"Medical brokerage" deals flourish in Jordan
(Part 1 of 2)
This is the first-part of a special investigation revealing enormous legal violations in the Jordanian medical sector.
Patients are overcharged for medicines, and undergo surgeries they do not need.
Hidden camera recordings reveal doctors striking deals with taxi-drivers for bringing in patients.
Amman – (Al Ghad newspaper and Radio Al Balad) “This is catastrophic!” the dentist screamed as he examined Um Ahmad’s teeth. “How could you leave them like this all these years? Had you not come to me, your teeth would have dropped right into your hands!”
Um Ahmad, a 55-year old Algerian, was very sacred to hear this ghastly prognosis, but she was even more terrified when she heard the cost of her treatment. The dentist, who works from a private clinic in Amman, told her she needed 20 transplants and 28 porcelain crowns for 30,000 Jordan Dinars. This was outlined in the medical report given to Um Ahmad and signed by the doctor, a copy of which we have obtained.
Good doers – or “awlad el halal” as Um Ahmad describes them in Arabic – dissuaded her from getting treatment at that clinic, and warned her that both the ‘diagnosis and fees were exaggerated.’
We showed Um Ahmad’s medical report to the chairman of the Fees and Wages Committee at the Jordan Dental Association, Dr. Imad Al Zu’bi, who confirmed that “the maximum total cost of all the medical procedures listed in the report, according to the Association’s Fees Chart, amounts to around 13,000 Jordanian Dinars”.
This means that the clinic was going to overcharge Um Ahmad by 17,000 Jordan Dinars.
We contacted the clinic several times, as well as the doctor who signed off on the report, to get a clarification. We also faxed a letter to the administration of the hospital that houses the clinic, but no replies were given.
A professional poll conducted for the purposes of this investigation indicated that 45.2% of patients have been exploited by clinics and medical laboratories, and that 30.7% of patients were victims of ‘medical brokerage’ – deals where the doctors, laboratories and taxi drivers get a commission on patients referred by one to the other.
The private sector in the Kingdom boasts 4057 doctors working in 2866 private clinics and 61 private hospitals alongside 400 private medical laboratories.
This report – researched over the course of an entire year and published in two parts – reveals the unethical conduct of some medical clinics and private labs that overcharge patients and violate the Medical Fees Chart set by the Jordan Medical Association (JMA). It also shows how some of them conspire with taxi drivers in return for a commission – a cost which is eventually passed on to the patients – to make the patients undergo unnecessary lab tests, medical tests, x-rays and scans as well as surgical procedures, not to mention medication that they do not need. Those involved exchange favours in this manner, maximizing their profits to the detriment of the patients, who suffer both financially and medically, and damaging the reputation of the Jordanian medical sector and services along the way.
These violations occur in the absence of any monitoring, whether by the Ministry of Health or the Medical Doctors and Dentists Associations. The Ministry received less than 19 complaints between 2008-2012, the majority of which were related to overpricing of treatments, as listed in the Medical Fees Chart. In one case, a patient was overcharged by 20,000 Jordan Dinars. The toughest measure taken by the Ministry against violators was to order ‘the reimbursement to the patient of the difference’. For its part, the Jordan Medical Association received 126 complaints over the past 5 years of which only 80 (68%) were taken into consideration.
A true story
Hanan, 22, went to see Dr. D. in his private clinic in Amman, for her obesity. When she left the examination room, the receptionist asked her to pay 60 Jordanian Dinars, in clear violation of the doctor’s Fees Chart issued by the Jordan Medical Association. According to the chart, check-up fees in private clinics must not exceed 20 Jordan Dinars. An additional 4 Jordanian Dinars can be added by specialists ‘with over 20 years experience in their field.’
The clinic was unaware that the patient, Hanan, was pretending to be a patient for the purposes of this report. The author of this report (i.e: Musaab Shawabkeh) was also pretending to be a taxi driver, and he had already struck a deal with the doctor whereby he would get a 20JD commission for each patient he brought in to see him.
The doctor said: “I will give you 10, 20, 30, 40 JD for every patient you bring in to the clinic, with my blessings”. But he only struck the agreement after reassurances that the man was not pretending to be a taxi driver. “I first thought you were a Preventive Security agent. We are always afraid of the Criminal Investigation and Preventive Security authorities”.
