KUALA LUMPUR, June 10 — The previous Barisan Nasional (BN) government did not raise clinic general practitioners’ (GPs) consultation fees even though it increased private hospital GPs’ rates in 2013.
Six years later, the maiden Pakatan Harapan (PH) administration appears equally reluctant to revise the paltry fees of private GPs operating shop lot clinics that have remained at RM10 to RM35 since 1992, almost three decades ago.
Over 300 private GP clinics shut down last year alone, according to Health Minister Dzulkefly Ahmad. Amid rising costs and inflation, while being squeezed by managed care organisations (MCOs) which manage the health care plans of workers and the insured, doctors warn PH that the solo GP practice will eventually die if their fees remain stagnant.
Some doctors even plan to go on a so-called “strike” tomorrow during Dzulkefly’s town hall meeting with GPs, when they will close their clinics for a day to protest the decades-long cap of their consultation fees.
According to the Malaysian Medical Association (MMA), 6,587 GP clinics were registered as of last December. There are over 7,000 private GPs working across clinics, hospitals, and diagnostic centres among others.
These are the issues that doctors’ groups who spoke to CodeBlue plan to bring up at their town hall with Dzulkefly tomorrow in Putrajaya that will be attended by more than 1,000 GPs:
Raise Clinic GP Fees to RM35-RM125
The Private Healthcare Facilities and Services (Private Hospitals and Other Private Healthcare Facilities) (Amendment) Order 2013 amended Schedule 13 of the Act and gazetted it on October 10 2013 to increase hospital GPs’ consultation fees to between RM35 and RM125.
But Schedule 7, which sets clinic GPs’ consultation fees at RM10 to RM35, was not similarly amended and gazetted together with the revised Schedule 13.
Federation of Private Medical Practitioners Associations Malaysia (FPMPAM) president Dr Steven Chow said this “anomaly” in Schedule 7 should be fixed within three months.
“The present government has been in power for more than a year and would have enough time and resource to rectify the anomaly,” Dr Chow told CodeBlue.
“All the necessary background work has been completed by 2010 and passed in the form of an Amendment Order in 2013 by the Minister of Health. The rate was RM35 to RM125. The doctors are not asking for more than what is due to them.”
He said excessive legislation and regulation was gradually making independent solo GP practice untenable, even as doctors’ fees have been “unrealistically” capped despite inflation and rising business costs. Some GPs have complained about Health Ministry officials “bullying” them by enforcing regulations that “control your floor, door, toilet”.
“Administrative cost for the endless paperwork have shot up the roof in private clinics. The situation is worsened by MCOs and TPAs (third-party administrators) unilaterally dictating and imposing restrictive rules (quasi-regulations) in GP contracts, making it difficult for both the patients to see their doctors and the doctors to see their patients,” said Dr Chow.
MMA president Dr Mohamed Namazie Ibrahim said raising clinic GPs’ consultation fees would allow doctors to minimise mark-ups when selling medicine.
“We’re not drug pushers. We want professional fees to sustain our practice. Sale of drugs should be a secondary issue. Many GPs have said if we get proper consultation fees, we don’t want to dispense,” Dr Namazie told CodeBlue.
Both FPMPAM and MMA urged the Health Ministry to regulate MCOs, some of which demand a registration fee for clinics to get on their panels that MMA said could be considered an inducement.
“This is unethical under our code of professional conduct. We shouldn’t pay somebody for us to get their patients,” said Dr Namazie.
He also said some MCOs charge GPs a fixed fee per transaction, while others take between 5 and 10 per cent of the GP’s total bill to the patient, which may be construed as fee splitting.
GPs previously complained to CodeBlue about MCOs that pay them only RM10 or RM15 for consultation. One also said MCOs caused his patient load to drop by 60 per cent.
“The Federation reiterates its stand that it will provide full support for a nationwide action by GPs not to accept MCOs who do not adhere to a minimum consultation fee of RM35 per visit. We urge all our medical bodies to support a resolution to this effect to be passed at the town hall meeting,” said Dr Chow.
He also pointed out that an MCO Bill drafted in the late ‘80s has yet to be legislated, while the Health Ministry has yet to fulfill its 2006 promise to regulate MCOs.
Postpone Drug Price Controls and Dispensing Separation
MMA said GPs must get “proper” consultation fees before the government regulates the price of medicines so that they don’t have to rely on drug sales to sustain their practice.
Dr Namazie also highlighted various complications in trying to control drug prices, such as varying currency exchange rates that would influence the import of patented drugs, generics, as well as raw materials to locally produce generics.
“So how can you control this?” he questioned.
He said drug price controls at the retail point will also be problematic because overheads in urban pharmacies are higher than those in semi-urban or rural areas.
Dzulkefly recently announced that price ceilings for medicines would be set at the wholesale and retail points, including at clinics, hospitals, and pharmacies.
Separating the prescribing and dispensing of medicine to doctors and pharmacists respectively, Dr Namazie said, also hinged on raising GPs’ consultation fees first.
“Many [GPs] are willing to give up dispensing completely, except for certain vital drugs they need immediately, because the logistics involved is tremendous,” he said, citing the hassle of frequent inspections by pharmacy enforcers.
A lot of paperwork and procedures are involved in ordering and keeping a stock of drugs, while Health Ministry pharmacy inspectors check a clinic’s inventory annually or once every two years, said Dr Namazie.
Dr Namazie also questioned how the government can prevent pharmacists from dispensing medicine without a doctor’s prescription.
“Pharmacies should not dispense without prescriptions, but this can only come about when the payment system is changed, which means you need a national health financing system or social health insurance,” he said.
Dr Namazie explained that a national health insurance will reimburse the cost of drugs, with small co-payments by patients, so pharmacists will not be incentivised to dispense drugs to patients without a doctor’s prescription.
“So our caveat for dispensing separation is two — proper consultation fees, second is when there’s a uniform health financing authority or social health insurance. Then only we’ll support dispensing separation. There must be check and balance.”
FPMPAM president Dr Chow urged the Health Ministry to outsource its outpatient department services to private GPs, pointing out that the ministry’s 1986 National Health Expenditure Survey has shown that the cost-per-patient-per-episode of care, including medicines and treatments, is cheaper in the private GP system at RM28 compared to RM54 in the public system.
“This will effectively relieve congestion and waiting time in outpatient facilities and allow MOH (Ministry of Health) facilities to focus on secondary and tertiary care,” Dr Chow said.
He also questioned why the Health Ministry has yet to enact regulations for the Pathology Laboratory Act 2007, even though the law was passed more than 10 years ago.
“In the meantime, patients and the public have clearly been exploited by the commercialised screening, treatment and wellness programmes run by certain private laboratories.”
Dr Chow also wanted the government to address the commercialisation of health care, amid the shift of medical specialists from public to private hospitals and a lack of special services at government hospitals like MRI, ultrasound, mammogram, and tomogram services.
MMA president Dr Namazie urged the government to create training programmes for GPs, like those in developed countries.
“We want the GPs to take on additional training in general practice or family medicine, but of course this involves costs, so we’re asking the government to assist the GPs in the training programme,” he said.
“If GPs are very confident in managing bad diabetics, hypertension, and non-communicable diseases (NCDs), then they don’t have to crowd the government clinics. But definitely they need assistance in their training.”