Much has been written in this blog about the future of medical graduates, the declining quality of products, oversupply of doctors and the eventual unemployment of graduates. The world is undergoing many changes. Wars are breaking out everywhere with extremist killing innocent people in the name of race and religion as well as territorial fight. Malaysians are only interested in Gaza but forgotten the fact that Syria has killed almost 170 000 of their own citizens, Boko Haram is killing their own citizens in Nigeria and ISIS in Iraq killing Christians who refuse to convert or leave. The Ukrainian crisis would not have come into the spotlight in Malaysia if not because of MH17! When people ask me why I don’t support Palestine openly, I ask them why they never bothered about what is happening in the rest of the parts of the world. Why people never marched to the Syrian embassy? Why don’t people march to the Arab country’s embassies for not helping the Palestine? Historically, more Muslims have killed Muslims compared by anyone else. I support humanity and that’s why I am a doctor! I condemn any atrocities no matter where it happens and who is involved. I do not support any particular race or religion or country. In fact, we may end up like them if our PM does not act as a leader in condemning the racial and religious bigots who are running amok in this country at the moment.
Now, coming back to the topic above, life as a practicing doctor does not seem to be getting any easier. We were just informed that the Annual Practicing Certificate (APC) fee would be increased by 2016. The proposed rate is RM 300/year, up from RM 50/year now. MMC will be corporatized as mentioned in the amended Medical Act 2012. Thus, one of the source of income for MMC will be the APC and NSR (National Specialist Register) fee. The NSR fee will remain at RM 1500 every 5 years. The renewal of APC will not be automatic anymore. You need to have a minimum amount of CME points to be renewed. I was informed that it would likely be 10 points per year for MO and 20 points per year for specialist.
Ministry of Health is also strengthening their enforcement unit and introducing many new rules and regulation for private hospitals and clinics. Recently, we were told that Visiting Consultants in a private hospital cannot admit any inpatients. They are only allowed to see outpatients. I understand that this new rule came about after the incident at the Chinese Maternity Hospital, Seremban where MOH had to close down the inpatient services, end of last year. The hospital was surviving with visiting consultants to run their inpatient services. Unfortunately, this new rule will have severe impact on hospitals and consultants. This basically means that a consultant who runs his own clinic outside would not be able to admit any patients to any private hospitals anymore. It also prevents Consultants from government sector to have any admission rights in private hospitals despite government allowing them to do locum/out of office hour’s session in private hospitals. Is this an indirect way of MOH in preventing their doctors from doing locum outside?
As for individual Maternity Centers, license is NOT going to be renewed if they do not have a full time Pediatrician and Anesthetist. This will force most maternity centers to close shop within the next 1-2 years. I have already had few O&G consultants from maternity homes calling our hospital for visiting rights. Unfortunately, it is a double whammy. We can’t accept them as visiting consultant as we can’t give them admission rights!
There is also another new rule, which says that we can’t run an ICU if we do not have at least 4 ICU trained nurses! Oh my, it looks like most of the small hospitals will have to close down their ICU services. How are we suppose to get ICU trained nurses when the training can only be done in a government hospital (under their post basic training) but they do not provide any allocation for private nurses?
By April next year, patients will have the option to choose between getting their medication from doctors as they do now, or to insist on the doctor giving them a prescription to buy the required drugs from a pharmacy. It was published in The Sun last month.This will be another big blow for the General Practitioners. It is a catch 22. Most GPs survive on the commissions they get from selling medications. If the above rule is implemented, they will have no choice but to increase their consultation fee. This in turn will chase away a lot of their patients. You can’t survive by charging RM 25-30 consultation fee! The Malaysian Pharmaceutical Society is fighting hard to get this implemented. As you would have noticed, many small pharmacies are merging to create big branded retail pharmacies almost everywhere in every town.
