11th of June 2019 was supposedly a uniting day for all our GP friends in Malaysia. It was the day when our new Minister had a town hall meeting with almost 1000 GPs from all over Malaysia. It all started when the Minister made a statement about a month ago that the Cabinet has approved drug price control and currently under review for implementation. This triggered an uproar among the GPs whose consultation fee is already regulated and capped under Private Healthcare Facilities and Services Act (PHFSA) 1998. Schedule 7 which controls consultation fee for GPs has capped the maximum price at Rm 35! This has been as such since 1998 but the act came into force in 2006. The hospital doctors on the other hand had a review in 2013 and Schedule 13th was amended with roughly 15% increment, starting 2014.
What are my views and take on these issues? Well, my comments, even in the past, had created a lot of negative feedbacks from fellow doctors. But as I had always said, I call a spade , a spade! Just look at the public feedback in Facebook etc when the above town hall meeting was reported. Videos of our GP colleagues venting their frustration was shown live and recorded by various media. Did you really expect the public to show sympathy? The answer is a BIG NO! For the public, doctors are sitting in a cozy air-conditioned room and earning tonnes of money! Only when their own kid ventures into becoming a doctor, hoping to live a glamorous life, they realise the actual life as a doctor! The hours of work, training, exams, risk taken, litigation etc before you can even think of earning a decent living.
Having said that, generally a doctor can still earn a living as long as they can get an internship post and complete their training. However, the era of earning tonnes of money and being “rich” is gone and going…….Our income will be similar to any other profession, allowing us to live a life. If you are still thinking that spending RM 500 000 to RM 1 million to be a doctor is going to give you a luxury life, think again! Jobless scenario is already happening in many countries.
Now, coming back to GPs. The day you open a private clinic, it is a business, period!Same goes to private specialist. In any business, there are gains and there are loss. Some businesses closes down and some businesses thrive and even become global players. Business is a business, nothing differentiates you than anyone else. Unfortunately , health is an essential service. Health and Education are 2 components in any country which should be the government’s responsibility. I have said and maintained this statement since I started this blog. Many may not know that the PHFSA 1998 was actually tabled and passed in the Parliament in anticipation of corporatisation of health care in this country. The corporatisation of healthcare aka National Health Financing Scheme was suppose to be implemented in 1999 as the last corporatisation exercise of Dr M! Everything was ready on paper.Unfortunately, the sacking of Anwar Ibrahim and subsequent reformasi etc totally shut down the plan till today.
Frankly I don’t agree with controlling of consultation fee. Let the market force decide. BUT healthcare is an essential service and thus the government need to be responsible. Thus, in Malaysia, they control it via the Malaysia Boleh way! Same goes in any other country as well. You may think that in other countries, the government do not control the consultation fee. On paper , yes but they do control it in another voluntary way. Their National Health Financing Scheme(NHFS) that pays for all the consultation/procedure fee do have a limit and standardised payment system. Anything more than that, the patient has to pay out of their own pocket. Public being public, obviously they will choose a doctor that only bills what the NHFS pays. NO one will ever want to pay out of their own pocket! In some countries, the doctors can only accept what the NHFS pays which is basically a fee control mechanism where everyone technically is a civil servant. Even in Australia, many patients prefer to visit the “bulk-billing” doctors (accepting Medicare fee) rather than cash billing doctors.
The GPs were arguing that they are only allowed to charge a maximum of RM35 for the last 21 years. Now, just look at the comments from the public in FB etc. You, me and all members of the public knows that a simple consultation and medication by a GP will cost RM 50-70 and in some cities, can even reach RM 100! Patients are smarter nowadays. Even my patients will go to a pharmacy and ask for the cost of the medications. Similarly, many cash paying patients would do that and will know the actual cost of the meds given by the GP. So, do you think they believe that you are charging only maximum of RM 35? You may argue all you want about the cost of running the clinic etc, but a business is a business! NO one cares whether you are running at a lost or not. No one believes the notion that you are providing a service to public. Didn’t you become a doctor to help man-kind and provide service (aka free service)?
