We refer to the Parliamentary question and answer session on September 23, 2021. during the presentation of the health minister, Khairy Jamaluddin. Private hospitals were once again blamed for the cost of treating Covid-19 patients in intensive care units (ICUs).
We, the doctors, nurses, pharmacists, physiotherapists, radiographers, and many other allied health care colleagues, together with our management teams, have been working hand in hand with our public sector colleagues in battling the Covid-19 pandemic.
And yet, the spotlight oftentimes is not on the work that has been put in, but the economics of it all, which is poorly understood by many.
Malaysians were shocked by the revelation that the cost of ICU care in private hospitals for Covid-19 patients amounted to RM400,000, which to us is not surprising at all.
This is the truth whenever we take into account ICU support and services, medication costs, and disposable personal protective equipment used. imagine a team of at least six doctors and nurses changing twice into Tyvek suits just to do their daily rounds for a month for a seriously ill Category Five patient.
These patients are facing their multiorgan failure, and will need all kinds of expensive medications and organ support like haemodialysis, mechanical ventilation, tracheostomy, and extracorporeal membrane oxygenation in some cases (ECMO), serial diagnostic imaging and the usage of continuous drug therapies.
This is on top of the multiple human resources needed to manage an average ICU stay of at least ten days, with some even requiring weeks to months before being discharged. The only way to lower the costs is not to initiate any of the therapies as outlined above, which is completely unthinkable, and presents an ethical dilemma.
As such, we take the approach of do first, while at the same time, informing the family about the cost implications.
If one refers to the cost incurred in hospitals in developed countries, it would amount to a similar figure. To simply assume that the RM400,000 as taking advantage in making profit from the situation is totally absurd.
Please understand that in health care economics, the revenue that is obtained by the private hospitals does not equate to high profits, as there will be other expenditures that need to be calculated against. At times, we may even have to write off some bills as bad debts.
What the public may not realise or choose to understand is the cost that the government spends for each patient that is admitted to ICU. The government would in principle subsidise if not absorb the total costs of ICU care.
This can be clearly seen in recent Ministry of Health (MOH) efforts in their official patient bill, which will show how much the real total cost of care is.
In 2020, we were not faced with these financial dilemmas, as the instructions were clear that all Covid-19 patients were to be managed by public hospitals, while the private hospitals can continue to focus on care for the non-Covid patients, which were also being compromised.
However, during the Covid-19 peak surge that occurred in 2021, there were not enough ICU beds for ill Covid-19 patients in the 140 government hospitals.
For the writer to allude that the patients had a choice is irresponsible. The hospitals had no choice at times but to manage patients as they come, as there were simply nowhere else to go, besides the option of languishing in an emergency department chair in a public hospital for a day or two, before a bed is secured. It was that bad.
We welcome any initiatives by the government, which is studying ways to help families cope with these bills. It was a crisis that the MOH had to act upon, and if the government can use some taxpayer money towards this, it would be beneficial, since the other way to look at the situation is that the patients only ended in a private hospital ICU because there were no ICU beds available elsewhere.
This is despite the fact that over a two-year period, almost half a billion ringgit was spent to increase the capacity and the number of ICU facilities to cater for Covid-19 patients. Total ICU beds are now double the number of beds we had in 2019.
When the Emergency Ordinance was announced, there was a possibility that private hospitals may potentially be taken over by the government under Section Three of the Act. The main question was who will fund the private hospitals for all costs incurred, as the sustainability of these centres depends upon the payment of the services which is provided.
There is no taxpayer money involved here. These facilities also pay their corporate taxes to the government, so by taking over, you are effectively shutting out one revenue stream for the government.
If these health care facilities are taken over without proper planning of cash flows and reserves, Malaysia will end up with these hospitals closed or becoming bankrupt, thus further burdening the public health system. This will lead everyone to flock to public hospitals and will lead to a collapse of the entire health care system.
What the Covid-19 pandemic has exposed is how expensive health care can be, and the current system we have may not be suitable for the government to sustain anymore. This is the hard truth, and politicians from both sides of the divide are well aware of this.
They have chosen to sidestep the issue for far too long instead of trying to find meaningful ways to engage with the stakeholders and coming up with a long-term solution. As some of these decisions are politically unpopular, the punches are then directed to the people who are actually sweating it out in PPEs in trying to make a difference and saving patients’ lives.
The politicians do not see the mental impact that the pandemic has wreaked on the private health care sector as well. We too go home with a heavy heart every time we lose a patient, which is no different from our public sector colleagues just because it’s private health care.
Whether we like it or not, running a private hospital is a business, and like any business, profitability must be taken into consideration to guarantee sustainability and continuity.
Issues such as the return of investment, upgrading and investing in newer technology and staff training is factored in too. This is all done to ensure patients get the best of the best.
The cost in government hospital is actually nearly the same as that in private hospitals, or slightly lower as the public hospitals buy in bulk, allowing some discounts in consumables, but in general, the cost is about the same. But such “cost saving” may actually be lost when we look in detail at how such items are actually being used in a clinical setting.
Most, if not all, of those who work in private hospitals know and understand the issue of cost. The cost to the patient and to the hospital is taken into account at every step of the patient’s treatment, from the moment of admission, right up to the patient’s discharge and post-discharge care and follow-ups.
We do what is needed and indicated in achieving the best possible outcome in patient care and treatment. The care and treatment given is not compromised or substandard.
We would like to end this letter by saying that post-pandemic, we can’t go back to business as usual. The public needs to understand that health care is an investment, and the burden of the financial cost will need to be shared by all in order to make it sustainable.
The government has done its part so far, but it can be better. We need the political will to institute meaningful reforms involving both public and private sectors to continue to make the health care system in Malaysia the envy of even the most advanced developed countries.
Let’s not wait for the next big health care crisis to hit us before we make these necessary reforms. We now have a new health minister, and judging by his first few weeks in office, we remain optimistic that things can change for the better under his watch.
Dr Mafeitzeral Mamat, Dr Gunalan Palari Arumugam, Dr Syed Rozaidi Wafa and Dr Shahridan Fathil are consultant anaesthesiologists in private practice.
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