malaysiakini: 1Care health reforms: Can one size fit all?... by Keruah Usit

1Care health reforms: Can one size fit all?

Keruah Usit
Aug 18, 11
11:36am

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After the delivery of his second child in Limbang, Sarawak, five years ago, proud father Ketua Baru, a farmer from a rural Penan community, was told to wait before he took his baby daughter Robina home.

He says the medical assistant at the counter at Limbang Hospital insisted that Ketua had to first pay the hospital bill. The sum was small - around RM10.

Ketua (left) asked for the bill to be waived. He is a subsistence farmer, with a negligible cash income, and every ringgit was precious to him. 

Ketua said the medical assistant insisted there could be no exemption, although a Health Ministry circular stipulates free treatment for Sarawakian families earning under RM700 a month.

"The medical assistant said, 'If you cannot afford to bring up your children, why do you make babies?' 

"I answered him: 'Where do you think I would get a salary of hundreds or thousands (of ringgit) from?' He told me 'you Penan people are always lying.' 

"In his mind, Penan people are really like animals. He walked into his office after that, otherwise I would have said angry words to him, I might even have spat at him," Ketua said.

Ketua is now a volunteer citizen journalist for Malaysiakini. His income remains the same, but thanks to training courses and a basic, AA battery-operated camera supported by Malaysiakini, he is now adept at making videos and conducting interviews.

He has become aware of the importance of taking note of the names of bureaucrats behaving in an uncouth manner. Ketua is creating his own record of the experiences of the Penan, a community facing encroachment by loggers, and trying to come to terms with modernity.

Ketua is also aware that local and international media are showing growing concern for the social and economic deprivation common among Sarawakian natives. .

Attempts to reach the state health director by telephone and email, to seek comments on Ketua's experience, were unsuccessful.

1Care 'nebulous and unclear'

Rural healthcare faces new challenges. 1Care is the latest manifestation of healthcare funding introduced by the government.

Under this reformed system, both private and public sectors will be funded by a national health insurance scheme, managed by government appointees and drawn from contributions from employers and wage-earners.

Briefings on 1Care have gone on throughout the nation. The briefings have been long on expositions on principles, and short of detail. It remains unclear where the funding will come from, who will manage the insurance fund, how healthcare will be rationed and which groups will be exempted, if any.

No minister has spoken on the legitimate concerns of Malaysian citizens with low incomes or without adequate documentation. Suhakam has noted large numbers of Penan citizens without MyKad.

The lack of these essential documents has affected all ethnic groups in the country, particularly among rural minority groups in Sarawak and Sabah. Promises and deadlines issued by the Registration Department to provide MyKad to these disenfranchised citizens have come and gone.

The proposal for a national insurance scheme picked up speed under the recently retired director-general of Health, Dr Ismail Merican. 

However, he was unable to provide concrete reassurance for undocumented Malaysians, or for the poorest segments of society, that they would receive free treatment under a new healthcare financing system.

No declared policy of equitable healthcare

Concerned doctors say Ismail told them that the MyKad issue had to be resolved by the Registration Department, not by the Health Ministry.

Dr David Quek, immediate past president of the Malaysian Medical Association (MMA), has on several occasions, called for concrete details and frank consultations with the public, over the proposed health funding reforms.

"We (in the MMA) lament the fact that up until now, Malaysia still does not have a declared policy of equitable healthcare for all... ideally healthcare should be freely accessible for all, regardless of ability to pay, and should be based entirely on the basis of need.

"Slogans such as 1Care remain nebulous and unclear, and are not convincing enough to encourage acceptance by our citizens, and certainly in the current form, not by the medical profession," Quek wrote last February.

Despite Quek's warning, no public dialogue on proposed 1Care reforms has ensued, and details have remained jealously guarded by the government.

Doctors and citizen groups, Quek asserted, are anxious that leakages, "already legend with many government and government-linked entities", would waste more money and shrink even the meagre benefits present under the current system.

Other healthcare professionals have expressed similar concernsthat the agency overseeing the healthcare fund would have enormous opportunities for largesse and corruption. 

Yet most of the debate over the proposed healthcare funding reforms, held by civil society groping in the dark, continues to centre on the issue of choice.

Urban Malaysians are concerned over their liberty to consult any family doctor. Many are worried general practitioners will be designated for them, in imitation of Britain's National Health Service. 

Others are also worried that they may be deprived of more expensive investigations or treatments, under a rationed 1Care scheme.

But in Limbang, as in many other poorer parts of Malaysia, most members of the public have never enjoyed the luxury of choice.

KERUAH USIT is a human rights activist - 'anak Sarawak, bangsa Malaysia'. This weekly column is an effort to provide a voice for marginalised Malaysians. Keruah Usit can be contacted atkeruah_usit@yahoo.com

FMT: ICare medical scheme – a crony treatment?

ICare medical scheme – a crony treatment?

FMT Staff

 | July 25, 2011

Private practioners nationwide are concerned about the government scheme, which they fear will only benefit a few private companies.

TAWAU: A proposed medical insurance scheme by the government has raised concern among private practioners here and across the peninsular.

Suspicion has risen over the 1Care scheme which many believe will only benefit a few private companies at the expense of patients and doctors.

The doctors fear that healthcare expenses will increase as 1Care will become a monopoly through a giant managed-care organisation (MCO).

Although the government is yet to reveal the full details of the 1Care scheme, initial disclosures have raised concerns.

According to doctors here, in theory the scheme appears to save money for the consumers but in reality it is otherwise.

“It should save consumers from having to pay out of their pockets for their primary healthcare and thus protect them from excessive healthcare expenses, but in reality 1Care will come under a new company and thus a middleman.The middle man will profit from patients and their caregivers.

“This will result in healthcare costs going up, the standard of treatment may drop and the public will be burdened with a new healthcare tax,” said a private doctor who requested anonymity.