I found that one of the main issue that was discussed the other day was about TPA (Third Party Administrators). Many were arguing that TPAs are only paying RM 10-15 per consultation and wants the government to make sure that they pay RM35 per consultation. Now, let’s go back to my statement above. It is a business! TPA goes around to negotiate the best deal in town. So, the person who is WILLING to take the offer will sign an agreement with the TPA. A business deal! So why are we complaining? You signed it and agreed to it but complain later? We all know that many GPs are dependent on TPAs. Almost 60-70% of a GP’s income comes from TPAs. Without TPA, many more GPs will close shop. This is similar to private hospitals. 95% of hospital admissions are medical card holders. If insurance companies go bankrupt, all private specialist will be out of jobs! That is the fact. So, TPAs can “tarik-harga” . Unless the GPs can unite and state their demands, no TPA is going to entertain your request. By 2021, the market is going to be flooded by GPs when 50-60% of doctors(roughly about 2000-3000 per year) completing their compulsory service not going to be absorbed into civil service. You think the TPA is going to symphatise you? They will be having a jolly good time of GP shopping! And don’t forget the “uberisation” of healthcare where even those who are waiting for housemanship seem to be giving “online” or phone advise!
Even if the government removes the fee schedule, how much do you think you can charge a patient? How much a patient is willing to pay out of his/her pocket? Under-cutting and bad-mouthing is going to be rampant and again TPAs will have the same modus operandi. They will continue to negotiate a deal for the cheapest possible GP. That is business and everyone wants to make the maximum profit.So, if you agreed and signed for it, you have no basis to complain. The government is not going to interfere with that.
I really felt that most of the arguments that were forwarded during the town hall meeting were emotional in nature. I was watching it live on FB and was putting myself as a member of the public. What I saw was just doctors arguing to make more money! And that was exactly how the public felt as seen in many comments on FB etc. Bringing politics into the picture made it even worst! Whatever political ideology we have, we should keep it among ourselves and should not display it publicly, as we are dealing with members of the public who may have different political ideology. Even more shocking and surprising for me was when one of the speakers rejected Universal Health Care! Lucky the MMA president came with a statement 2 days ago that MMA and all medical associations had signed Declaration Titiwangsa in support of Universal Health Care.
When 1Care was mooted in 2012, the GPs went against it as well, mainly because of dispensing separation. It was scheduled to be implemented in 2014 but the 2013 election results made it to be shelved indefinitely. We have to admit that it is the dispensing rights that the GPs have which is giving them the survival. With limited consultation fee, they make profit from dispensing medications. IF this is removed, more GPs will close shop and become unemployed. This was the reason why GPs were shocked and reacted when the Minister announced last month that drug price control mechanism will be implemented. To me, I support the drug price control mechanism. We have to look at the public and see what benefits them. Working in a private hospital, I very well know how the hospital mark-up the medication prices. Some are up to 100% mark-up, especially for inpatients. That’s the reason I don’t like to give generic medications to patients as the organisation that makes the most profit will be the hospital. The cheaper the drug, the higher the mark-up. I rather ask the patient to buy from a pharmacy via a prescription slip from me. As for a GP, having a price written at the box may reduce their overall charge.
Now, let’s come to the solution! WE have to change and move forward. We can’t be harping on the same model that we have been doing since the 1960s! The world is changing and many countries have moved on to new models. Whether these new models are better or worst is something to be decided later. We have to move to a win-win situation, for the GPs, doctors in general, government and the public. Our healthcare system is not sustainable. I have said this many times before. Two parallel system running concurrently, competing against each other for an essential service is doomed to fail. We have a public system totally funded by tax payers and a private system almost 80% funded by insurance (aka out of pocket). The insurance companies are also bleeding in billions and the only reason they are still providing medical cards is because it is mandatory under Bank Negara rules. If not, which company wants to continue a loss making business?
