For Future Doctors: Either we change or we die a slow death…………[html]11th of June 2019 was supposedly a uniting day for all our GP friends in Malaysia. It was the day when our new Minister had a town hall meeting with almost 1000 GPs from all over Malaysia. It all started when the Minister made a statement about a month ago that the Cabinet has approved […]
11th of June 2019 was supposedly a uniting day for all our GP friends in Malaysia. It was the day when our new Minister had a town hall meeting with almost 1000 GPs from all over Malaysia. It all started when the Minister made a statement about a month ago that the Cabinet has approved drug price control and currently under review for implementation. This triggered an uproar among the GPs whose consultation fee is already regulated and capped under Private Healthcare Facilities and Services Act (PHFSA) 1998. Schedule 7 which controls consultation fee for GPs has capped the maximum price at Rm 35! This has been as such since 1998 but the act came into force in 2006. The hospital doctors on the other hand had a review in 2013 and Schedule 13th was amended with roughly 15% increment, starting 2014.
What are my views and take on these issues? Well, my comments, even in the past, had created a lot of negative feedbacks from fellow doctors. But as I had always said, I call a spade , a spade! Just look at the public feedback in Facebook etc when the above town hall meeting was reported. Videos of our GP colleagues venting their frustration was shown live and recorded by various media. Did you really expect the public to show sympathy? The answer is a BIG NO! For the public, doctors are sitting in a cozy air-conditioned room and earning tonnes of money! Only when their own kid ventures into becoming a doctor, hoping to live a glamorous life, they realise the actual life as a doctor! The hours of work, training, exams, risk taken, litigation etc before you can even think of earning a decent living.
Having said that, generally a doctor can still earn a living as long as they can get an internship post and complete their training. However, the era of earning tonnes of money and being “rich” is gone and going…….Our income will be similar to any other profession, allowing us to live a life. If you are still thinking that spending RM 500 000 to RM 1 million to be a doctor is going to give you a luxury life, think again! Jobless scenario is already happening in many countries.
Now, coming back to GPs. The day you open a private clinic, it is a business, period!Same goes to private specialist. In any business, there are gains and there are loss. Some businesses closes down and some businesses thrive and even become global players. Business is a business, nothing differentiates you than anyone else. Unfortunately , health is an essential service. Health and Education are 2 components in any country which should be the government’s responsibility. I have said and maintained this statement since I started this blog. Many may not know that the PHFSA 1998 was actually tabled and passed in the Parliament in anticipation of corporatisation of health care in this country. The corporatisation of healthcare aka National Health Financing Scheme was suppose to be implemented in 1999 as the last corporatisation exercise of Dr M! Everything was ready on paper.Unfortunately, the sacking of Anwar Ibrahim and subsequent reformasi etc totally shut down the plan till today.
Frankly I don’t agree with controlling of consultation fee. Let the market force decide. BUT healthcare is an essential service and thus the government need to be responsible. Thus, in Malaysia, they control it via the Malaysia Boleh way! Same goes in any other country as well. You may think that in other countries, the government do not control the consultation fee. On paper , yes but they do control it in another voluntary way. Their National Health Financing Scheme(NHFS) that pays for all the consultation/procedure fee do have a limit and standardised payment system. Anything more than that, the patient has to pay out of their own pocket. Public being public, obviously they will choose a doctor that only bills what the NHFS pays. NO one will ever want to pay out of their own pocket! In some countries, the doctors can only accept what the NHFS pays which is basically a fee control mechanism where everyone technically is a civil servant. Even in Australia, many patients prefer to visit the “bulk-billing” doctors (accepting Medicare fee) rather than cash billing doctors.
The GPs were arguing that they are only allowed to charge a maximum of RM35 for the last 21 years. Now, just look at the comments from the public in FB etc. You, me and all members of the public knows that a simple consultation and medication by a GP will cost RM 50-70 and in some cities, can even reach RM 100! Patients are smarter nowadays. Even my patients will go to a pharmacy and ask for the cost of the medications. Similarly, many cash paying patients would do that and will know the actual cost of the meds given by the GP. So, do you think they believe that you are charging only maximum of RM 35? You may argue all you want about the cost of running the clinic etc, but a business is a business! NO one cares whether you are running at a lost or not. No one believes the notion that you are providing a service to public. Didn’t you become a doctor to help man-kind and provide service (aka free service)?
