TMI: What is happening to the medical profession — by Concerned senior citizen

What is happening to the medical profession — by Concerned senior citizen

July 20, 2011

JULY 20 — As I write this I am saddled with a sadness wondering if the years of hard work and effort spent at the medical college by medical students before they can be certified as medical graduates is indeed worth all the labour and time.

I have spent more than 30 years serving the people but today I am at a crossroads wondering if I am witness to the beginning of the end of the glorious and noble profession that is the medical health sciences. Sadly there are growing signs that the sacrosanct ideals of the profession seem to be fading.

My close observation of the profession — and that includes all healing sciences be it medical, dental or any other as long as healing is involved — is that the number of doctors present in this country is ever increasing. The number of hospitals is equally impressive; both government and private.

The private establishments attempt to equip themselves with the most expensive facilities in terms of style, décor and sophistication in terms of equipment for diagnosis, treatment and of course patient recovery. This must also be accompanied by patient comfort. Having said this, my observation is that the cost of patient care has become inflated to an extent that it is hugely frightening for a citizen when he/she falls ill.

Is the medical cost in tandem with the citizens per capita income or within his/her means? If a patient is struck with an illness like stroke or cancer or organ failure then the fear of not being able to meet the cost is even more frightening. If this is really the case then are the doctors still holding on to the sacred belief that their duty is to heal the patient at all costs.

Now, the phrase at all costs may be contentious for a debate but not forgetting that it is the aim of every doctor to heal the sick. If a patient cannot be healed by a doctor then it defeats the purpose of that visit and it also defeats the purpose of the doctor meeting with the patient. What does a doctor do then? Has he a choice of doing anything else to achieve that goal. This is something that is left to the doctor himself/herself.

The point I am driving at is this. Being able to come to a correct diagnosis is good and this can be obtained with expensive technology.  But is this going to make it impossible for the patient to afford this service? If it is really the case then how does the doctor adapt himself to make it possible for him to do what he is supposed to do and that is to attend to the patient and achieve the healing.

Now the question: Is healing based on all the expensive machinery and the most expensive drugs available in the market? This is something doctors must most honestly search their minds and answer. Then again I have to ask. With all the expensive machinery and drugs available, why is it that many of the diseases are still left incurable. Is cough and cold curable? How then does it get cured? Is cancer curable? Is diabetes curable? Is eczema curable? When I say cure I mean that the disease becomes non-existent.

This is what I mean. If a patient has to be on a drug on a lifetime basis then it is not a cure. The disease is still inherent with the symptoms merely being blanketed by drugs till death takes over. The aim of a doctor is to heal the sick. If the healing has not been obtained then it is only logical that the treatment could have been either wrong or insufficient.

This unfortunately is the saddest part of being a doctor. Where then is the missing link? This is food for thought. Is it the training or the modus operandi of the system that has led to this sad state? Or is there a divine anomaly somewhere that doctors have lost sight of. The answers to healing is available in this universe. It is all left to the doctors to go and look for the answers.

There seems to be blatant disregard for ethics. Advertising seems to be rampant though however hidden it may appear. Lighted neon lights are being flashed around at the place of business. Many doctors are found to be rude, arrogant, and dishonest with their diagnoses. The dishonest diagnosis is meant to scare the patient into accepting the expensive treatment. This is not a myth or fault finding but is a real happening in the market.

Doctors’ behaviour towards patients can be a rude awakening for patients. They shout, scold and threaten as if the patient can be subject to bullying at his whims and fancies.

I have personally seen and witnessed doctors being rude, disrespectful and even threatening to patients in the presence of their spouses and children. This cannot and should not be condoned.

I have seen doctors even quoting their fees to patients based on whether he/she wants a second-hand Proton or a Mercedes Benz. I have seen doctors who despise other doctors with no care for their reputation or welfare. Everyone else is wrong except himself.

The extent to which professional jealousy exists is frightening. If one doctor begins to do well in practice out of sheer dedication and hard work, then the others in the same profession would do everything to cause him/her harm. This indeed is despicable.

Are doctors waiting for the day when patients will begin to lose their patience and bring in gangsters into clinics and beat up doctors before the other patients. Please do not wait till that sad day.

Remember, the people are becoming wiser and more knowledgeable day by day due to technology. Or are they lost in their own time wrap? Time to wake up.

These days it is common for one doctor to derecognise another doctor when he/she comes for treatment. They charge fees as they like. Of course there is nothing wrong with charging a decent fee to cover costs, no sane person would deny a doctor this.

But it is the blatant mercenary attitude that I condemn. There have even been instances when a colleague has been “detained” in the clinic/hospital till the full fees have been brought by family members. How low and despicable is this.

Today, private hospitals have become a business enterprise and that is why so many businessmen have started investing in them. It costs almost half a million ringgit to become a doctor today and there one must make his or her first million in the first year of work. This seems to be the prime motivation of every medical graduate. This is shameful.

My honest suggestion is that every doctor should open their doors to cater to patients at least once a week and start healing the sick at no cost. If you can do this for the rest of your life then and only then will you realise what healing the sick really means and then you will begin to value the great and sacred virtues of the profession. Till then I offer my prayers for each one of you.

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 5^th 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