We used a hidden camera to film our agreement with Dr. D., as well as other subsequent meetings.
After he made his diagnosis, the doctor asked us to take Hanan to a laboratory – specified by him – to conduct 6 tests at a total cost of 175JD. Among the filmed material, we have picked up over 3 lab reports ordered by Dr. D., using his own letterhead.
During our visit, it became clear that Hanan was neither Dr. D.’s first victim nor his last. In the waiting room, a Saudi man sat next to us waiting for his brother’s family to leave the doctor’s examination room.
The Saudi family was being treated for infertility and they were accompanied by a taxi driver called Abu Rashed. When the author of this report introduced himself to Abu Rashed as a “fellow taxi driver”, the former immediately started talking about the difficulties and general conditions of brokering among doctors. “This doctor pays well”, he whispered, then he reached into his pocket and took out a business card listing all his numbers and describing him as offering “taxi services”.
We tried to give Dr. D. the right to reply by sending him an official letter – which was delivered to him by courier service – outlining the allegations against him. A few days later, we received a phone call from a senior governmental official, inquiring about the matter and praising Dr. D and his professionalism. He also warned us not reveal the doctor’s name, saying that this would be tantamount to ‘defamation’.
Within a few hours, Dr. D. himself came to ‘Al Balad’ Radio Station. He denied that he overcharged patients or violated the Medical Fees Chart. He also denied having brokered any deal with the ‘taxi driver’, claiming that he had given him money out of pity. He refused to be interviewed on camera and claimed that he had kicked him out the first time they met. This, of course, contradicted what the hidden camera had documented.
A dead end!
Our hidden camera filmed Dr. D claiming that he was qualified to treat 18 conditions including; allergies, rheumatism, arthritis, diabetes, urinary and digestive tract infections, infertility, internal and pulmonary disease, hypertension, chest and heart disease.
This reporter contacted the Jordan Medical Council in order to ascertain Dr. D.’s medical qualifications. However, the JMA – which is the only institution responsible for training and accrediting doctors, and certifying specialists with Board Certification – refused to answer the author’s request, citing the 2007 Right of Access to Information Act.
In response to a complaint that was then filed with the Jordan Information Council – which is charged with ensuring the right of access to information – the JIC issued its decision number 6 of 2012 stating that the requested information was considered “protected documents” under the law.
Dr. K., a plastic surgeon, and this reporter – again disguised as a taxi driver – came to an agreement whereby the former would pay him a 15% commission – a total of 150 JD – for every 1,000 JD paid by a patient for plastic surgery, with an additional 5JD fee for every patient he brings into the clinic.
It was Hanan, again, who accompanied us to Dr. K’s clinic and fooled him into thinking she wanted a nose job. He suggested a number of hospitals with whom he works, asking her to choose one in accordance with a ‘package’ system whereby the doctor claims all his expenses as well as the hospital fees in advance and on behalf of the hospital. The cost of Hanan’s surgery, as suggested by the doctor, was to range between 1500 and 2000 JD.
The ‘package’ systemis in clear violation of the Medical Fees System number 46 of 1989, which states; “no doctor is allowed to negotiate hospital expenses in advance and on behalf of the hospital”. We tried to obtain a response from Dr. K to this but he did not respond to our calls or the letter sent to him by “registered” express mail.
When we took this to the private hospital that alleged to be involved in the ‘package system’, the hospital’s medical director responded that the small number of patients and the amount of work justified this. He added: “The hospital cannot prevent a doctor from doing this because, as far as the hospital is concerned, the doctor is as much a client as the patient is”. He asked, “How is it the hospital’s fault if the doctor agrees with the patient on a fee that differs from the standard hospital fees?”
Brokering deals is not limited to some clinics but also extends to certain laboratories.
The laboratory to which we were referred by Dr. D. offered this author – posing as a taxi driver – 30 to 50% of the total amount paid by any patient brought into the lab. We confronted the lab director with the footage documented by our hidden camera, which we sent to him by mail, but we never received a reply.
Patients are doctors and taxi drivers
Using the hidden camera, the author documented offers made by 22 out of 29 medical clinics and labs he visited on Al Khalidi Street (Ibn Khaldoun Street). All 22 were willing to pay a commission – ranging from 5JD to 50% of the total amount paid by the patient – for redirecting patients to their establishments.
