How Doctors learned to sell health packages
If you have five minutes, read the summary at the end.
If you have 10, read the whole story.
If you have ever been handed a print-out with forty-two coloured bars and wondered which two actually matter, this is about you.
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I. The Resident who said “No”
During residency, the quickest way to be humiliated in morning report was to present a slide titled “Investigations” that listed more tests than actual problems.
“Why ferritin when the iron studies are already diagnostic?” the professor would ask.
“Because the lab offers a combo?” you mumbled once.
Silence. Then: “The patient’s vein is not a buffet. One question, one test.”
We left that room convinced that minimalism was a moral virtue.
II. The Consultant who clicks “Yes”
Five years later, the same resident—now a consultant—sits in a 200-square-foot cabin with a glass door that reads “Senior Cardiologist.”
The electronic health record (EHR) flashes:
“Patient: 42-year-old male, atypical chest pain.”
Pop-up suggestion: “Comprehensive Cardiometabolic Package – 38 tests at 15 % discount. Click to authorise.”
The mouse hovers. Time remaining before the next patient walks in: 90 seconds.
Click.
III. The Anatomy of a Package
The slide that follows usually appears only in internal audits, but I managed to screenshot one:
1. Lipid profile
2. Apo-B
3. Lp(a)
4. hs-CRP
5. Homocysteine
6. HbA1c
7. Fasting insulin
8. NT-proBNP
9. Troponin-I (high-sensitivity)
10. CK-MB (for legacy insurance codes)
11. TSH
12. Free T4
13. Free T3
14. TPO antibodies
15. Vitamin B12
16. Vitamin D
17. Magnesium
18. Uric acid
19. Serum creatinine
20. eGFR
21. Urine microalbumin
22. Liver function tests (8 sub-tests)
23. Complete blood count (21 sub-tests)
24. ESR
25. Iron studies (4 sub-tests)
26. Ferritin
27. Transferrin saturation
28. Hb electrophoresis
29. Hs-Troponin re-check (because one troponin is never enough)
30. 12-lead ECG (technically not a blood test, but bundled)
31. 2-D Echo (also not blood, but hey)
32. Carotid IMT (ultrasound add-on)
33. CT calcium score (discounted only if booked today)
Total cost to the patient: ₹9 400.
Clinical yield that changes management: maybe two tests.
IV. How did we get here?
1. The Revenue Engine
In a 300-bed private tertiary care hospital, diagnostics contribute 30 % of gross revenue and 45 % of EBITDA. A single automated immunoassay analyser can multiplex 240 analytes per hour; the marginal cost of the 17th test is pennies, but the marginal revenue is full sticker price.
2. The KPI
Consultant contracts contain a line that nobody reads aloud: “Resource utilisation indices will form part of variable pay.” Translation: If the average revenue per outpatient encounter drops, so does your quarterly bonus.
3. The Insurance Buffer
Third-party administrators (TPAs) negotiate “packages” with hospitals. A patient who might have paid ₹600 for a targeted lipid profile will now have the same ₹6 000 panel reimbursed because it is pre-approved. The doctor becomes the path of least resistance.
4. The Medico-Legal Shadow
“I ordered everything because I did not want to miss anything” is now a defensible statement in court. “I ordered only what was necessary” invites the counter-question, “How can you be sure?”
5. The EHR Nudge
Machine-learning order sets learn from past behaviour. The more you click, the more the algorithm suggests. In behavioural economics this is called a “default bias.” In hospital economics it is called “growth.”
V. The Government teaching hospital paradox
Residents there still hand-write requisitions with a blue ballpoint pen. Each test needs a consultant’s countersignature the next morning. You would expect minimalism to thrive.
Yet even here, creep has begun.
Reasons:
a) Research panels – “Let’s add one extra tube since we are already drawing blood.”
b) Routine pre-op bundles – easier than individual justification.
c) Free tests – when the hospital absorbs the cost, the moral brake loosens.
VI. The hidden patient tax
Assume a 30-year-old software engineer walks in with fatigue.
Residency era: CBC, TSH, ferritin. Total ₹900.
Consulting-room era: Master health check-up ₹6 500.
Opportunity cost: the same ₹5 600 could have paid for two months of gym membership, five therapy sessions, or a week of unpaid leave—each of which might have cured the fatigue.
VII. The diagnostic chain’s business model
Global chains run on throughput. The phlebotomist who draws 120 patients between 6 a.m. and 10 a.m. unlocks volume discounts on reagents. The leftover plasma is bar-coded for future research sales. The consultant who orders extra tests is not corrupt; she is simply the last unpaid node in a vertically integrated supply chain.
VIII. Conversations I have had
1. With a 28-year-old anaesthesiologist who moonlights in a corporate lab:
“I get ₹40 for every extra analyte I add under the ‘research grant’ column. It pays my EMIs.”
2. With a 55-year-old professor in a government college:
“We teach residents evidence-based medicine by day. By night, the casualty MO orders a ‘sepsis panel’ because the machine is idle and the Dean wants utilisation numbers.”
3. With a 45-year-old patient who brought a suitcase of reports:
“Doctor, I just wanted to know if my cholesterol was okay. Why do I have vitamin D, K, and something called homocysteine?”
I had no answer that fit into the seven minutes the scheduler had allotted.
IX. The Morality Play
We enter medicine swearing primum non nocere—first, do no harm.
We exit residency swearing primum non expendere—first, do not waste.
Between the two oaths lies the unspoken third: primum non lucrum—first, do not profit.
The architecture of modern healthcare makes the third oath the hardest to keep.
X. Four experiments that reversed the trend
1. Display the Price at the Point of Order Entry
A private hospital in Mumbai piloted a pop-up that showed the out-of-pocket cost of every add-on test. Low-value orders dropped 18 % in three months.
2. Reverse KPI
A Bengaluru chain tied 5 % of consultant variable pay to “avoided tests” benchmarked against historical baselines. Revenue dipped 2 %, patient satisfaction rose 12 %.
3. Resident Stewardship Rounds
Government medical college in Kerala let senior residents present weekly audits of outpatient investigations. Faculty graded appropriateness; the winning team got conference travel grants. Unnecessary tests fell 22 %.
4. Patient Co-Decision Aid
A Tamil Nadu insurer mailed every policyholder a one-pager: “These four tests are enough for annual wellness. Anything more—ask why.” Claims ratio fell 7 % without adverse events.
XI. A Modest Proposal
Imagine an EHR prompt that asks three questions before letting you sign the order:
1. Will this test change management today?
2. Has this patient already undergone this test in the last 90 days?
3. What is the cost to the patient if insurance denies coverage?
If the answer to question 1 is “No,” the system refuses to proceed unless you type a 50-character justification that is automatically sent to the patient’s mobile.
XII. The Way back to One Test, One Question
We will not reclaim minimalism by preaching austerity. We will reclaim it by redesigning incentives:
• Decouple consultant income from test volume.
• Make utilisation data transparent to the public.
• Reward residents for NOT ordering tests, not for ordering them.
• Teach patients to ask, “What will this number change for me today?”
Until then, the resident who once said “no” will keep clicking “yes,” and the diagnostic chain will keep printing barcodes that neither the doctor nor the patient fully understands.
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Summary (for the five-minute reader)
If this post makes you pause before your next click, tag a colleague who needs to read it.
#MinimalMedicine #ValueBasedCare #DoctorsForPatients