Unregulated operations by unscrupulous online health service aggregators pose grave risk to public health

The damage caused by the unchecked presence of health service aggregators online is snowballing into a major healthcare crisis which the Union and state governments can ill afford to ignore. Instead of becoming a part of the solution, they have added to the problem by pushing aggressively for tests, surgeries and healthcare services without any medical requirement or prescription.

Practo, AIWO, mFine, Pristyn Care, Call Health, Healthian, Portea, DocsApp, Glamyo Health, Zoctr, Medibuddy and KlinicApp are some such apps which advertise about doctor consultations, quick surgeries and direct-to-consumer laboratory tests.

Then, there are the online medicine-ordering services like 1mg, Netmeds and PharmEasy which enable people to bypass the prescription-only policy with ease. All of these platforms advertise personalised treatment, transparency and quality care.

This is where the trouble begins.

Akhil (name changed for privacy) in Karnataka had burns on his buttocks after a Hemorrhoidectomy (piles) surgery done by doctors working with Pristyn Care. The patient got a communiqué from Pristyn Care stating that it is a day procedure and will be done using laser and under local anesthesia.

After the surgery, there was no post-operative care and as a result the patient suffered burns. The patient had to go to another hospital to get treated again. Laser treatments are rarely recommended by doctors for anorectal surgeries such as these.

In case of another Hemorrhoidectomy patient, he ended up with an anal stricture two months after the initial surgery organised by a healthcare aggregator. The doctors at the hospital he later consulted were worried they would have to do a colostomy, but they avoided it with dilation and sphincterotomy.

In another case, the same healthcare aggregator suggested surgery for constipation. The mention of surgery scared the patient, who then approached a hospital where they advised him to improve his diet.

For a kidney stone issue, a healthcare aggregator suggested a laser surgery to Arjun (name changed for privacy) without consulting a urologist. The laser surgery was done and the stones got stuck in his pelvi-uretery junction of the kidney-uretery track. Arjun became aware of it two weeks later when he had severe pain in his flank, because of which he walked in to a hospital after the app refused to acknowledge his concerns.

In all of these cases, the apps charged almost double the existing rates for surgeries. For a piles operation, in a general ward, a hospital charges between Rs 50,000-70,000, inclusive of medicines in a patient without co-morbidities. The apps charged between 1.25 lakh to 1.5 lakh, while the national public health insurance scheme Ayushman Bharat rates for such surgeries begin at Rs 10,000.

For removal of kidney stones, hospitals charge Rs 50,000, while the apps charge upwards of Rs 1 lakh, while on the government’s Ayushman Bharat scheme, it is Rs 33,000.

Circumcision is priced at Rs 60,000 by the healthcare aggregators, when hospitals charge Rs 10,000 for a surgery such as this and it is Rs 3,000 for those availing it using Ayushman Bharat.

Their modus operandi? The healthcare aggregators have tie-ups with certain departments in certain hospitals, where after the app does the diagnosis, a doctor on their payroll is sent to the hospital to perform the surgery. After the surgery, the doctor walks away without any care and the patient is left at the hospital until he gains consciousness. At which point, if there is any immediate post-operative care, the nurse concerned does it based on the instructions of the doctor who left. Then the patient checks out.

A fee is paid by these healthcare aggregators to these hospitals for use of the premises for the surgery. In most cases, they approach smaller hospitals where either the top administration turns a blind eye towards these activities or they come to know of it only after complications in the surgery arises as it did in Akhil’s case.

His relatives and family barged into the private hospital (name withheld) demanding better services and post-operative care. It is at that point that the issue escalated as when questions were asked, the hospital found out that the doctor who performed the surgery was not on their rolls, but that from a healthcare aggregator.

Eventually, the hospital had to take a look at the patient as the healthcare care aggregator had washed its hands off the case.

“The health service aggregators – Practo or PristynCare or Healthian or MFin – have no skin in the game. Neither do they invest in hospitals nor do they have the responsibility of running a hospital, but they want the money which a patient will spend on their health in a hospital. They have conveniently created online apps and are ranked top on search websites. This whole process is against what healthcare delivery is supposed to be,” said Dr Jagadish Hiremath, CEO of ACE Suhas Hospital in Bengaluru.

Government rules prevent hospitals from advertising or soliciting for surgeries, pointed out Hiremath, but these companies live on advertising.

Such health care aggregators are feeding off hospitals and they need to be regulated. “If you remove the advertisements, these companies don’t exist. They have no physical presence except for a few labs or clinics,” he added.