The doctor said most fraternity members are worried that their ability as medical practioners to provide quality medical care will be compromised by the scheme which will collect fixed funds from all working adults and their employers.

They are also preparing to face criticism from the establishment who may see their opposition to the plan as trying to protect their income first.

Scheme may lead to ‘undertreatment’

Meanwhile in a letter obtained by FMT, a group of doctors from the peninsular have also listed their concerns and are urging the government to engage all parties, including patients and the public before deciding to introduce the scheme.

They said it is important that dialogues be intiated and stakeholders respond to valid questions on the scheme.

Spelling out their concerns and worries, former Penang Medical Practitioners’ Society (PMS) presidents Dr Ong Hean Teik and Dr Haniffah Abdul Gafoor along with ex-Penang branch leader of the Malaysian Medical Association Dr SP Palaniappan, said the scheme is being promoted as having an immediate impact on improving the country’s healthcare system while also addressing the poor government medical facilities in Sabah and Sarawak.

“The experience worldwide is that a fixed capitation fee per patient will lead to inadequate and under-treatment since physicians tend to conserve resources to prevent financial loss.

“Although patients do not directly pay for their treatment, they are still indirectly paying since a portion of their income will automatically be deducted and given to the insurance company running this programme.

“Instead of spending only for their healthcare, patients are actually contributing to finance the operation of a private insurance corporation,” the doctors noted in their letter.

The doctors believe that to qualify for the scheme, they may have to buy computers and software from a designated supplier and also pay for certification.

“This appears to be a business model guaranteeing profit for the computer programme seller and the body providing education/certification of doctors.

“Patients don’t pay for drugs, which will be prescribed by doctors only from a standard list, and can also be dispensed at participating designated pharmacies. Clinics and pharmacies will then collect payment from the insurance corporation.

“Patient treatment will be limited to only these approved drugs, and any other drugs used will be paid fully by the patient out-of-pocket,” the letter noted.

Patients may pay more

The doctors said that while patients need not pay, quality of treatment will drop since the range of drugs will be limited.

“There is a monopoly in deciding which drugs get onto the approved list and profit will be guaranteed for the company supplying and manufacturing these drugs. Patients will be registered with a particular doctor and treatment must be only from this doctor.

“If a patient chooses to see another primary care doctor or if specialist treatment or hospitalisation is needed, patients will again pay out-of-pocket.”

The doctors said patients will no longer be able to seek a different primary care doctor, even if they travel to another town or if the initial treatment is ineffective.

“Since the scheme does not cover specialist and hospital costs which are far higher than primary care charges, patients may actually end up paying large out-of-pocket fees despite contributing to the new insuring company.”

malaysiakini: 1Care: Unhealthy lack of public engagement... by Dr Helmy Haja Mydin

1Care: Unhealthy lack of public engagement

Dr Helmy Haja Mydin
May 20, 2011, 1:05pm

 

 

One of the essential features of a successful healthcare system is the presence of a well-organised primary care service that provides comprehensive services to the public that it serves.

Primary care services are usually delivered by a general practitioner(GP) and should ideally deal with a wide range of healthcare issues, from dealing with minor acute ailments to keeping a lid on the development of chronic illnesses.

In Malaysia, we tend to only visit our GPs if we are plagued by a sore throat or any other common acute illnesses. We also have a tendency to move around and not stick to a single practitioner; we tend to be satisfied as long as the costs are covered by a 'panel doctor' that is recognised by our insurance company or employer.

This is obviously disadvantageous, as a key characteristic of primary care is continuity - the GP is meant to act as the gatekeeper to secondary care services, and also plays the role of the family physician.

There is reason to believe that the Ministry of Health has plans to reconfigure the primary care landscape. There will be focus on a number of areas, namely policy development and program direction, comprehensive primary care services and benefit packages, quality assurance and performance indicators and last, but not least, human resource development and training.

With the latter issue, it is worth noting that there are less than 400 qualified GPs who are registered with the National Specialty Register, with another approximately 8,000 practitioners who will need to be trained in a recognised postgraduate course.

This contrasts with the situation in the United Kingdom, where primary care services are provided by around 36,000 GPs in approximately 8,200 practices for a population that is roughly double that of Malaysia.

These GPs carry out over 300 million patient consultations a year, and play a significant role in not only improving the lives of their patients, but also ensure that financial and human resources for secondary and tertiary services are not overwhelmed.

An integrated service would also be beneficial in helping identify areas of medicine for which more emphasis should be given or those that could be improved upon. It would also prove to be an invaluable research tool, one that will allow us to target our population appropriately, as we have a unique ethnic mix that is not replicable elsewhere in the world.

It is understandable that the government intends to restructure of our healthcare system and it will be laudable should they devolve power to the periphery. By transferring authority and emphasising the greater role of primary care, the centre of decision-making is shifted towards that of the patient, who is ultimately the main stakeholder in any shift in healthcare provision.

Unfortunately, negotiations are currently being made behind closed doors without any engagement with the public.

In tandem with this conversation, we should also place more efforts on the education of the public, as most users of the Malaysian healthcare service are not aware of their rights and access to healthcare, nor of the important role of primary care.

There is also a troubling lack of emphasis in highlighting issues pertaining to healthcare issues, as evidenced by the lack of constructive debates regarding healthcare policies.

It is therefore our hope that the government will be more forthcoming with regards to the upcoming changes in our healthcare system. For too long we have allowed our primary care services to languish in the shadows. With sufficient public support and political will, the necessary changes made will lead to a more comprehensive and accessible service for all of the rakyat.

Dr Helmy Haja Mydin is a fellow at the Institute for Democracy and Economic Affairs

malaysiakini: 1Care outpatient scheme - middlemen didahulukan?... by Drs Ong, Haniffah & Palaniappan

1Care outpatient scheme - middlemen didahulukan?

