Having Middlemen In Private Medical Care Is Bad – Dr Mohd Tajudin Shaffee

“Experience over the past 20 years has shown that the MCO business model is that of cost control by ‘rationing of care’, not ‘cost-containment’. It imposes rationing, exclusions, and limits choice, in order to control cost to increase their profit margin.”

In keeping with the objective to enhance private-public partnership in health care, I would like to urge the government to adopt and nuture the existing primary care system by private general practitioners (GPs) nationwide.  

Up until 2010, private GPs have been catering for 60 per cent of the total outpatient care burden of the nation. 

Private GPs have been the main factor for reducing queues and waiting time in government facilities.

It is known that the GP system is among the most affordable and accessible in the world. Studies from the Ministry of Health (MOH) have shown that the cost per visit per episode for private GP care is lower than visits to government facilities.

However, all this is before the advent of middlemen in the delivery of private primary care. 

Experience over the past 20 years has shown that the managed care organisation (MCO) business model is that of cost control by “rationing of care”, not “cost-containment”. 

It imposes rationing and exclusions and also limits choices, in order to control cost to increase profit margins, much to the detriment of the patient.  

In addition, GPs are often not paid in full, in accordance with the existing government-approved professional fee schedule.

Over the years, GPs have had to face losses, with many cases of MCOs/ TPAs (third-party administrators) closing shop, leaving behind millions of ringgit of unpaid medical bills owed to doctors. 

In simple terms, for the patient to see a doctor, she or he has to go through an appointed middleman, and for a doctor to see a patient, she or he has to go through a middleman as well. 

A fee is extracted from each party, either in the form of co-payment, management or registration fee, or hefty joining fees for the doctor. 

The access, choice, and pre-approval guarantee letters for patient referal to specialists  is determined by fine-print provisions in the master contracts between the middlemen and employers, which are not revealed to the doctor or the patient.

The middleman has the inherent right to approve or disapprove the payment for care, much to the distress of the patient and the doctor.

The end result is that in order to pay for middlemen services, costs for employers and patients, and ultimately, the rakyat, has gone up instead of going down. 

The patient ends up paying more money for less care.

The government should immediately pass and enact regulations to protect the patient from the middleman. 

I am aware that the draft proposal of such regulations was first submitted to the MOH as far back as 2006. 

Patients and doctors alike have been waiting for these regulations for more than 17 years to come into force. 

It is fair to ask where the political will is to protect the sick rakyat from the clutches of these middlemen.

Doctors feel that their patients must be empowered to choose their provider and option of essential medical care, without undue influence from third parties like middlemen.

Dr Mohd Tajudin Shaffee is a retired private practitioner in Kedah.

  • This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.

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