It’s not just surgeries booked online that have rocked the boat. Online health aggregators have also begun operating as diagnostic and lab collection centres, especially during the pandemic, despite guidelines against it.

AIWO was offering a complete blood test package for Rs 18,000 in Chennai, while Healthian offered full body test for Rs 399. Pharm Easy’s FAQs promised that it allows you to get a test done even when you don’t have a prescription.

“The problem is getting compounded by these discounts and offers for unnecessary medically and unwarranted testing in the name of wellness/immunity packages. It is a price war to offer maximum number of tests at lowest prices which is totally meaningless,” highlighted Malini Aisola, co-convenor of All India Drug Action Network (AIDAN)

A look at the Facebook pages of all of these healthcare aggregators indicates the patients’ disgruntlement against them. There are complaints about faulty results, poor patient care and delay in results.

These online health service aggregators have added to issue of illegal pathology laboratories mushrooming all over, pointed out Dr Jagadish Keskar of the Maharashtra Association of Pathologists and Microbiologists. He reminded about the lab reports which provided fake COVID-19 test results during the Kumbh Mela in 2021.

“Illegal labs existed even before these aggregators became a nuisance. During the pandemic, these illegal labs began offering COVID-19 tests. From online listings, you can’t judge if the lab is authentic or not. We have been fighting cases against them in Maharashtra since 2005. The final order to check such labs came in 2017, but the then government did not do anything,” said Keskar.

Almost all of them have roped in big names as brand ambassadors – actor Hrithik Roshan for Pristyn Care, Amitabh Bachchan for MediBuddy, singer Guru Randhawa for Healthian, Rahul Dravid for Practo, actor Sonu Sood for mFine, actor Rajat Kapoor for Glamyo Health, while DocsApp teamed up with Neha Dhupia, Yuvraj Singh and Randeep Hooda to talk about specific health issues. MS Dhoni is the brand ambassador for Netmeds.

“They have all these famous names as brand ambassadors as if they will perform the surgeries or look at your blood in a lab. This confuses the public, who are already bombarded with too much information,” quipped Hiremath.

Consumer Drug Advocacy group All India Drug Action Network (AIDAN) argued that the direct-to-consumer advertising has to stop completely. “It is too dangerous in healthcare. Aggregators are inducing demand when people are at their most vulnerable due to the pandemic. They are pushing promotions and offers on tests and surgeries and healthcare services without medical assessment or prescription,” said Aisola.

There is a danger particularly with surgeries, contended Aisola, because this could lead to bypassing medical opinions and identifying alternative treatments. When doctors, hospitals and labs associate themselves with the aggregators, there are ethical issues too, she pointed out.

The practice of doctors associating themselves with these healthcare aggregators have alarmed several doctors’ associations. Association of Minimal Access Surgeons of India (AMASI) wrote to its members stating that any member who has made such a contract with healthcare aggregators should disengage immediately failing which a member found to be in contract thereafter may be liable for disciplinary action by regulatory authorities.

They warned that any litigation arising from such practices will not be defended by the association during legal process by way of expert opinion or otherwise.

“It jeopardises adequate clinical judgment by a trained person regarding need for surgery and decision as to the type of surgery that would be optimum for the particular patient. The apps are made for the sole purpose of making money,” said the AMASI notification.

The Bangalore Ophthalmic Society asked its members to desist from associating with healthcare aggregators such as Practo and warned that any member found doing the same would be referred to the medical council for necessary action.

A similar warning was sent out by the Association of Surgeons in India (ASI). The association warned that an alliance with mediators such as PharmEasy and Practo are illegal.

The Urological Society of India (USI) underscored that alliances with third-party mediators such as PharmEasy, Practo and Pristyn Care are illegal and noted that some of their members had already associated themselves with such brands. USI requested these doctors to disassociate themselves at the earliest.

By entering into contracts with the aggregators to grow their business and access patients, and by taking commissions, doctors are breaching their duty towards patients and not providing the appropriate care, underscored Aisola.

In the case of doctors, solicitation of patients in this manner is a violation of Chapter 6 of the Indian Medical Council (code of ethics) Regulations, 2002.

Knotted rules

The Telemedicine Regulations of 2020 released by National Medical Commission and Niti Aayog describe tele-health as the delivery and facilitation of health and health-related services including medical care, provider and patient education, health information services, and self-care via telecommunications and digital communication technologies.