Drs Ong, Haniffah & Palaniappan
Apr 19, 2011, 2:29pm

 

The government is introducing a new financing scheme for primary care (1Care for 1Malaysia) by forming a private company/corporation to act as an insurance company and managed-care organisation (MCO). We believe this company will:

i) collect funds from all working adults and employers

ii) pay for all primary care expenses ie. for outpatient visit, test and medication at both private and government clinics

In theory this scheme will save consumers from having to pay out-of-pocket for their primary care and thus protect them from excessive healthcare expenses. In reality the new company may become a middle man profiting from patients and their caregivers, with the result that healthcare costs go up, standard of treatment may drop and the public is burdened with a new healthcare tax.

We foresee these problems may arise:

i) Doctors will be paid an annual fee to look after a designated number of patients on their list. This fee is for medical consultation and service only, excludes drugs and tests, and is fixed annually.

If the needed medical attention exceeds the capitation amount, patients have to pay out-of-pocket. At the same time, doctors can continue seeing other fully paying patients.

The experience world-wide is that a fixed capitation fee per patient will lead to inadequate and under-treatment since physicians tend to conserve resources to prevent financial loss. Although patients do not directly pay for their treatment, they are still indirectly paying since a portion of their income will automatically be deducted and given to the insurance company running this program. Instead of spending only for their healthcare, patients are actually contributing to finance the operation of a private insurance corporation

ii) To qualify for the scheme, doctors may have to buy computers and programs from a designated supplier. Doctors also may have to pay an educational provider who will then certify them fit to enter and continue in the scheme. The educational provider may have a monopoly on assessment. No other form of present activity such as journal reading, conference attendance or presentation, will be considered appropriately educational for participation in this scheme.

This appears to be a business model guaranteeing profit for the computer/program seller and the body providing education/certification of doctors.


iii) Patients do not pay for drugs, which will be prescribed by doctors only from a standard list, and can also be dispensed at participating designated pharmacies. Clinics and pharmacies will then collect payment from the insurance corporation. Patient treatment will be limited to only these approved drugs, and any other drugs used will be paid fully by the patient out-of-pocket.

Patients need not pay, but quality of treatment will drop since range of drugs available is limited. There is a monopoly in deciding which drugs get onto the approved list and profit will be guaranteed for the company supplying and manufacturing these drugs.

iv) Patients will be registered with a particular doctor, and treatment must be only from this doctor. If patient chooses to see another primary care doctor, or if specialist treatment or hospitalisation is needed, patients will again pay out-of-pocket.

Patients can no longer seek a different primary care doctor, even if they travel to another town or if the initial treatment is ineffective. Since the scheme does not cover specialist and hospital costs which are far higher than primary care charges, patients may actually end up paying large out-of-pocket fees despite contributing to the new insuring company.

v) Hospitalisation cost actually accounts for the bulk of a country's medical expenditure. In Malaysia, in 2008, the government is responsible for 78 percent of total hospital beds in the country and accounts for 74 percent of total admissions.

Yet the government spends only 44 percent of the total healthcare expenditure in the country; private hospitals see only 26 percent of total admissions, yet use up 56 percent of total healthcare spending. Under-funding and excessive work has led to unsatisfactory patient service in government hospitals, forcing patients to seek attention from private healthcare. If efficiency and service in the government hospitals improve, patients will not have to seek treatment from the expensive private sector.

The government must improve service in their hospitals. If government hospitals can cater effectively to patient needs, the private hospitals will be forced to lower prices to compete and attract patients, as has happened in Singapore.

A national healthcare financing scheme that increases investment in public hospitals will thus automatically lead to a lowering of fees in the private hospitals. This will then greatly reduce total healthcare spending for the whole country since hospitalisation accounts for the bulk of healthcare expenses.

To seriously reduce national healthcare spending, the government must develop a financing scheme to increase public hospital investment and improve its service. How can the setting up of a private corporation to act as an insurance company cum MCO reduce overall health spending? Have not hospital bills in the private sector escalated with increasing health insurance and middle-man MCOs?

In no other country in the world has the government started a financing scheme for outpatient clinics before dealing with the more expensive and more important problem of hospitalisation cost.

Suspicion is thus raised that this scheme may be to benefit a few private companies at the expense of patients and their medical caregivers. When healthcare expenses go up, everyone suffers.

Workers take home a smaller income since an increasing portion of the salary will be deducted, while business costs will rise since employers will also be forced to contribute to the operation of the private insuring company.

Details of the 1Care scheme have not been fully revealed but we list above our concerns and urge the government to engage all parties, including patients and the public, to respond to valid questions.

The poor must not end up the big loser as we saw recently when the Private Healthcare Act was used to close down charity dialysis centres. It is our duty as responsible citizens to try to look after the sick irrespective of income level. Since the government derives its revenue from all tax-payers, it must not seek to profit from its activities, but develop a system to protect the health of all, especially those unable to pay for their own needs.


This is a joint letter by Dr Ong Hean Teik and Dr Haji Haniffah b Haji Abdul Gafoor, former presidents of PMPS (Penang Medical Practitioners' Society), and Dr SP Palaniappan, former chairman of MMA (Penang branch).

Health Reform: Why We Need Caution & More Meaningful Dialogue (Part 1)... President's Message, Berita MMA, Feb 2011 Dr David KL Quek

Health Reform: Why We Need Caution & More Meaningful Dialogue

(Part 1) 
This has now been published in The Malaysian Insider, 8 Feb 2011 
This is also published in Malaysiakini, 9 Feb 2011

President's Message, Berita MMA, Feb 2011

Dr David KL Quek, drquek@gmail.com

“The Government's response to its consultation on the White Paper, ‘Liberating the NHS’, was a missed opportunity to demonstrate to the profession, and others, that it genuinely was listening to the concerns that many had put forward. We are not opposed to reasoned and evidence-based change, and accept that there needs to be some improvement to the way services in England are planned and run, but it is our duty to speak out when we can see the NHS we care about and work in being put at risk.