The way forward for a GP to have a lifeline is to have a National Health Financing Scheme which will integrateĀ public and private healthcare system. This is the only way you are going to survive and have a decent living. You may not make tonnes of money but at least you can earn a living. With the NHFS, GPs will be paid by the scheme with an agreed fee. GPs can charge extra with removal of fee capping but how many patients will be willing to pay out of pocket is something we need wait and see. Eventually, most GPs will do bulk billing! It will come with a price. Dispensing separation will become inevitable with NHFS, where subsidised or fully funded medications by the NHFS will have to go through a dedicated pharmacy. But the overall cost of running a clinic will drop as you do not need to employ staffs to dispense or to run an in-house pharmacy. GPs have to form group practices like in many other countries. The NHFS may have to pay higher fees for a specialist GP which will make more GPs to upgrade themselves. Sometimes I feel very sad when I attend CME talks to see the same GP’s faces all the time! And guess what, most of them are senior GPs! The younger ones are hardly seen as they are busy trying to run their clinic.
With the NHFS paying the consultation, procedure fee and medications, there are bound to be audits. Again, this is nothing new as most countries with NHFS do such audits. You will have feedback audits, prescription practise audits and even average consultation fee audits. The number of patients you can see a day may be limited in the context of quality care. Prescription of certain drugs like opiates, steroids , antibiotics etc will be monitored. At the moment, these are never audited and the GPs can do whatever they want. Do we even have the data of total usage of antibiotics by GPs in Malaysia? We do have data from KKM and private hospitals but not from GPs as there are no laws to mandate GPs to be audited for such usage. IN any system there should be check and balance and doctors are not or should not be exempted. Unethical practices will rise if these issues are not kept in check, as what is happening increasingly in private hospitals.
There is no point arguing with the government when it comes to essential services. A government’s duty is to provide such service to public. Just see what happened when education was privatised! We made someone rich by making the public to go into debts!While the NHFS will have to get the money from the public in the form of premiums plus funding from the government, at least it will distribute the health service to a united system. Patients can go anywhere without paying anything and the GPs will be able to get the load with lower overhead cost, enough to have a job to survive.
Either we change to live a reasonable decent life or we die a slow death……. it’s our choice.
I am surprised you are supporting the infamous “1Care” which was shelved. I was mentioning this a while ago, and was flamed left right centre by the public and the doctors (some only!) I have said it before that the doctors in private (aka business, like u rightly said) cannot be playing “saint” (to jaga the welfare of the public, keeping cost as low as possible for them) and at the same time trying to be “business man” (trying to earn a decent or better living). The intitial 1Care or NHFS was quite “fair” so to speak to the doctors – no need to stock up much medicine, and get a decent RM30 per consultation (so if 20 patients a day for 22 days, that is easily RM13200 per month, without having to worry about stock pile and undercutting each other). Patients can choose to buy medicine from the GP or just go pharmacy for the cheaper dispensary. Win-win. But so many GPs were against it… really can’t comprehend why. Now they have this townhall meeting which make things worse for themselves, and the public already have the perception that the “cruel” GPs are all out to cut-throat the public. Sigh…
I had written and supported 1Care when it was under discussion. For that I got a lot of negative remarks from my fellow GPs because i supported dispensing separation. If doctors really care for the welfare of our patients, we must support a universal health care. NHFS is the way forward to improve healthcare by integrating public and private system.
Spot on. I think with the rot that took on ever since irresponsible policy makers decided to open the flood gates for people to get into med school and qualify in this country, the rot is just continuing and we’re heading to a point of no return. At this rate, it’s best to just serve your time, take your pay and leave once the opportunity arises. The recent town hall in focus is a good indication of where all this is going.
