Tuesday, June 8, 2010

Of Doctors' professional fees, and Rising Healthcare costs

Of Doctors' professional fees, and Rising Healthcare costs

By now most of you would have heard about the distorted Bernama abstracted report which has been  overblown out of proportion regarding doctors' fees.

Unfortunately the Bernama report has selectively picked on issues by the DG and taken the interview out of context from our May issue of the Berita MMA. Bernama has selectively left out my Presidential discussions on many issues including that of fees, medical schools and graduates glut, etc.

During the AGM in Melaka, the MMA also has brought to the attention of the Health Minister YB Dato' Sri Liow, some of these issues. The fees, if revised will be upwards and not down, as these have not been revised or changed since 2002!

The question of exorbitant fees is not true, but only a problem with a small proportion of some errant doctors (<5%) where the issue of unclear or ambiguous surgical procedures have been argued by insurers as too high, but in many instances are in line with the Private Healthcare Facilities and Services Act and regulations.

The fees in the regulations (2006) were adopted almost wholesale from the MMA schedule of fees of 2002! Some insurance companies refuse to accept additional charges for more complex procedures which lead to disagreements--these are what have been referred to the MOH. But we are still sorting out the disagreements.

The press have all gone to town regarding this so-called exorbitant fees and thinking that the revision is called for to reduce the fees. This is furthest from the truth.

Doctors on the other hand are all very upset that they have always been made to be the fall guy when hospital charges are concerned.

Specialist doctors are highly trained and experienced who have undergone long and arduous training at huge financial costs, effort and personal and family sacrifices. Medical college tuition fees are among the highest of all university courses, and the best brains are usually selected for this coveted professional training. Thus, this should be a factor to remember, parents expect this better 'reward' too, at some point in the future.

This does not make us mercenary, but as doctors, most of us believe that we should be paid our due remuneration which is fair and in tandem with other similarly educated and experienced professionals such as lawyers, accountants and engineers.

Importantly our wages and earning power must be similar to those of our neighbouring countries in purchasing parity value. But most of us do believe in social responsibility and are willing to sacrifice for some of our lesser endowed patients.

A comprehensive study of the income for doctors vis-a-vis other professionals will demonstrate that our fees have stagnated or have even come down in the last decade or so. We strongly urge that the press or the government to look into this study to dispel all the mistaken beliefs that doctors are unjustifiably profiteering from their patients

The MMA is working with the MOH to work out a more comprehensive fee schedule which will address all variants and variations in the many new and unaccounted for new specialised procedures and medical therapeutic charges, to lessen conflict with insurers.

The MMA believes that health insurance companies should worry less about doctors' fees and their insurance company unrealistic profits, but more with hospital charges which are totally unregulated. By antagonising doctors and patients with unreasonable denials and delays, as well as multiple 'pre-admission', 'interim' and 'discharge' forms and clarifications, these trails of paper work only take up too much precious time of busy doctors!! If only doctors can charge insurance companies for every document requested/demanded as per legal profession, we are sure these sorts of practices will be much simplified!

Below is a statement which I have prepared for another query from another newspaper:

Professional Fees—Revisions and Amendments on the way…
It is useful to remember that the latest schedule in the Regulations was based on our MMA rates first tabled in 2002! It is already 8 years old and the health insurance / third party payer companies are still fighting to reduce and limit our fees!

We are now embarking on refining the fees schedule, which has proven to be particularly contentious with third party payers and insurance companies. Although we have stated that we would prefer this fee schedule to be removed from the regulations, the Ministry has categorically rejected this suggestion.

Our 5th Schedule (tendered to the MOH for consideration, since 2008) is unfortunately delayed due to concerns of costs inflation and disagreements with certain specialty societies, but we continue to urge that it be incorporated and updated soon, after some discrepancies have been ironed out. Doctors have been patiently waiting for this to be resolved soonest possible.