“Whilst we support proposals to increase clinical involvement in the design and delivery of healthcare, enable greater public and patient involvement and put the focus on quality and outcomes, rather than crude targets, we have real concerns about other aspects of the planned reforms. In particular, the lack of detail in many areas, the increasing emphasis on competition and the market, and the significant risks created by the process of rushed and unnecessarily risky transition…” ~ Dr Hamish Meldrum, BMA Council Chairman on the NHS Reform[1]

‘Health For All’ 11 years on…

In 1999, The MMA published a monograph on ‘Health For All’, a document, which was intended to promote and urge for a more systematic approach to our healthcare.[2] The MMA leadership then and even now, felt that Malaysia could do better by enhancing our healthcare system so that health equity can be assured for everyone residing in Malaysia—a single payer model was proposed as a possible approach towards ensuring this objective.

In that document, we discussed the dichotomous public-private divide, which was seen as wasteful and occasionally leading to lack of access or affordability for some of the less endowed, the marginalized and those encountering catastrophic ailments.

We lament the fact that up until now, Malaysia still does not have a declared policy of equitable healthcare for all (although in reality the huge healthcare subsidies are considered by many to approach such a system). Ideally healthcare should be freely accessible for all, regardless of ability to pay, and should be based entirely on the basis of need.

Although the social aspects and ideals were widely discussed in this monograph, there was a distinct slant towards social equity taken in the context of the prevailing socioeconomic circumstances then. There was and still is that great need for courageous and prudent leadership in addressing structural as well as financial reform when it comes to healthcare.

Health Systems Malfunction—a Global phenomenon

Simply put, the past 2 decades have seen the unraveling of many health systems even among the richer first world economies globally. Healthcare costs have simply outstripped all economic projections and segued onto exponential trajectories, causing severe strains on national budgets.

Healthcare issues continue to arouse deep-seated partisan passions and disagreements that have become so central as to even destabilize and/or derail governments and leaders! This global phenomenon is now a core sociopolitical issue debated in every nation, rich or poor.

The USA has been struggling with the more inclusive but mandated aspects of Obamacare vs. the Republican Tea-Party push for autonomous patient choice (with zero or as little government intervention as possible) with no regard for the huge 49.6 million uninsured.[3] And the new conservative UK government is trying to dismantle the 62-year old NHS by offering a radical GP commissioning restructuring programme in the vain hope of reducing healthcare costs by some £15 to 20 billion over the next 5 years; this is pitting primary care GPs against tertiary and hospital care.[4]

Surprised? The USA health system is about the most market-driven ever, consuming some US$2.57 trillion (17.3% of GDP!), with arguably the most superlative state-of-the-art care, but with huge problems of inequity: neglected uninsured poor and staggeringly high costs; whereas, the UK system has been a socialized state-organised single-payer system for decades, but with increasingly unmanageable delays and queues angering even the most patient of stiff upper lip Brits!

So what is happening? Such fraying of these entrenched systems is not entirely new. The troubles within the various if disparate health systems have been brewing for some time. The costs and structural tensions have been straining about its seams for decades, and are now finally close to bursting…

So it is questionable who has got its health system right, and it now begs the urgent question that “if it ain’t broke, why change or mend it”? Because, there is no system the world over, which is of one size or one standard that fits all!

Knowledge Economy empowers greater personal choice and demand

Stupendous technological advances, diagnostics and therapeutics, have been so well-publicised that these are creating extraordinary demands for these scarce if initially exclusive and expensive technologies, surgeries and medicines. The result: more and more ordinary people are coveting these life prolonging or health enhancing treatments, all of which are simply overshooting most conceivable health budgets!

Compounding the problem is knowledge explosion and enablement for ordinary people. The Internet and WWW has empowered huge swathes of people with information, and created even more personal demands and wants!

More often than not such ‘k’ empowerment enhances more individualistic tendencies and self-focused behaviour.

That is a given. Knowledge begets personal power. Everyone has become more self-centred and more consumerist. Many are exposed to being more concerned as to individual rights, health and medical possibilities and ‘cures’ for themselves and their loved ones. Many would seek Medicine’s best and especially last gasp therapeutic measures, regardless of costs or actual longer-term benefits.

So, how do we tell different groups of people that not everyone can have everything that he or she desires, especially in the current pervasive free market consumer-driven economy? Open society means non-filtering of data, which in turn means unfettered diffusion of knowledge to all who wish to access such information.

How do we explain self-restraint and eschew selfish demands to instantaneous gratification for quick diagnosis, testing and treatment? Who is to say which patient deserves to be seen first or cared for sooner? Who would have to wait and possibly suffer more pain and/or delayed complications, etc.?

How do we balance such growing demands for better, more select, more costly healthcare for a few, against the greater need for wider lower level primary care for more? How do we damp down these rising costs without appearing to curtail the free-spirited advances of medicine, of science, or the freedom to choose by patients?

Rationalising the need for Reform is not universally an accepted given[5]

How do we persuade medical professionals and patients alike, that perhaps primary care gate-keeping is the way of the future? Would top-down edicts or dictates work? Would our society tacitly allow such a prescription of radical change without adequate consultative debate or choice?

In this day and age, it would be foolhardy to expect that such changes can be brought about without adequate buy in by most if not the majority of the people. This is especially so, when more uncertainties than benefits appear in the preliminary pronouncements of the government, regarding the healthcare reform plans. Slogans such as 1Care remain nebulous and unclear, and are not convincing enough to encourage acceptance by our citizens, and certainly in the current form, not by the medical profession.

Many have asked why reform now? These reforms have been proposed due to concerns that healthcare costs have been escalating, particularly private spending, that there have been too much out-of-pocket (OOP) payments, that there have been possible duplication and wastage of utility of resources, and that the divide between public and private healthcare services have widened to worrying levels.