These regulations also state that, “In general, telemedicine is used to denote clinical service delivered by a registered medical practitioner while tele-health is a broader term of use of technology for health and health related services including telemedicine”.

However, in India, only a registered clinical establishment, with license to operate, can run a clinical establishment to offer clinical services and clinical establishments in the country are governed by Clinical Establishments Act 2010 and Rules.

A gazette notification from the Medical Council of India dated May 12, 2020 states that telemedicine practice guidelines are designed to serve as an aid and tool to enable registered medical practitioners to effectively leverage telemedicine to enhance health services and access to all in India.

Health service aggregators offer clinical services, so they have to follow same regulations as specified under the Clinical Establishment Act.

There are aggregators who deal with healthcare products such as selling pharma drugs and medical devices online. They have to follow regulations as per the Drugs and Cosmetics Act and they have to be regulated by Central Drugs Standard Control Organisation (CDSCO).

According to rules, no business can sell drugs or medical equipments online or offline without a license from CDSCO.

This underlines that health service aggregators are offering services by subverting the law. They are operating businesses, where a license to operate the business is mandatory, by not obtaining them in the first place.

Clinical Establishments Act says online aggregators are not recognised as clinical establishments under CEA.

The National Council stated that the public should be made aware of “such illegal online health aggregators and the online lab service aggregators and service providers should have a registration number and provide information regarding the lab where the samples are being sent for testing’.

Now it gets murky. Despite these rules, BJP-ruled Karnataka government issued licenses to online aggregators under Karnataka Medical Establishments Act.

Healthian was issued license to operate lab services in two locations in Bangalore, but not for surgical treatments, which also the aggregator advertises online.

Practo was issued licence to offer surgeries only in seven locations in Bangalore.

Aisola emphasises that it is unclear if these seven locations met the minimum standards under the Karnataka CEA to be in line with the surgeries being promoted and offered. There is no easily available information about what services and facilities are offered at those locations and how they are able to fulfill criteria for registering as clinical establishments.

The National Council of CEA clearly states that there are no standards or regulations drafted for online aggregators under Clinical Establishments Act.

With this being the case, a question arises as to how the Karnataka government has been issuing licenses to these aggregators.

“We have two issues with the online healthcare aggregators. The online medicine delivery is not permitted under the Drugs and Cosmetics Act and yet they are doing it. Several medical drugs require prescription. So, how are they going to process prescriptions online and how will they understand if it is a prescription for the person who is ordering it?” asked Praveen Khandelwal, secretary general of Confederation of All India Traders (CAIT).

He pointed out that they have asked the government to create a regulating authority for e-commerce business of all types.

Most of these online healthcare aggregators don’t have any grievance redressal mechanism. There aren’t adequate mechanisms on the portals to guarantee that prohibited drugs are not sold.

“These are the basic fundamentals which need to be decided before these organisations are allowed to operate. We have sent several complaints to the government but they have not taken any action so far,” added Khandelwal.

In 2019, Maharashtra Medical Council responded in the negative to pathologist Dr Prasad Kulkarni’s RTI query asking whether a registered medical practitioner can be associated with online platforms such as Practo which allow online consultations and revenue sharing.

Pathologist Dr Rohit Jain filed writ petitions in August 2020 in the Delhi High Court against several of these healthcare aggregators for immediately banning them from collecting the diagnostic samples including the diagnostic samples for testing of COVID-19 as they misrepresented themselves as medical diagnostic laboratories.

He had submitted that the lack of regulations for online health service aggregators and its unfettered operation through the online websites were causing confusion about their legitimacy and legality.

Dr Jain had pointed out that they were testing for COVID-19 without any legal authority, accreditation by NABL and were acting contrary to the Indian Council of Medical Research guidelines.

He also submitted that the online health service aggregators were not following the Bio-Medical Waste Management Rules, were illegally advertising and soliciting patients.

The HC ordered in 2020 to take action against these illegal online health service aggregators, but the Union and state governments have failed to take action. As a result, a contempt case is being heard in the matter and it has been listed for next hearing on February 14, 2022.

National Herald sent questions to all the above mentioned health service aggregators a week ago, but got no responses from any of them. Questions were also sent to the Ministry of Health, Ministry of Commerce, Ministry of Consumer Affairs, ICMR, Niti Aayog, Indian Medical Association, Advertising Standards Council of India and National Medical Commission as all of them have a regulatory role with various provisions under which these health service aggregators operate. None of them responded. This article will be updated if and when they respond.