The cost of private healthcare is increasing tremendously. There was a saying that only 20-30% of the population seeks treatment from private hospitals. Unfortunately, the number of cash paying patients in private hospitals is dwindling over the years and only constitutes about 10-15% of the total number of patients attending a private hospital. The rest depends on insurance such as employee benefits and medical cards. In my hospital, almost 90% of patients are paid by insurance. This is where another huge problem is arising.
Since the New Fee structure was introduced by MOH in February this year, insurance companies are becoming more stringent in their assessment. For those who do not know, the fee increase of about 15-30% is the first increase after almost 16 years! And yes, our fees are regulated by the government but not the hospital fees. The insurance companies are now dictating what we should do and what we should not. They are even limiting the number of times we can see a patient in the ward. I have had insurance companies which specify that only 1 visit per day is allowed. If you visit more than once, either the patient has to pay or we have to do it for free! It does not matter whether the patient is ill or not! My surgical colleagues are having a tough time, as some of the fees are not being paid as it is deemed unnecessary by insurance companies and they decide this by sitting 400km away without even looking at the patient! Yes, I agree there are black sheep’s in our profession. I had written enough about this. Unethical and “go for money” doctors are increasing day by day due to stiff competition and reducing income. However, to query what a doctor should do and should not do, cannot be decided by some junior doctors who might not even have completed housemanship! FYI, insurance companies do take those who quit housemanship to become their underwriters! They even got the stupidity to ask why an appendicectomy cannot be done the next morning just because doing after office hours increases the cost! I hope we can say that to them when they get admitted for a similar problem. Interestingly, these insurance companies do not say these directly to their client/patients!!
All insurance companies are increasing their premiums as of now, to minimize their loss from the recent fee increase. How many percent of the population will drop out of the scheme? As the premiums increases there will definitely be certain portion of the population who will not be able to sustain their policy. This in turn may reduce the number of patients visiting private hospitals. On the other hand, the cost of private healthcare will continue to escalate. Eventually it will reach a tipping point where the private healthcare system may collapse, especially the big tertiary private hospitals. This did happen in the US in 1990s after which they started building smaller primary and secondary care hospitals to keep their overhead cost lower.
While we are having constant pressures from all these external factors, the litigation rate seem to be going up by leaps and bounds. Last year the court of appeal decided to award RM 3.5 million (before interest) in damages for a cerebral palsy case in a private hospital in Klang Valley. It has set a record as the highest amount ever awarded as well as a benchmark for future cases. Recently, a government hospital was asked to pay RM 2.78 million in damages for a similar type of case. Interestingly, the mother of the child is a doctor who is still in government service! Another consultant in a private hospital in Klang Valley was asked to pay RM 280 000 for causing death of a child due to mismanagement of labor, and the patient is a foreigner! Just today, another case involving an Orthopedic surgeon and a government hospital was found guilty of negligence. These are just the tip of the iceberg as many cases are being settled out of court!
These cases have now increased the premiums for our medical indemnity insurance and it will only go higher! A couple of months ago I had a father who said that doctors can’t be suit in court because no doctors will give evidence against another. I think he is leaving in the 80s. Those days are gone. We have many consultants hired by lawyers to attend court cases as expert witness. On the other hand, an increasing litigation rate will also increase the cost of healthcare as doctors will become over cautious and order unnecessary investigations (as happening in US). It is known as CBM: Cover Backside Medicine! The production of poor quality doctors with poor training during housemanship will only make things worst for the field of medicine in the future.
Well, many things are changing in medical fraternity. Some are for good as it ensures safety of patients and general public. The practice of medicine will not be the same anymore as many rules and regulations are being put in place. Income of doctors will continue to decline due to various factors mentioned in this blog. Doctors will be pressurised from every corner, which include debts, high indemnity premiums, high litigation rate and high maintenance cost of practice. AND I have not even started talking about TPPA and ASEAN Trade agreement! So, never do medicine for easy life and money!
2014 has not been a good year for this country. Anyway, I wish everyone a Selamat Hari Raya and have a safe journey home……………
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