The MOH believe that the private sector is not sufficiently disciplined or robust in addressing the growth of chronic ailments, and are not promoting primary care and health maintenance enough. The private sector is thought to be too disjointed and have not been providing holistic or family care for patients. The MOH appears unduly concerned that there have been too much doctor-hopping/shopping and thus resulting in poor continuity of care in the private sector. We have asked for specific data to prove this arguable presumption.

Indeed, we have argued that the converse is true in practice. In the private sector, although the cost is higher, more patients and their families follow up with a specific doctor or group of linked doctors, than is the case in the public sector. Most private patients have family doctors who know them and their families intimately. We agree that for the more itinerant patients who doctor-hop around, or those who do not subscribe to seeking healthcare on a regular basis, this might occasionally be a problem.

But for these groups of sporadic and difficult patients, this would almost certainly also be the case within the public sector! We know for fact, that patients following up with outpatient clinics or klinik kesihatan’s encounter a different doctor (MO) almost every time, or a medical assistant, and a different one at best! Most clinical notes and prescriptions are often hurriedly transcribed as harried doctors ‘rush’ to see through the long lines of patients! Otherwise, why should patients pay more to see private physicians, if not for greater personal and more attentive care? Also if patients were really poorly taken care of, surely market forces would dictate a discontinuation of such a failed relationship!

Notwithstanding such a preconception, the MOH understandably believes that its public sector functions more efficiently at offering this modicum of services, touting their capacity at addressing these healthcare concerns from ‘womb to tomb’. We argue that because of debatable accounting methods (which do not take into consideration, infrastructure cost or manpower support staff and wages), the public sector healthcare is more costly per patient seen than that in the private GP sector.

Proposed Gate-keeping role of Primary Care Physicians feared…

One way to reduce healthcare cost is to restrict free access to doctors by any one citizen, especially to reduce self-referral behaviour to specialists and hospital. These have been shown to have an economic conflict of interest, which leads to possible over-use of already available resources and amenities.

So if every citizen can be registered, then this would perforce discipline everyone better to follow a prescribed path of healthcare access, through a primary care physician: whether a GP or a family medicine specialist. More importantly these primary care physicians would be the de facto entry point or access person, from which to approach further secondary or tertiary care, i.e. they function as gate-keepers.

With such a system, it is hoped that healthcare costs can be better streamlined and kept under control. Direct referral to specialists or unnecessary testing or investigations would hopefully be discouraged and reduced, especially if reimbursement disincentives are inbuilt into the system.

Bypass the gate-keeping function of the primary care doctor and such medical bills will not be covered, i.e. this will have to be reimbursed personally, via costly OOP means. Government-assisted payment is only assured when the prescribed pathway is followed. Thus, the plan is to integrate the public-private sector at least at the level of primary care for a start, to create a seamless approach for all citizens.

But can such a system work, especially with our people being so used to the current ‘free access’ mechanism when seeking medical help? Do people want such a change when there would be a drastic restriction of access and care to one doctor? Do our citizens wish to be confined to one GP or FMS for all time? If not, how can anyone change doctors, and how easily can this be done? Would such GPs or designated doctors be forced down on the patients, as already happening with the issue of foreign worker medical examinations? What about free choice, second opinions, etc?

Also how much would this cost the citizen? How much would this restructuring exercise costs? How much would everyone have to contribute to the planned social health insurance (SHI)? Or would such changes only lead to additional costs and additional taxes, without enough tangible benefits or coverage, or possibly with even less access?!

These are the pressing questions and concerns, which have arisen during our dialogue with doctors and citizen groups. Many are extremely worried that leakages (already legend with many government and government-linked entities) and inefficiencies would waste even more money and shrink their already meagre benefits with the current system.

No one is willing to pay more (through the SHI), when they are not reassured that the system would truly benefit them more and reduce OOP and costs! Why change if it benefits only a few concessionaires etc.? We have to address these perceptions, these questions, before we can get support from our increasingly skeptical and knowledgeable citizens.

Practical Concerns remain unanswered

Other more practical questions also come to fore. Can we exert control efficiently enough so that duplication and overutilization of tests and services be truly truncated; that hospitals and tertiary care be services of last and evidence-based needed resort, without aggravating patient safety, endangering lives, even causing delayed therapies, precipitating or provoking complications or deaths?

Who would pay or be responsible for higher chances of medical misdiagnoses, delayed diagnoses, errors and mishaps possibly associated with such rational ‘rationing’ of healthcare?

How do we change physician behaviour that perhaps fee-for-service mechanisms may not be the best approach to rational healthcare cost reform? How do we convince professionals that they would have to accept a new reality and a possible modifying cut in fair wages for fair work based on a new paradigm? Would we be ready for case-mix DRG forms of reimbursements for health professionals as well as for corporate owners of for-profit private medical establishments?

What about the planned commissioning of healthcare services to selected consortia or regional trusts? Would these be carried out without the much-feared corruption or leakages crippling the process? Would private care survive such a change? Or would this go the way of secretive and preferential government-linked concessionaires so much a curse and exemplar of profligate waste and hiked-up costs in recent Malaysian sociopolitical discourses?

How indeed do we revolutionise an entrenched system such as ours, which can lead to probable disruption in healthcare, in reduction of choice for patients, in possible lowered and constrained professional autonomy and remuneration, as well as possible redistribution of resources and re-delineation of authority?

Clearly there is currently neither any simple solution, nor can there ever be.

Let us take the example of the current malaise in the UK’s NHS reform. Health secretary Andrew Lansley has bulldozed his way towards extremely aggressive reform plans, which are now threatening to disrupt the much vaunted if flawed NHS.

