Restrictive Madani Medical Scheme Underfunded, GPs Moot Co-Payments

FPMPAM and MPCAM want a co-payment model in the Madani Medical Scheme, which they say is underfunded, to enable GPs and patients to make their own decisions on care. Doctor groups also complain about excessive paperwork that discourages GPs from joining.

KUALA LUMPUR, Dec 19 — Private medical practitioners have called for more funding and a co-payment model for the Madani Medical Scheme (SPM) that they say is too restrictive and less effective for both providers and patients.

Due to low annual benefit limits of just RM75 for singles, RM125 for seniors, and RM250 for households in the programme allocated RM100 million by the federal government for 2024, doctors’ groups say the programme should allow patients to pay the balance – instead of diverting them back to public health care facilities if the bill exceeds limits. 

Federation of Private Medical Practitioners’ Associations, Malaysia (FPMPAM) president Dr Shanmuganathan Ganeson said the co-payment model – like the one implemented in the Iltizam Selangor Sihat (ISS) programme that SPM is modelled after – was a better option compared to the “strict limit with an ‘all or none’ rule” imposed by ProtectHealth Corporation on panel clinics. 

The ISS programme by the Selangor state government, formerly known as the Skim Peduli Sihat, provides subsidies for patient visits to private general practitioner (GP) clinics, offering up to RM70 per visit. Upon reaching the RM70 cap, patients will need to bear the remainder of the cost. Thus, if the total cost of treatment is RM90, the ISS programme will reimburse GPs up to RM70 and the remaining RM20 will be billed to the patient. 

“The Madani scheme does not allow GP clinics to charge these patients. If care is expected to be exceeded, they ask to refer to the government facility. So the decongestion is a fallacy,” Dr Shanmuganathan told CodeBlue.

“To be fair, the SPM is a pilot project. I doubt there is any significant decanting to the private sector so far. The limit imposed and the subsequent advisory to refer such patients to public facilities is contradictory to the original objective. If implemented nationwide, it would be publicly ridiculed.”

Medical Practitioners Coalition Association of Malaysia (MPCAM) president Dr Soo Tai Kang said that while SPM is a good idea to aid the B40 community, pre-set conditions and limitations in the programme that fully subsidises acute treatment at panel GP clinics make it “not very effective”.

Despite the programme’s flaws, Dr Soo said that the newly negotiated fees make the scheme especially attractive for GPs in sub-urban and rural areas, as well as new clinics. 

“However, the cap on treatment and limitation on medication choices hinders our options,” said Dr Soo in a written response to CodeBlue

He concurred with Dr Shanmuganathan that a co-payment model was a better fit that would allow doctors to “choose better medication for the patient”. 

Too Much Paperwork, Poor Public Awareness, Below-Market Medicine Prices

Federation of Private Medical Practitioners’ Associations, Malaysia (FPMPAM) president Dr Shanmuganathan Ganeson speaks to a patient in his clinic in Kuala Lumpur on February 3, 2020. Photo taken by Saw Siow Feng.

FPMPAM rated the unity government 2/10 for its running of SPM.

“This pilot project has the following criticisms: it is user-unfriendly for the GPs; it is not well publicised even in pilot area populations; it needs more transparency as to where the funds are going,” said Dr Shanmuganathan. 

“It appears to be a ploy for votes rather than a scheme for the poor; it is uninspiring to both providers and patients; screening of enrollees appears to be defective; the GPs seem to be used by a third party to fish data for free; 

“The pricing for drugs is defective; and the aim is decongestion of public facilities, but the modus operandi contradicts this. Awareness is lacking and there is provider reluctance to participate.

“In urban areas, there is a lack of B40 enrollees anyway, so most clinics do not bother.

In rural areas, even with more B40 enrollees, not many GPs are joining it.”

Health Minister Dzulkefly Ahmad said in a statement last Thursday that as of December 14, a total of 1,005,645 treatments for mild illness to 785,623 patients from 2,506 private clinics that cost RM62.5 million in total.