Greater detail in the itemizing of the schedule of fees would help remove misinterpretations and arguments as to the spirit of the fees chargeable by doctors. This aspect has been severely lacking in the adoption of our MMA schedule (of 2002) into the current PHCFS Regulations in 2006. This is what is mean by the DG of Health by comprehensive review of the fees for doctors--it is not to reduce the fees per se!

I am happy to note that the DG has agreed to extend our MMA initiative to revise this schedule by collectively gathering more input from all relevant societies and specialties. We hope to wrap this up before the end of the year.

Perhaps a permanent committee to revise these reimbursement guidelines and fee schedule amendments can be set up for annual review, so that these will be more timely as Ministerial regulatory directives, which do not need Cabinet or Legal clearance.

This is the method of revision practiced by more advanced countries such as Australia, the USA and even in neighbouring Indonesia, which would be fairer to all stakeholders. More regular revisions also allow insurers to estimate premium revisions more accurately, and thus decrease the hassle of inflationary worries.

Rising healthcare costs: not just professional fees but more so hospital charges
Contrary to the recent public announcement of the DG about “exorbitant” charges, the amendments being sought is to help streamline the fee structure so that ambiguities can be avoided or lessened.

The MMA does not believe that the professional fees are excessive, although there might have been isolated minority (<5%) of black sheep among the profession, who do engage in such ambiguous practices of unbundling of fees.

Some of the reasons, which have been offered are that the current fee schedule does not address rising complexity, after hours consideration, and even duration of complex procedures and direct specialist input or required presence, and extremely high medical negligence insurance premiums.

This new exercise will be to better refine  the charges so that there will be less denial of claims by insurers, or excessive charges by doctors.

In all likelihood the fee restructuring will lead to timely increase in fees, in tandem with the inflation over the years. Remember that this has been frozen since 2002!
What we urge the MOH to consider is to look into hospital fees and charges which are thus far unregulated and which is the uncontrolled bulk of the cost escalation in many private medical centres.

The MMA feels that the entry of big business corporations into the healthcare sector has been instrumental in pushing these costs increases and this has been unfairly blamed on the doctors’ fees, which are already pegged and limited by schedule.

We understand that recent corporations such as Khazanah, KPJ groups (they collectively own more than 90% of all major private hospitals in the country) are placing the performance burden of huge profit margins of some 20 to 30% on non-medical CEOs, thus leading to a variety of extraneous miscellaneous charges. This unfortunately is the unfettered role of the free market economy which is adopted by the country.

It is useful to remember that in the past, when medical doctors own and manage these centres, the profit margins rarely exceed 6 to 10%.

Thus industry-driven and profit-orientated business entities are the direct cause of the recent ballooning of costs for tertiary healthcare.

Furthermore the rising demand for luxury care and 5-star services and amenities also add to competition to provide all and sundry, in terms of expensive state-of-the-art CT scanners, MRI scanners, laser machines, etc. which have a low shelf-life but high maintenance and running costs.

It is said that in the Klang Valley we have more CT scanners, Catheterisation laboratories, and MRI scanners than the whole of Australia! This is the case of ‘kiasu’ attitude, which can lead to patient/doctor/administrator demand or pressure for overutilization of services because it is there to be used! 

Another cause is the rising medical indemnity premiums, which have grown by some 8 to 12% year or year. For obstetric and neurosurgical practices, the premiums are now more than RM 50,000 per year! There may need to be a way for doctors to factor in this charge, as already happening in parts of the USA, where a portion of the medical protection fee is levied on each procedure or patient.

We sincerely hope you will shed a true perspective on the real situation of private healthcare costs in the country. It is important to remember that all the government's health care budget is exclusively utilised for public sector healthcare needs with almost nil for the private sector.

As significant taxpayers, the MMA believes that special matching grants should also be given to the private sector doctors, esp. those who do not belong to large corporations to enhance their capacity, continuing professional development, clinical information systems, and the later possible integration of care with the public sector in due course.

Dr David Quek
President, MMA

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