best judgment, the doctor should act in accordance with the patient's wishes. A review of empirical studies reveals that patients do indeed expect to receive more information and to be included in the decision-making, but relatively few doctors consistently try to develop partnerships with patients, and not much is known about the outcomes of such relationships.

This study attempted to determine whether Russian doctors follow informed consent guidelines in their practice and their attitudes towards informed consent. Most respondents had used the informed consent model and reported that the majority of their patients perceived it as the right thing to do.

However, a number of obstacles hinder the real-life application of informed consent. In particular, elderly people often are unwillingor unable to take responsibility for their own health and believe instead that it is entirely up to the doctor to make them well again.

Another limitation is the doctor's ability to engage patients in a dialogue; even consistent proponents of doctor-patient partnerships have to admit that some doctors may not have the necessary skills; younger doctors are generally more willing to engage with patients, while older and more experienced doctors often find it more difficult.

At the same time, doctors observed that more patients today are both legally literate and well-informed about their condition (mainly thanks to the internet). Some patients even tend to blindly trust the internet and expect medical providers to implement whatever the patient has learned on the web, which some doctors can find particularly annoying.

Some of the respondents said that patients often provoke conflict by demonstrating an unreasonably low level of trust in the medical profession. "Now they know all about their disease via the internet and sort of test the doctor's knowledge ... But the internet cannot teach you everything ... Even good doctors complain about the lack of patient trust ... But it is difficult to work without being trusted," noted one of the respondents, the chief of a city hospital urology department. Faced with having to convince patients that prescribed treatments are appropriate, doctors resent the lack of respect formerly enjoyed by the medical profession.

Media Undermine Doctors' Authority

Doctor view patients’ excessive expectations as yet another reason for the tensions in doctor-patient relationships. Many patients – particularly younger and middle-aged people – tend to think that a visit to the doctor and a prescription should solve all their health problems.

Patients also tend to hold their doctors responsible for the entire public health policy, including institutional and other shortcomings of Russia's health care. "Patients have been told that they are entitled to this and to that... but if the things [they are entitled to] are not available, the doctor is the one held responsible for it. It is not accidental, but a deliberate part of state policy," said a department head at the Central District Hospital in Kaluga.

Medical professionals voice many complaints, such as staffing problems, poor work conditions, insufficient time allocation for patient visits, and excessive paperwork, all of which contribute to tensions in doctor-patient interactions.

Many doctors believe that mass media also play a role by publishing stories "without sufficient understanding of the situation" and by doing so, undermine the reputation of the medical profession and help to forma negative image in the public’s mind, thus giving the patients permission to be "very disrespectful" towards their doctor.

What Is Considered a Bribe

Doctors, quite predictably, tend to blame patients for most conflicts that arise. The authors note, however, that many doctors are inattentive towards patients; extortion and poor quality of care are also common, and the medics admit it.

There are two types of informal payments in Russia's public health system: payment at a fixed rate required by the doctor and payment as gratitude.

The former means that the patient is informed beforehand of the price and decides whether or not they can afford the service. Reportedly, it is usually not the doctor who tells the price, but a nurse or another patient, and if the patient tries to pay less they may be asked to pay more. "I know of cases where the doctor would hand back the envelope to the patient saying, 'my rate is much higher'," said the chief doctor of a polyclinic in Kaluga.

In contrast, payment as gratitude is initiated by the patient who also determines the amount. Typically, payment is made upon completion of the treatment, but sometimes patients pay in advance hoping to receive better care. In a number of recent interviews, doctors consider it perfectly fine to accept any informal payments initiated by a patient who can afford it.

At the same time, a growing number of doctors favour tougher sanctions against those who set an informal price on their services and thus engage in extortion. Some in the medical community believe that doctors who extort informal payment should face strict sanctions, such as dismissal or even prosecution.

Certain doctors, however, particularly younger ones, find informal payment at a rate set by the doctor acceptable – for example, when it comes to highly skilled practitioners. "If you have a name, you can set a price on it. If a blouse can cost that much, why can’t surgery?" says a 28-year-old physician in a Moscow polyclinic.

According to the researchers, however, even payment as gratitude is not harmless and may be a barrier to access for patients who cannot afford it. The borderline between payment as gratitude and extortion is not as straightforward as it may appear from the interviews with medical providers. However, doctors are only prepared to give up informal payments altogether if the state agrees to pay them 'decent salaries'.


Author: Гринкевич Владислав Владимирович, June 02, 2014