I was in the task force of 1Care financing and I can say it was a good plan. But when a certain section of the doctors (not MMA) went against it together with the opposition political parties (the current government) I was called to attend a meeting with the then Minister of Health who asked why we are against it. I made it clear to him that MMA is not against it as the frame work for 1Care is similar to the framework proposed by MMA in 1999 in the MMA publication āHEALTH FOR ALL – Reforming the Healthcare of Malaysiaā. The problem was the the trust deficit with the Government which had performed badly in other privatization schemes. I mentioned that the Governance structure was not clear and people were worried who was going to put the hand in the till. It is inevitable that there must be a health financing reform and NHFS with the single payer system is the way to go. I have advocating that we do not have to reinvent the wheel. SOCSO can be used with legislative modification as the vehicle to roll out NHFS. They have the infrastructure to collect and disburse funds.
Hi Doctor! I have just completed my foundation studies(matrics) after my spm. My all time dream is to become a doctor. Although I have passed the MMC requirements,chances to get in a public university for mrdicine is low for me as the requirements is very high in public uni. I want to consider private university like UCSI(RM300K) and MSU(RM300K). I am not from a very rich family. I planned to take PTPTN loan(full amount for B40 RM250K). But all I scared is, do I have to burden my parents so much for pursuing my dream? Although there is ptptn, for living cost my parents will be paying. If I don’t go for medicine , I can get many good courses in public university,which save alot of my parents money. After reading your articles, I can see the way of becoming a doctor is not easy clearly. But my heart want to try all of it and achieve something. I’m literally so confused now. And although becoming doctor is my dream, having a settled life is also important in our future. I want to really hear some good advice from someone like you. Thank you š
I think all the answers are in my blog. Frankly, to me there is no point spending huge amount of money to do medicine. Unless you get scholarship or into public university, you need to think twice if you want to do medicine.
It is strange how people support 1Care without looking at the feasibility of the project. If you want some NHS style scheme, you need proper governance to plug leakages first. I have proposed a better solution than what is said in this article way back in 2012. Here read this https://theblackcactus.wordpress.com/2012/02/05/1-scare-scheme-part-1/. It explains the mechanics and why 1Care can’t be immediately implemented now. Remedial actions to the pre-existing system is needed. For all you know it can function way better. If that doesn’t work, at least you have surveyed all angles before you proceed to 1Care high demands a greater level of meritocracy and transparency (which means we need computer systems in all clinics). Good luck!
Sorry Dr Pagalavan, I have a question.
Can a houseman who was previously extended still stand a chance to become a specialist?
Thank you.
Yes but for local Master’s program , your SKT marks must be above certain level for 3 consecutive years.
Hi Dr Paga,
NHFS is something youre suggesting our government to do or is it being already discussed now ? because i havent heard any news about it.
I do agree it will be win win situation both for the public and our medical fraternity. Although i feel our government is still not matured and brave enough to come up this national scheme at the moment.
The government has been talking about NHFS since the last 20 years! Unfortunately no political will to implement it
What is the update on the floating Medical Officers starting from the Dec 2016 batch? How many were placed on permanent position and contract position ?
I have not got the figures yet but heard some did get permanent post but got posted to East malaysia.
Just curious how doctor can maintain marriage life and take care family if both are medical doctors?
it’s difficult and divorce rates are high
Hi Dr Paga,
When do you think Malaysia’s GP scene would be comparable to that of countries like Australia and New Zealand, where GPs are considered a respected speciality?
not anytime in near future, a long way to go……….
In your opinion what are the main factors hindering this process?
Firstly we need a national health financing scheme to be in place. This is a political decision and as I have written above, objections are from everywhere. Only after NHFS is in place, we can start talking about GP being a speciality.
Thats actually quite sad. We need GPs even more than ever. Otherwise the specialists would be overwhelmed with problems that can be managed at the GP level
Yup and that has been voiced out for many years but Malaysia tend to spend more money for tertiary care than primary care.
A very good post doc! This is the exact argument being debated in the US for a universal healthcare system, where the cost of healthcare in the US is prohibitively expensive. At least in Malaysia we have public hospitals, but its being so overstretched!
I am all for a universal health care system in Malaysia, as God forbid a system whereby healthcare becomes unaffordable for ordinary Malaysians. Like you have rightly pointed out doc, many doctors in Malaysia now are only worried about making money that patient’s welfare is taking a back seat.