Lessons from the current NHS stalemate¹

In the wake of the financial meltdown of September 2008, The Cameron-Clegg administration seems bent on restructuring the NHS to reduce costs. This was unveiled in July 2010. Despite its purported public consultations, its rushed implementation has left much to be desired. But like most authorities, health secretary Andrew Lansley had not waited for much feedback before he unleashed the timelines or the details for the restructuring.

Sadly, this has cast a strong confrontation with the British Medical Association, which represents some 144,000 doctors in the UK. BMA, a doctors' union, argues that the NHS reform plans are potentially damaging. The rushed approach risks pitting groups of clinicians against each other, appearing to encourage competition in saving costs, which might actually be detrimental to patients’ safety. Furthermore, it is not at all assured that this will bring about more prudent use of public money to enable the NHS to save a predicted £15bn-£20bn by 2015.

The BMA warns that there are many aspects of the reform proposals which could undermine the stability and long-term future of the NHS," [6] Other critics of Lansley's strategy, such as the Royal Colleges of Physicians and Surgeons, have also warned that these measures would spell the end of the NHS in its present form.

BMA warns that changing the status of existing NHS providers to foundation trust status has threatened the character and ethos of NHS provision… Deploying more corporate entities could also destabilise the NHS, the security of its employees and their terms and conditions of service, it says.

BMA had also cast serious doubts on many of the policies, which are thought to be vital to improve NHS performance, reduce bureaucracy and improve the outcomes of treatment for patients.

In a robust message to Lansley, the BMA adds: "We urge the government and NHS organisations to focus on those areas where they can truly eliminate waste and achieve genuine efficiency savings rather than adopt a slash-and-burn approach to health care, with arbitrary cuts and poorly considered policies."

The BMA's stance questions the rationale of empowering family doctors fully with unprecedented autonomy, almost total influence over their patients' treatment, and control of the £80bn NHS budget through a switch to GP-led commissioning of healthcare, while leaving out hospitalists and specialist groups, thus leading to possible conflict and disagreements. Such a ‘divide and rule’ approach cannot hope to offer a better, more seamless health service for Britons.

Dr Hamish Meldrum, the BMA chairman, argues that doctors approve of some measures, such as patients having more say and a greater focus on outcomes. "But there is also much that would be potentially damaging. The BMA has consistently argued that clinicians should have more autonomy to shape services for their patients, but pitting them against each other in a market-based system creates waste, bureaucracy and inefficiency."

It appears that governments around the world are not dissimilar… Its pronouncements often have grave and momentous bearings on its citizens and for healthcare and medical professionals as well as for the patients and citizens!

We wait with bated breaths as disruptions and stalemate shake the very foundations in the touted NHS, which model, our very own MOH is trying to emulate!

Let’s hope common sense and a greater consultative approach emerge, with most of the grievances and misgivings given a chance to be resolved for the ultimate good of the public!

---

[1] Hamish Meldrum. New Year message from the BMA's Chairman of Council. 31 Dec 2010. http://www.bma.org.uk/representation/newyearmessagehamish.jsp (Accessed 26 Jan 2011)

[2] MMA. Health for All. 1999, Kuala Lumpur

[3] By Andrea M. Sisko, Christopher J. Truffer, Sean P. Keehan, John A. Poisal, M. Kent Clemens, Andrew J. Madison. National Health Spending

Projections: The Estimated Impact Of Reform Through 2019. HEALTH AFFAIRS 29, NO. 10 (2010). doi: 10.1377/hlthaff.2010.0788

[4] Department of Health. Equity and excellence: Liberating the NHS. The Stationery Office Limited, London, July 2010.

[5] David KL Quek. Health Reform in Malaysia: What should MMA’s Response be? MMA News, August 2010.

http://myhealth-matters.blogspot.com/2010/08/mma-news-august-2010-health-reform-in.html (Accessed 26 Jan 2011)

[6] British Medical Association. NHS reform consultations, responses and briefings. 19 January 2011 http://www.bma.org.uk/healthcare_policy/nhs_white_paper/consultationpaperswp.jsp (Accessed 26 Jan 2011)

NST: Too early to tell on 1Care, say doctors

Too early to tell on 1Care, say doctors

NST, 11.01.2011

 
KUALA LUMPUR: The Malaysian Medical Association welcomes the 1Care system initiated by Health Ministry but at the same time is uncertain whether the system is the most suitable one for the country.

MMA president Dr David Quek in a statement said a clearer plan on how this method of integration and implementation of healthcare services could be worked out seamlessly, was needed.

"We are unsure if the system will actually reduce the waiting time for patients because in many countries, that have similar systems, appointments to see doctors are equally long.

"While we support government's efforts to streamline and improve the healthcare system, we also look forward to a more comprehensive approach to the restructuring plans," he said.

On Sunday, Health Minister Datuk Seri Liow Tiong Lai said all private and government clinics would be integrated under the 1Care system when a blueprint was ready in two years.

Dr Quek said the blueprint should touch on every aspect of the system so that all the stakeholders, namely doctors, healthcare providers, hospitals and insurers, should be comprehensively debated and any potential problems should be overcome.

"Until this is available, it is pre-mature and may be difficult to implement the system which may lead to breakdown of the services initiated on new grounds."

The system was part of the restructuring of the country's healthcare system under the 10th Malaysia Plan which was drafted similar to the National Health Services (NHS) system adopted by the United Kingdom.

Association of Private Hospitals of Malaysia president Datuk Dr Jacob Thomas on the other hand said that it was still early to comment on the system.

"This is just a preliminary announcement by the ministry and since it was just the initial stage, I think more discussions with all the stakeholders, including the management of private hospitals, will have to take place. It will be too premature to comment on the plan," he said in a statement.

Meanwhile, Malaysia Medical Council has yet to come out with a statement on the new system. It was learnt that a more in-depth outline on the system would be disclosed by MMC within the next two days.

