The issues you’ve described in Indian corporate hospitals—particularly the revenue-driven model tying doctors’ salaries to patient billing—highlight a systemic problem in the country’s private healthcare sector. This setup, often referred to as “target-based incentives” or “fee-for-service” models, has been criticized for prioritizing profits over patient welfare. Below, I’ll elaborate on the mechanics of this system, its incentives for unethical practices, supporting data and examples, potential causes for high doctor earnings, and why challenging it remains difficult. My analysis draws from reports, studies, and discussions on the topic.

The “Horoscope” Review: How Revenue Targets Work

In many corporate hospital chains (e.g., Apollo, Fortis, Max Healthcare), consultants—typically specialists like neurologists, cardiologists, or surgeons—are not salaried employees in the traditional sense. Instead, they operate on a “fee-sharing” or “revenue-sharing” basis, where the hospital provides infrastructure, and the doctor receives a cut of the billings from consultations, procedures, and admissions they generate. Monthly or quarterly meetings, as you mentioned, review performance metrics: salary paid vs. revenue earned.

• Typical Ratios: The 1:5 ratio you cited (e.g., ₹5 lakhs salary requiring ₹25 lakhs in revenue) aligns with industry norms. Reports indicate that hospitals often expect doctors to generate 4-6 times their payout in billings to cover overheads like equipment, staff, and profits. For instance, a 2022 analysis by the Indian Journal of Medical Ethics noted that in urban corporate setups, targets can escalate to 7-10 times for high-earning specialists, incentivizing volume over value. This is often tracked via dashboards showing metrics like bed occupancy, procedure counts, and test orders.
• Incentives and Pressures: To meet targets, doctors may order unnecessary diagnostics (e.g., MRIs, CT scans) or recommend elective procedures. A 2019 study by the Public Health Foundation of India estimated that 20-30% of healthcare spending in private hospitals stems from over-investigation, driven by these quotas. Hospitals sometimes offer bonuses for exceeding targets, further fueling this cycle. Critics argue this violates ethical codes like those from the Medical Council of India (now National Medical Commission), which prohibit commissions or kickbacks.

Rising Doctor Earnings: Volume vs. Inflation

Reports of ₹35 lakhs monthly salaries for top consultants aren’t exaggerated, especially in metros like Mumbai, Delhi, or Bangalore. For context:

• High Patient Volume: In high-demand specialties, a neurologist might see 50-100 patients daily in OPD (outpatient department), plus inpatients. With consultation fees of ₹1,000-2,500 each, plus shares from admissions, this can add up. A 2023 Economic Times report profiled senior doctors in corporate chains earning ₹2-4 crores annually (₹16-33 lakhs monthly), attributing it to post-COVID patient surges and medical tourism.
• Inflated Charges: Hospitals often markup procedures dramatically—e.g., a stent costing ₹20,000 might be billed at ₹1-2 lakhs. A 2021 investigation by The Wire revealed that chains inflate bills by bundling unnecessary services, with doctors pressured to upsell. Both scenarios raise concerns: high volume can lead to rushed care and errors, while inflation exploits vulnerable patients, especially those without insurance (only ~30% of Indians have coverage, per IRDAI data).

Your example of the elderly patient with walking difficulty mirrors common complaints. Immunoglobulin therapy (IVIG) is expensive (₹50,000-1 lakh per dose) and typically reserved for autoimmune neuropathies, not mild symptoms without diagnosis. Complications like allergic reactions or infections can necessitate ICU stays, ballooning bills to ₹10-20 lakhs. Studies show IVIG overuse in neurology, with a 2020 BMJ article estimating 15-20% of prescriptions in India as inappropriate, often for revenue. This breaches “primum non nocere” (do no harm), as unnecessary interventions increase risks without benefits.

Broader Implications and Unethical Practices

This model creates a fertile ground for corruption:

• Over-Treatment Epidemic: A 2018 WHO report flagged India for high rates of unnecessary C-sections (up to 40% in private hospitals vs. 10-15% recommended), driven by revenue targets. Similarly, oncology sees overuse of chemotherapy or scans.
• Patient Exploitation: Low-income or elderly patients are hit hardest, often facing “defensive medicine” excuses (ordering tests to avoid lawsuits). Social media platforms like X (formerly Twitter) abound with stories—e.g., threads on overbilling during COVID, where families paid lakhs for ventilators despite poor outcomes.
• Hospital Defenses: Chains argue targets ensure efficiency and attract talent amid doctor shortages (India has ~1 doctor per 1,000 people, below WHO norms). Some, like Apollo, claim transparent audits, but whistleblowers (e.g., ex-employees in 2022 Mint reports) dispute this, alleging manipulated billing.

Why No One Challenges It: Bottlenecks in Reform

The system’s entrenchment stems from multiple factors:

• Regulatory Gaps: The Clinical Establishments Act (2010) mandates transparency, but enforcement is weak—only 11 states have adopted it fully. The NMC can suspend licenses for ethics violations, but cases are rare due to underreporting.
• Stakeholder Complicity: Doctors fear job loss; hospitals prioritize shareholders (many are publicly listed). Patients hesitate due to asymmetry of information or urgency. Media coverage is sporadic, and lawsuits are lengthy/expensive.
• Cultural Acceptance: In a profit-driven economy, this is normalized as “business.” A 2024 survey by LocalCircles found 62% of Indians suspect overbilling but feel powerless.
• Reform Efforts: Initiatives like Ayushman Bharat aim to cap costs in empaneled hospitals, but corporate chains often opt out. Advocacy groups (e.g., Alliance of Doctors for Ethical Healthcare) push for fixed salaries over revenue shares, but progress is slow.

Ultimately, this model undermines trust in healthcare, contributing to India’s high out-of-pocket spending (55% of total health expenditure, per World Bank). Shifting to value-based care—paying for outcomes, not volume—could help, but it requires collective action from regulators, professionals, and patients. If you’ve encountered more specifics or want dives into particular hospitals/cases, I can explore further.