In view of how public hospitals are bleeding specialists to the private sector when the majority of patients are still going to public hospitals, we need a complete revamp to ensure our healthcare standards remain world class. There are already so many cases of overcharging in private hospitals that makes me wonder are our private specialists not earning enough??
I laud you for supporting a universal health care system doc. You do have the patients welfare at heart. Keep up the good work doc!
You will be surprised looking at how doctors are trying to make money in private sector.Trust me, once you see money coming in, no money is enough!
This is so unfathomable doc. With all these opposition to universal health care and also these section of doctors who are profiteering in the private sector, has the income of these doctors gone so bad?
Many of the young ones nowadays, and even my friends who are MOs now believe they are going to earn rm80k -100k upwards. I don’t know how true this is anymore but it doesn’t sound well for the future of medicine in our country if the universities (doctor mills) are to continue to feed this obsession. Your thoughts doc? I do hope universal health care becomes a reality in our country!
It is not about income but how much is enough! Greed will always take over you if you allow it. It is the people like your MOs who are the ones who will end up doing all sort of unethical stuffs to make the money that they “thought” they would be making in private. They enter the private sector thinking they are going to make tonnes of money. Few months later, they probably making less than half of what they thought they would be earning. Then starts the unethical medical practices. E.g: scope everyone that comes with abdo pain, admit every patients that walks into your clinic with a complain as long as they have a medical card and keep them for a minimum of 4 days, FESS for every rhinitis/sinusitis, remove any gallbladder with a single stone etc etc. Trust me, I have seen all these right in front of my eyes. So, if anyone says they are earning 80-100K/month, just do an audit of what they are doing, you will get an answer!
Wow doc the examples you outlined seems like only scratching the surface! Hearing this live examples is so disheartening to hear when doctors are supposed to be honest and diligent when carrying out their work. Patients lives are at stake and we tend to trust whatever our doctors suggest as it concerns our health. But knowing that doctors don’t have the patient’s best interest at heart will only make the situation worse! Don’t these insurance companies do their own audit to find out if they are being overcharged?
This actually explains why universal healthcare is going to be opposed by a majority of doctors in Malaysia. How many doctors out there would have the same thinking as you Dr Paga? My guess is not many. With many doctors nowadays thinking that doing a single surgery is going to earn them tens of thousands, and our private sector being financed by the insurance sector, I wonder if this dream is going to remain a dream. Like you said doc, greed begets greed! Do you ever see a solution to this doc?
Lately insurance companies have started doing just that! They have blacklisted some consultants in some hospitals. The insurance company would not issue a guarantee letter for these doctors.
The only way this system can change is when the government decides to do so! Only when there is s single pay master, audits can be officially carried out. Currently insurance companies do not have any authority to audit your case notes/management. Like in Australia, Medicare has the right to audit your notes and billings since they are the pay master for the GPs and private doctors.
I’d like to ask a question. I was informed by the star newspapers our housemanship is recognised by the GMC. How true is this?
Only for graduates of Newcastle University of Malaysia and must be done in selected hospitals only.
Hi Dr!
Me and my significant other wanted to practice in the same hospital for our housemanship. Is it possible to do so? Or the e-housemen system will only place you according to whatever you rank regardless of your marital status? Does marital status changes the way they place you?
I don’t think so. Each one choose their own. If you are lucky, you may be able to choose the same hospital.
Evening doc. Iām currently 4th year medical student in Indonesia-already clinical year. Somehow, i realize i am not kinda people person in which i think iām more interested in less human interaction job. Therefore, i consider to pursue lab-related area later such as microbiology, clinical pathology. But, do i have to finish my HO and MOship first ? Is there any other pathway? Thank you. š
Yes, you need to undergo housemanship and get full registration even before being eligible to apply for those Master”s program.
When is your next article doc?? And Happy Deepavali in advance š
Same to you . Need to find time to write my next article
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