Read more: Too early to tell on 1Care, say doctors http://www.nst.com.my/nst/articles/20ploc/Article#ixzz1AiuiA76y

Berita Harian: Semua klinik digabung... Oleh Syed Azwan Syed Ali

Semua klinik digabung
Oleh Syed Azwan Syed Ali

BERITA HARIAN, 2011/01/10

KERATAN muka depan akhbar Berita Harian yang disiarkan 3 Januari lalu.

 

Pusat kesihatan swasta, kerajaan bersatu di bawah 1Care tingkat akses rakyat

KUALA LUMPUR: Semua klinik kerajaan dan swasta akan digabungkan di bawah Skim Penjagaan Kesihatan Nasional 1Care bagi meningkatkan akses rakyat kepada perkhidmatan kesihatan yang lebih komprehensif, selaras dengan pelan induk penstrukturan semula sistem kesihatan negara yang dijangka siap sepenuhnya pada 2013.

Melalui skim yang mengguna pakai model Perkhidmatan Kesihatan Nasional (NHS) di United Kingdom itu, kira-kira 800 klinik kerajaan dan lebih 7,000 klinik swasta di seluruh negara akan berfungsi sebagai doktor keluarga rakyat dan membuat saringan untuk menentukan sama ada pesakit boleh dirujuk ke hospital untuk rawatan lanjut.

Apabila dilaksanakan kelak, setiap individu diwajibkan memilih atau melantik pengamal perubatan sama ada di klinik kerajaan atau swasta berkenaan sebagai doktor keluarga dan mendapatkan rawatan bagi sakit biasa sebelum boleh dirujuk ke hospital untuk rawatan lanjut.

Cadangan skim 1Care dan penstrukturan semula sistem kesihatan negara itu dilaksanakan berikutan kenaikan kos penjagaan kesihatan yang meningkat setiap tahun dan mencecah RM14 bilion tahun lalu.

Menteri Kesihatan, Datuk Seri Liow Tiong Lai ketika mengumumkan butiran skim itu semalam, berkata ia akan dilaksanakan secara berperingkat dalam enam fasa dengan penggabungan semua klinik kerajaan dan swasta dalam fasa ketiga, selepas fasa menaik taraf kepakaran dan kelengkapan di klinik serta hospital kerajaan dan fasa integrasi sistem ICT klinik kerajaan dan swasta disiapkan.

Katanya, cadangan pen-strukturan semula perkhidmatan penjagaan kesihatan dibentang kepada Majlis Ekonomi tahun lalu dan mendapat persetujuan Perdana Menteri, Datuk Seri Najib Razak yang mahu Kementerian Kesihatan menyiapkan pelan induk dalam tempoh dua tahun.

“Pembaharuan itu mengambil ambil masa yang panjang untuk dicapai, tak boleh buat tergesa-gesa. (Kementerian Kesihatan) ambil masa dua tahun untuk sediakan pelan induk yang akan ambil kira pandangan semua pihak berkaitan,” katanya selepas merasmikan Galeri De HomeBiz, di Great Eastern Mall, di sini semalam.

Kenyataan Liow mengesahkan laporan muka depan akhbar ini pada 3 Januari lalu mengenai cadangan kerajaan memperkenalkan skim 1Care bagi menambah baik sistem perkhidmatan kesihatan sedia ada dengan menggunakan model NHS di UK.

Antara objektif utama skim itu ialah memberi pilihan kepada rakyat mendapatkan rawatan di hospital kerajaan atau hospital swasta tanpa mengira kedudukan sosial dan kewangan mereka, selain mengurangkan beban hospital kerajaan yang menerima pesakit berlipat kali ganda berbanding hospital swasta

Melalui cadangan itu, kos penjagaan kesihatan rakyat akan ditanggung dana kesihatan nasional yang dibiayai melalui peruntukan kerajaan (lebih 90 peratus) dengan selebihnya disumbangkan individu berkemampuan sama ada melalui potongan cukai, bayaran premium insurans atau kaedah lain yang sedang dikaji.

Dana nasional itu akan diuruskan sebuah badan khas yang akan ditubuhkan dengan kos rawatan dan perubatan asas pesakit ditanggung oleh dana itu, tetapi pesakit mungkin dikenakan bayaran bersama sebagai komitmen, bergantung kepada jenis pesakit.

Sebelum ini, beberapa pihak antaranya, Gabungan Persatuan Pengguna-Pengguna Malaysia (FOMCA) dan Persatuan Perubatan Malaysia (MMA) mahu kerajaan menjelaskan secara terperinci cadangan skim itu, terutama membabitkan aspek kewangan dan pengurusan dana kesihatan nasional.

Liow berkata, kertas cadangan skim itu akan dibentangkan kepadanya bulan depan untuk diperhalusi sebelum dibawa kepada perhatian Kabinet.

Katanya, kementerian mengambil masa menyediakan pelan induk itu kerana ada pelbagai perkara yang perlu diperhalusi, walaupun kerajaan secara prinsip mengakui mengenai keperluan menambah baik sistem kesihatan negara berikutan pertambahan jumlah penghidap penyakit tidak berjangkit (NCD) di negara ini.

Katanya, peningkatan penghidap NCD semakin serius dengan RM1.3 bilion diperuntukkan tahun lalu untuk membeli ubat, selain kerajaan menubuhkan Jawatankuasa Kabinet Mengenai NCD bulan lalu untuk mengkaji serta mengambil tindakan perlu bagi mengatasi masalah itu.

NST: Easing hospital crowds, Clinics to issue referrals under 1Care system

Easing hospital crowds
Clinics to issue referrals under 1Care system

NST, 2011/01/10
By Ling Poh Lean

KUALA LUMPUR: The Health Ministry will integrate all private and government clinics under the 1Care system for better service.

Health Minister Datuk Seri Liow Tiong Lai said it would produce a blueprint of the plan in two years.

