Thursday, January 7, 2010

1M Clinic: Advice and Comments from Senior Doctors

Further Advice and Comments from Senior Doctors

Dr Steven Chow, President, FPMPAM (MMA member):

I can empathise with you the difficulties navigating through the challenges leading our medical fraternity in today's scenario.

Clearly,Klinik 1Malaysia is just another nut and bolt of a bigger political agenda. It is a political response to the issue of medical provision disparity in the urban poor. Legally and morally, the government of the day has the mandate to do so. The current public perception is that it is wrong for the private medical profession to challenge this.

When the Klinik 1Malaysia program was first revealed on Budget Day 2009 it was a body blow to the private practitioners. On the one hand, the PHFSAct and Regulations clearly requires private clinics to be manned at all material time by a registered medical practitioner. On the other hand, these 1Malaysia clinics need only to be manned by HAs and MAs. We fully agree with you and our doctors on this point and have already written earlier to express our concern regarding this irregularity.

After the launch of the PHFSAct Regulations 2006, we met the then Minister of Health on 16.8.2006 with our set of proposed amendments to the Regulations. He was absolutely supportive and the following points were categorically stated:

1.    The said Regulations simply prescribes the basic minimum standards that private healthcare facilities must adhere to by law and that these standards were applicable to BOTH private and public healthcare facilities. This was the explicit comment of the Minister in the presence of his entire senior MOH officials.

2.    The objective of the Law was not to criminalise the private doctors or to jail anyone of them.

However, the Minister did add a caveat, ie: "as long as he was the Minister" etc etc. Well, time and history has told a different story. I am afraid, history may repeat itself again with your forthcoming meeting.

The unfortunate thing is that GPs have previously been prosecuted and clinics closed when they were found to have HAs or MAs covering for them. The basic principle is that there cannot be a different set of laws for the private and the public sectors.The way forward is to push for specific amendments in the  PHFSA Regulations to specifically state that likewise  private clinics can also engage HAs and MAs.

The notice is already out for a meeting to discuss the draft amendments to the PHFSA Regulations on 12.1.2010. We need to focus our efforts on this meeting.The promised amendments are already 3 years late.

The rice-bowl of the GPs is unlikely to be significantly affected by these 50 clinics. The patients they cater for are likely to be those who are going to the government hospitals OPDs anyway. The PR line of the MOH is politically correct ie.  the scope of their function and capability will be different to that of a private medical clinic and they are there to serve a unmet social need. We can see that as a strategy, these clinics are likely to be situated in areas where the urban poor have limited access and also affordability to private care.

In a bigger picture, the livelihood of the GPs will be severely affected by the following:

1.    Private hospitals opening chains of feeder clinics under the guise of wellness screening centre etc etc 

Surprisingly, the MOH have approved the registration of such feeder clinics. This is already happening and will escalate with the developing scenario where the major private hospitals are already under GLCs. .The present laws and regulations are silent with regards to the business dealings of these hospitals.Their justification is that some university hospitals are also providing such services.

2.    Foreign enterprises opening private healthcare facilities in Malaysia and or buying up  GP/ primary care clinics with the inception of AFTA and the MRA with effect from 1.1.2010.If Malaysian doctors are too expensive to employ they may jolly well import them from lower-cost neighbouring countries.

3.    Loss of the dispensing facility of private clinics - this is being actively pursued by the pharmacist lobby and it does appear that it has the MOH sanction.To our knowledge, there is stated policy in the MOH and a roadmap is already in existence for its implementation in less than 5 years time..

4.    Incursion into the traditional medical practice by industry like private laboratories, health screening enterprises etc. including operating and running of clinics.

5.    Discounts, administrative charges,management fees etc etc extracted by MCOs. TTPs, insurance companies and all sorts of medical middlemen.

6.    Profession Fee schedule not in synchrony with rising operational cost 

What is extremely worrisome is the future implications and evolution of the 1MClinic model. The way things are going, there is nothing to prevent some enterprising private healthcare companies with the backing of GLCs to capitalise on the 1MClinic model and develop this into a full blown industry. It makes good business sense.

The stage is now set for a perfect storm when all these players get their act together.

Sadly, soon we will see the demise of the existing independent private GP system of this country that has faithfully provided for 60% of the outpatient care at an affordable cost. We are already hearing of comments by some in the MOH clamouring for the "nationalisation" of the independent private GP system.. Aren't we all "One Malaysian doctors",we have asked  "What is there to nationalise further? Why are we not treasuring a system that has worked wonderfully well for our rakyat? Why do we allow commercial entities to suck away the money that the people have diligently put aside for their healthcare?