I found that one of the main issue that was discussed the other day was about TPA (Third Party Administrators). Many were arguing that TPAs are only paying RM 10-15 per consultation and wants the government to make sure that they pay RM35 per consultation. Now, let’s go back to my statement above. It is a business! TPA goes around to negotiate the best deal in town. So, the person who is WILLING to take the offer will sign an agreement with the TPA. A business deal! So why are we complaining? You signed it and agreed to it but complain later? We all know that many GPs are dependent on TPAs. Almost 60-70% of a GP’s income comes from TPAs. Without TPA, many more GPs will close shop. This is similar to private hospitals. 95% of hospital admissions are medical card holders. If insurance companies go bankrupt, all private specialist will be out of jobs! That is the fact. So, TPAs can “tarik-harga” . Unless the GPs can unite and state their demands, no TPA is going to entertain your request. By 2021, the market is going to be flooded by GPs when 50-60% of doctors(roughly about 2000-3000 per year) completing their compulsory service not going to be absorbed into civil service. You think the TPA is going to symphatise you? They will be having a jolly good time of GP shopping! And don’t forget the “uberisation” of healthcare where even those who are waiting for housemanship seem to be giving “online” or phone advise!
Even if the government removes the fee schedule, how much do you think you can charge a patient? How much a patient is willing to pay out of his/her pocket? Under-cutting and bad-mouthing is going to be rampant and again TPAs will have the same modus operandi. They will continue to negotiate a deal for the cheapest possible GP. That is business and everyone wants to make the maximum profit.So, if you agreed and signed for it, you have no basis to complain. The government is not going to interfere with that.
I really felt that most of the arguments that were forwarded during the town hall meeting were emotional in nature. I was watching it live on FB and was putting myself as a member of the public. What I saw was just doctors arguing to make more money! And that was exactly how the public felt as seen in many comments on FB etc. Bringing politics into the picture made it even worst! Whatever political ideology we have, we should keep it among ourselves and should not display it publicly, as we are dealing with members of the public who may have different political ideology. Even more shocking and surprising for me was when one of the speakers rejected Universal Health Care! Lucky the MMA president came with a statement 2 days ago that MMA and all medical associations had signed Declaration Titiwangsa in support of Universal Health Care.
When 1Care was mooted in 2012, the GPs went against it as well, mainly because of dispensing separation. It was scheduled to be implemented in 2014 but the 2013 election results made it to be shelved indefinitely. We have to admit that it is the dispensing rights that the GPs have which is giving them the survival. With limited consultation fee, they make profit from dispensing medications. IF this is removed, more GPs will close shop and become unemployed. This was the reason why GPs were shocked and reacted when the Minister announced last month that drug price control mechanism will be implemented. To me, I support the drug price control mechanism. We have to look at the public and see what benefits them. Working in a private hospital, I very well know how the hospital mark-up the medication prices. Some are up to 100% mark-up, especially for inpatients. That’s the reason I don’t like to give generic medications to patients as the organisation that makes the most profit will be the hospital. The cheaper the drug, the higher the mark-up. I rather ask the patient to buy from a pharmacy via a prescription slip from me. As for a GP, having a price written at the box may reduce their overall charge.
Now, let’s come to the solution! WE have to change and move forward. We can’t be harping on the same model that we have been doing since the 1960s! The world is changing and many countries have moved on to new models. Whether these new models are better or worst is something to be decided later. We have to move to a win-win situation, for the GPs, doctors in general, government and the public. Our healthcare system is not sustainable. I have said this many times before. Two parallel system running concurrently, competing against each other for an essential service is doomed to fail. We have a public system totally funded by tax payers and a private system almost 80% funded by insurance (aka out of pocket). The insurance companies are also bleeding in billions and the only reason they are still providing medical cards is because it is mandatory under Bank Negara rules. If not, which company wants to continue a loss making business?
The way forward for a GP to have a lifeline is to have a National Health Financing Scheme which will integrate