He said under the system, patients would go to clinics, which would decide whether to refer them to hospitals.

“The system will make sure everyone receives premium healthcare. Patients can choose whether to go to private or government clinics,” he said after opening the De HomeBiz Gallery outlet at Great Eastern Mall here yesterday.
He said the ministry would carry out the system in six phases.

The first phase involves strengthening the facilities and services in government hospitals and clinics.

The second phase will cover the integration of private and government clinics.
The third phase will see the ministry making sure that all clinics serve as gatekeepers and refer cases to hospitals. This is to reduce the crowds in hospitals.

Liow did not touch on the other phases.

The system is part of the restructuring of the healthcare system under the 10th Malaysia Plan.
“We expect the blueprint to be ready in two years, but I’m not sure how long it will take to complete all phases.

“The prime minister understands that healthcare is a crucial sector and, hence, we need to study this system carefully before we can carry it out. We can’t rush into this.” Liow was commenting on a report in Berita Harian, which said the system was meant to upgrade healthcare services in the country.

It is similar to the National Health Service in the United Kingdom.

He said the ministry would get opinions and suggestions from the Malaysian Medical Association on the system.

There are about 4,000 private clinics and 800 government clinics in the country.

Last year, the government spent RM14 billion on healthcare.

Liow urged people in the high-risk group for influenza A (H1N1), such as pregnant women and elderly folk, to get vaccinated.

He said there were 16,061 H1N1 cases in the country as of Jan 8.

Read more: Easing hospital crowds
Clinics to issue referrals under 1Care system http://www.nst.com.my/nst/articles/2011011000140720110110001407/Article/#ixzz1Actd3sRP

Berita Harian: Mekanisme klinik keluarga kurangkan kos perubatan... Oleh Syed Azwan Syed Ali

Mekanisme klinik keluarga kurangkan kos perubatan
Oleh Syed Azwan Syed Ali
syedazwan@bharian.com.my
Berita Harian, 2011/01/05

Kertas cadangan guna model dipraktikkan di UK dibentang Februari

KUALA LUMPUR: Kos penjagaan kesihatan di negara ini dijangka berkurangan apabila cadangan mewajibkan setiap individu melantik klinik pilihan mereka sebagai klinik keluarga di bawah Skim Penjagaan Kesihatan Nasional 1Care dilaksanakan kelak.

Melalui mekanisme yang mengguna pakai model Perkhidmatan Kesihatan Nasional (NHS) United Kingdom (UK), individu hanya boleh dirujuk ke hospital untuk rawatan pakar dengan sokongan doktor keluarga, kecuali bagi kes kecemasan.

Mekanisme itu apabila dilaksanakan kelak akan mengurangkan kos penjagaan kesihatan yang signifikan, termasuk pembaziran ubat dan ujian makmal yang tidak diperlukan pesakit.

Presiden Persatuan Perubatan Malaysia (MMA), Dr David KL Quek, berkata ketika ini, kebanyakan individu cenderung untuk terus mendapatkan rawatan di pusat perubatan swasta kerana tidak sanggup beratur panjang di hospital kerajaan.

“Ini mengakibatkan kos penjagaan kesihatan di negara ini menjadi mahal."

Dengan menjadikan doktor keluarga sebagai ‘gate-keeper’ di bawah skim dicadangkan, pesakit tidak perlu terus ke hospital untuk rawatan,” katanya kepada Berita Harian.

Dr Quek mengulas laporan muka depan akhbar ini, Isnin lalu mengenai pelaksanaan Skim 1Care, antara lain bertujuan meningkatkan akses rakyat kepada perkhidmatan penjagaan kesihatan kerajaan dan swasta mengikut pilihan tanpa mengambil kira status kewangan mereka.

Melalui skim yang menggabungkan perkhidmatan kesihatan kerajaan dan swasta itu, sebuah dana kesihatan nasional yang dibiayai kerajaan (lebih 90 peratus), pekerja dan majikan (melalui potongan cukai, bayaran premium atau kaedah lain yang ditetapkan) akan ditubuhkan untuk membiayai kos penjagaan kesihatan rakyat.

Pelaksanaan skim itu antara lain bertujuan mengurangkan beban di hospital kerajaan dengan menyeragamkan kualiti perkhidmatan, kelengkapan, sumber manusia, caj rawatan dan perubatan antara hospital kerajaan dan swasta, sekali gus memberikan pilihan kepada rakyat mendapatkan rawatan di hospital pilihan mereka.

Difahamkan, kertas cadangan skim penjagaan kesihatan menggunakan model NHS UK sudah disediakan Kementerian Kesihatan dan akan dibentangkan kepada Perdana Menteri, Datuk Seri Najib Razak, selewat-lewatnya bulan depan.

Dr Quek berkata, ada beberapa isu perlu diperjelaskan kerajaan sebelum melaksanakan skim itu, antaranya pelaksanaan integrasi kedua-dua perkhidmatan kesihatan kerajaan dan swasta serta aspek kewangan, terutama mengenai sumbangan individu kepada dana kesihatan nasional yang dicadangkan.

Katanya, kerajaan juga perlu menjelaskan mengenai bayaran bersama yang mungkin dikenakan kepada pesakit supaya semua pihak jelas mengenai komitmen mereka, sekiranya cadangan skim itu dilaksanakan.

Ketika ini, kira-kira 40 peratus daripada rakyat Malaysia mengeluarkan wang sendiri bagi membiayai kos penjagaan kesihatan mereka di hospital atau pusat perubatan swasta.

Pada 2009, kemasukan pesakit ke 130 hospital kerajaan yang mempunyai 33,083 katil adalah 2.13 juta, iaitu 2.6 kali ganda lebih tinggi daripada 209 hospital dan pusat perubatan swasta yang mempunyai 12,216 katil serta menerima 828,399 pesakit.