The bottom-line is that healthcare cost will sky-rocket, the public will complain, the doctors will be blamed and the government will enact more regulations and there will yet be another cycle of self-perpetuating change.

Best wishes for your meeting.

Datuk Dr DM Thuraiappah (Chairman, AFPM):

We think we should address a fundamental question.
  1. The MOH should stop creating reactions from the profession on knee-jerk proposals from politicians.
  2. I have heard from a MOH official that the MOH does have a blue-print of the national health reforms. However, if there is a blue print, then MMA should be consulted.
  3. MMA should push for reform of the health care system by MOH divesting itself and bringing about the following:
    1. MOH to be a policy maker and monitor of regulations.
    2. Healthcare to be delivered by Primary, Secondary and Tertiary Care Trusts.
    3. The National Health Fund to be the payor for the delivery of health care.
MMA can then deal with the three institutions as and when necessary for different needs. Good uniform healthcare delivery in the nation should be a common goal and we should not be competing with each other.
I think we should put this forward as our contribution to the nation.

Dato' Dr Joseph Eravelly (Past President Academy Medicine, Malaysia): 

I have been following the many comments from leading office bearers of the MMA past and present. I am glad that the general tone is one of common sense, moderation, and not a rush to rash action.

Dr. Mohan Das’ comments are rational and needs to be studied carefully.  So also is the paper sent by Dr. Steven Chow.  

I am afraid the President should not wait to be guided by the views of the majority. The majority view may sometimes become emotional and almost mob-like. Instead as a leader he must lead.  Any crisis is an opportunity to think strategically and come up with solutions that earn the respect of your members.

After reading the many comments I thought I will add my two cents worth to everything that has been expressed. 

I believe there are two issues to be addressed here. The first is not just an incident which has generated all this heat. That incident is but a part of the larger and emerging risks of private medicine especially for GPs. Steven Chow has described these risks in some detail but does not offer solutions. 

The second issue is what the MMA can do for its members.  It requires thinking rationally and planning ahead instead of reacting to every crisis as it occurs.

Let me take the first issue. It is a fact that every doctor that goes into private practice (specialist or GP) has one primary overriding objective. That is to earn a better income for himself and his family.  He moves into the free market. He must but usually does not, understand the principle of SWOT. His limitations are imposed by the way he practices as well as by competition and the price elasticity of supply and demand.  His patients are really customers who must perceive value in paying his charges. Nowadays that customer is getting smarter and realizes that there are choices.

Businesses plan according to perceived behavior of customers.  They also use marketing tools to influence customer behavior.  Sure costs go up but clever marketing can persuade people to bear higher costs.

The business environment that the doctor works in will, and does, change. The pace of this change will quicken. Now freely available are BP sets, glucometers, and self-requested complete lab tests. Soon abdominal ultrasounds, brain scans, and even CT angiograms on-demand may become available. Consumers will also increasingly buy medicines directly from pharmacies without prescriptions or get a prescription for a small fee without consulting a doctor.  There are other dangers that have been lucidly pointed out by Steven Chow.  
Why consumers have changed is because of economics – price, convenience and speed. There is also an increasing belief that there is little value in consulting GPs. This is perhaps also reinforced by the GP himself behaving like he is selling medicines.   This is why I think it is better to give up dispensing and charge for prescriptions. 

But change in business models associated with altered consumer behavior is also affecting other businesses.  Mobile phone companies, PC makers, automobile companies, airlines, and even retailers suffer in the face of this change. They spend millions trying to anticipate and adapt not only to new technology but changing regulations by the regulator. Some die and fade from the scene.   Why then should a medical business playing in the same market complain and ask for protection. 

All these businesses play by the rules of the free market. That market is remorseless and unforgiving but generally fair and favors efficiency.   In the case of medicine especially governments will intervene if there is a sense of market failure by which I mean a failure to allocate resources efficiently according to needs.  Think Obama and his healthcare plan in the USA. 

The trigger event for today’s discourse is the implementation of 1Malaysia Clinics. As Tan Sri Ismail has said, that should not affect GPs and I agree. What is being planned in Malaysia is also occurring in different ways in the world. Let me explain.

In the US for example, for many years now nurses have been trained as anesthesiologists, and give G.A. even for brain and heart surgery operations.  At the Mayo Clinic they are using nurse practitioners to stand in for doctors on night calls with the power to prescribe and to call for tests. Technicians do bone marrow biopsies almost as if on an assembly line. Nurses and technicians insert and manage ventricular assist balloon pumps and pass pressure lines and Swan-Ganz catheters when required. These providers are trained and certified. The point to note is that it is possible to use non-doctors to do relatively sophisticated medical procedures.   It is a fact of life we must anticipate and accept. 