Under the Jordanian Medical Constitution, a doctor is prohibited from “establishing any kind of relationship, based on brokering or rewarding others, be it fellow medical doctors, medical institutions or other supporting medical services and/or their staff, or to hire anyone who does this work”.
The President of the Private Hospitals Association, Dr. Fawzi Hammouri, commented on this by saying that the taxi phenomenon ‘did exist in the past but is nonexistent today with hospitals and doctors are now able to reach their patients at home without intermediaries, the internet having reduced its incidence because of the ease and speed with which one gets to doctors and hospitals”.
The head of the Taxi Association in the Jordanian Public Cars Union, Ahmad Dwayla, says the Union has never received a complaint regarding any brokering activities amongst taxi drivers and doctors, not in the past 35 years since its inception.
The Difficulty of obtaining detailed invoices
The Minister of Health, Abdul Latif Wreikat, says that part of the responsibility lies with the patients who should obtain detailed invoices that show the items for which they paid. This is needed for the Ministry to follow up on complaints and punish violators.
We, in turn, asked 20 randomly selected patients if the doctors gave them receipts detailing the services offered to them. 17 had never obtained any receipt whatsoever whereas the other 3 said they had obtained receipts but only after they requested them.
Upon examining 10 invoices issued by different doctors, we found five of them to be no more than abbreviations in English, making it difficult to understand what they said and another four without any details concerning the amounts paid.
Clinics without signs
The Medical Fees Chart Regulations of 2008, issued in accordance with Medical Fees System number 46 of 1989 and its amendments, are considered to be the optimal way for patients and consultants to verify the cost of the treatment. Law number 46 of 1989 stipulates: “It is the doctor’s responsibility to display the fees s/he charges, according to the approved tariffs, in a prominent area in her/his clinic”.
However, most doctors do not abide by this law.
The author of this report visited 55 specialized clinics from amongst 700 found on Al Khalidi Street and in Jabal Al Hussein, all of them were in violation of this section of the law.
This is an offense that warrants disciplinary action under the JMA’s Law and related regulations, as defined in article 8 of the Doctor’s Fees Regulation system, which states that “Violation of the rules by any doctor, including failure to display the tariffs in conformity with the law and related regulations, is deemed a disciplinary offense as defined by the JMA law and related regulations”.
The chairman of the Fee Estimation Committee at the JMA, Dr. Raef Faris, admits that the overwhelming majority of clinicsviolate the law when it comes to displaying the fees chart. At the same time, he acknowledges that the JMA does not have the staff or resources needed for such inspections, not that any complaints have been lodged with the Association in this regard.
Article number 13 of the Jordan Medical Association law of 1972 assigns to the JM Council and the Fees Estimation Committee the task of monitoring doctor’s fees as well as the resolution of conflicts arising between doctors and patients, or their guardians, over the cost of doctors’ fees.
The Professional Permits and Licensing Department at the Ministry of Health, which is in charge of licensing ‘medical clinics’ says it is not within its mandate to ensure the compliance of doctors with the Medical Fees Chart approved by the JMA or its display within the clinics. Their authority is limited to ensuring that clinics are licensed by the JMA and the Municipality, and verifying their compliance with hygienic standards and checking the accuracy of their signage.
The director of the Professional Permits and Licensing department at the Ministry of Health, Dr. Qasem Al Rahahleh, says the only institute with authority over the regulation of fees, is the JMA.
He adds that the Ministry refers all public complaints to the JMA as well as any registered violations of the Medical Fees Chart.
The author of this report examined article 47 of the Public Health Law (2008), and article 13 of the JMA Law (1972), as well as the Medical Fees Chart system, and found no clear legal text outlining the penalty for violations of the Fees Chart or failure to display it.
In an attempt to examine whether the Jordan Dental Association supervises and monitors its affiliates, we asked the Association on May 30th, 2012 to provide us with the relevant information. This included responses to four questions regarding the Association’s supervisory role, the dentists’ compliance with the Medical Fees Chart and the requirement to display it in their clinics as well as what the Association does to protect the rights of patients. Despite numerous visits and telephone calls to the JDA to follow up on our request, the Association never responded.