Compared to all these things that paramedics are being better trained to do, the work of the GP in his clinic looks like a walk in the park. To oppose the 1Malaysia proposal by the government will be tantamount to saying that better educated, better trained doctors cannot compete with nurses and medical assistants in the free market.  This argument sounds absurd.  Hence opposition to this activity should stop.

I come to my next point.  What can the MMA do for its members?  I fear that the MMA has become gridlocked in a huge bureaucracy. Most of this mess is created by doctors themselves, not the leaders.  There is nothing that the MMA seems to do for the betterment of its members.  No wonder your membership declines. 

Yet MMA is a very important organization that must be protected and enhanced.  It calls for a paradigm shift in thinking.  I have raised a few points on this line of thinking in a letter to you in August 2009. There is no point repeating everything else that I said before. The most important point worth repeating is that the MMA has Market Power.   We must understand this and learn how to use it in the free market.  

My Comments (DQ):

Thanks for all the feedback and comments. As I have said so earlier, approaches to leadership differs from one to another. 

One can opt to be autocratic, consultative, or leading by consensual direction, based on personal conviction and majoritarianism. The latter is what I practise. I do not believe I have the sole right to simply push ahead with my own opinions alone, although I may have a broader perspective than most.

Most of the points raised have actually ben raised by me in my President's pages and past editorials. But they are certainly worth repeating for those not in the know.

Regarding Steven's points of GP challenges, most if not all were enumerated in my September MMA News President's page, where I addressed the many issues which we are helping to resolve. Yes we will be fully committed to be present at the Amendment exercise for the Private Health Care Facilities and Services Act which will be held next Tuesday, where I will lead our MMA team.

I agree with Joe Eravelly that the 1M clinics will make only a very small dent, if at all, on the urban GP's financial concern, which is what I had stated at the earliest statements. 

However, this nonconsultative manner in which such policy change of task-shifting had been announced and implemented, is disturbing, and may become a very critical slippery slope from which all other government-MOH-doctor relations might in future be defined. 

If projects or policies are deemed for the so-called 'public good' or worse, for political mileage, then any authority can and will go ahead, regardless. 

I believe doctors as a group should not stand by as toothless tigers. We have to make a stand to be counted, that is my position as defined in my election manifesto, and I will pursue this if supported by my members, without fear or favour. 

Just because something is a done deal and/or foregone conclusion, if it is wrong or unacceptable, does not make it an irreparable right. It should still be opposed and hopefully rectified or modified to an acceptable compromise. This way, we move forwards with our cross-purposes being assuaged in some small ways, evolving into what we call a win-win situation. 

We must not allow our status to be continually eroded so that we can be dismissively bypassed without being consulted. Indeed we must learn to imagine the bigger picture; imagine a master plan when the entire National Health structure becomes revamped overnight, then what? 

It is a frightening scenario. But thankfully, thus far we the MMA, have been consulted on the preliminary aspects of the possible revamp embedded in the 10th Malaysia Plan.

In this day and age and especially after March 8, 2008, the Malaysian people have found a new and exciting liberated voice of empowerment--to question, to dialogue, to be counted and to help input their concerns and voices, so that a burgeoning sense of people power can be instilled into a laggard behemoth of more-of-the-same government. 

But be rest assured, we will not simply scream and shout, we will work earnestly but energetically together as best we can, but we must be counted as partners, not as mere puppets...

Although, many physicians especially specialists appear to see the 'bigger picture's and are somewhat  dismissive of the 'molehill' plight of the GPs;  my grapevine from the ground has been thunderingly loud, agitated and disturbed! I hear you all, and that is why I feel compelled to empathise with the GPs more. 

Personally, I am not in the least impacted by this issue, as of now. But I foresee a possible erosion of our strength and professional interests, if politicians and bureaucrats continue to simply enact policy changes and laws or even administrative dictates at will, without proper consultation with as many stakeholders as possible. 

A letter to the editor in The Star today, addresses a similar concern, while pointing out the shortcomings of our MA/nurses-led clinics even at our klinik kesihatans, already  so entrenched and in existence in the country. 

I believe we do have legitimate concerns, which must be resolved to the best possible compromise, with promises for greater consultation in the future. I think we are not asking too much, after all we are in this together, strange bed-fellows and all...

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