Therefore, we filed a complaint with the Jordan Information Council. On the 29th of August 2012, the council issued its decision approving our complaint and asking the JDA Council to provide us with the requested information. The JDA, however, still did not respond, preventing us from obtaining the required information.
Private clinics’ consultation fees amount to 80 JD’s
We accompanied a Yemeni patient called Saleh on a visit to one of the best cardiologists in Amman and when he asked the secretary about the cost of the consultation she replied “80 JD for all patients regardless of nationality”.
A random check by the author of this report of consultation fees at 20 private medical clinics in Amman revealed that consultation fees at 9 of them ranged between 30 to 80 JD, while 6 other clinics charged 25 JD, and the remaining 5 charged between 10 to 20 JD.
The Fees Chart issued by the JMA states that no consultation may exceed 24 JD and then only for specialists with more than 20 years experience after specialization.
The violations documented during the course of this investigation by private hospitals and clinics in terms of the fees they charge to their patients do not seem new. A study conducted and published ten years ago by Medical Responsibility Expert, Dr. Mohammad Shreim, reveals that 19.7% of complaints filed by patients against doctors relate to exaggerated medical charges, above the prices set by the Association.
Different ways of exploiting patients
In one gynecologist’s clinic – whose name we will not reveal because we do not have video evidence – almost every female patient has to undergo a Loop Electrosurgical Excision Procedure. The cost for this surgery is 70JD.
Um Ahmad is one patient who underwent this surgery. She was told by the clinic’s receptionist that all patients who come in to see the doctor undergo this surgery.
Pathologist Dr. Imad Ibrahim acknowledges that a lot of patients undergo unnecessary surgeries especially gastroscopy and both gallbladder and varicocele removal procedures. Stories about this abound and are witnessed by many.
Ibrahim adds: “A doctor collaborates with a surgeon, suggesting that his patient undergo surgery he does not actually need. The surgeon then makes an incision, without really operating on the patient. The incision serves to convince the patient that the doctor treated her/him and that s/he actually underwent surgery.”
For his part, the President of the Private Hospitals Association and the general director of Shmeisani Hospital, Dr. Awni Al Basheer, considers these to be isolated incidences which do not not add up to a phenomenon. “The doors are open for anyone to file a complaint.” Al Basheer also adds that the margin of error is very small and mostly involves Sudanese and Yemeni patients who come to Jordan seeking treatment but without prior planning.
Poor monitoring and registering complaints is the order of the day.
When we examined the registry of complaints at the Ministry of Health between 2008 and 2012, we found only 19 complaints related to violations of the Medical Fees Chart. The measures taken by the Ministry involved referring 7 complaints to the Jordan Medical Association for it to take its own measures; requesting that patients be reimbursed for the difference between the fees charged and the fee limits set by the JMA in 5 complaints (the difference ranging from 120 JD to 29,000 JD); 3 complaints are being processed; 3 others filed away and one complaint currently before the courts.
Patients have lodged 126 complaints with the JMA over the past five years against doctors who violated the Medical Fees Chart. 86 of them were filed away – 68% of the total number of complaints – and only 9 of the doctors were asked by the JMA to reimburse the patients for the difference in fees. The sums involved ranged from 320 to 1,310 JD.
Former Minister of Health Dr. Zeid Hamza believes that the Ministry of Health and the JMA have both failed when it comes to monitoring. He called on the JMA to be forthcoming about its inability to get back the patient’s rights, especially that the JMA’s authority is limited to giving warnings to violators.
He believes that the JMA can do a better job and feels that the problem lies with political parties being in control of the Association, making it difficult to sanction anyone who is a member of a party while it controls the Association. The reason for this is the mandatory membership in the Association which is in violation of International Charters”.
The current Minister of Health Dr. Abdul Latif Wreikat states that imposing sanctions against doctors in the private sector – and following up on their cases – is the responsibility of the JMA in collaboration with the Ministry of Health, which is able to shut down any hospital or clinic that violates the law.
JMA President Dr. Ahmad Al Armouty denies any complicity between the Association and any of its members, asserting its ability to sanction doctors who commit violations and stating that the JMA protects the rights of patients.
This investigation was conducted with the Investigative Reporting Unit set up at Radio Al Balad, with support from ARIJ.