When SPM was launched last June, Dzulkefly’s predecessor Dr Zaliha Mustafa said SPM targeted 700,000 households.

FPMPAM said private GPs were reluctant to join SPM because of time-consuming administration procedures required to process beneficiaries who come seeking treatment. 

The system utilises a one-time password verification method; doctors are also required to key in large amounts of patient data. 

Additionally, doctors need to get their patients to sign a consent form upon arrival at the clinic. The clinic will then need to scan this form and submit it on the SPM’s online platform. This form, known as a “Q” form, needs to be submitted within 24 hours along with an itemised list of medications. 

Normal claims need to be submitted within three days. 

Furthermore, the issue of below-market medication prices still persists and forms yet another barrier to doctors signing onto the programme. 

“There has been better reception after the increase, but once they see the admin part, many shy away,” Dr Shanmuganathan said.

“Interference in independent professional medical management via pre-listed, pre-priced drugs, and lack of independence for patients to make decisions on further care.”

SPM faced initial backlash from GPs for its low consultation fee of RM30, low reimbursable claim of RM60 per patient visit for combined consultation and medication, and the requirement that doctors adjust treatment plans or send patients to public health facilities if treatment costs exceed the cap. 

After much condemnation by health groups, ProtectHealth – the third-party administrator owned by the Ministry of Health (MOH) that runs SPM – increased the consultation fee for panel GPs by RM5 to RM35. 

The limit for combined consultation and medication per patient visit was raised from RM60 to RM70, while ProtectHealth added approximately 20 medications to the existing list of 152 drugs. ProtectHealth also told panel GPs that they raised payment rates for certain medication. 

Penang Panel GP: Government Must Raise Funding For SPM 

Patients wait at a private general practitioner (GP) clinic in Kuala Lumpur. Photo taken by Saw Siow Feng on February 3, 2020.

Dr Saravanakkumaran Perumal – a GP whose clinic Poliklinik HL is registered with SPM – urged the government to allocate more funds so that the programme can pay doctors more and increase patients’ treatment limits.

The Penang-based GP held that the consultation fee only covered the doctor’s time and was insufficient to cover the complete services rendered, including paperwork for the SPM scheme.

“They should allocate more payment for the service provider to make the programme successful, and to keep private doctors in the programme. 

“Even in restaurants, when we order a chicken, there is a minimal price for that, and in addition to that, we have a service charge. We pay for the facility and environment,” said Dr Saravanakkumaran in a written statement to CodeBlue

He proposed that the increase in fees could vary based on services rendered by the GP. As an example, he stated that for acute cases, consultation be set between RM20 and RM35.

For chronic cases, consultation should be set between RM45 and RM60. However, when it comes to medicine prices, Dr Saravanakkumaran said, “Stick to the government price of medicine.”

He suggested increasing the benefit limit for SPM beneficiaries to RM1,000 per year that should be “sufficient enough”. Currently, the programme provides annual benefit limits of just RM75 for singles, RM125 for seniors, and RM250 for households.

While Dr Saravanakkumaran complimented the scheme on its ability to assist the B40 community by allowing them to gain access to longer consultation sessions and better medication in the private sector, he held that the government needs to do more to promote SPM.

His clinic in Bukit Minyak, Penang, saw numbers jump from 10 SPM patients in October to 83 patients in November, showing there is demand for the programme. 

Despite the minimal amount paid to doctors and the other flaws of the scheme, Dr Saravanakkumaran gave an “A” to the unity government, but only because he viewed the programme as a pilot project. 

“At the same time, the government should have two parties: the government side and the private sector auditing [the SPM programme], so that the system is sustainable in the long run without any failures due to unwanted hurdles.”

MMA: Expand SPM To Cover NCD Management

Malaysian Medical Association (MMA) president Dr Azizan Abdul Aziz. Photo courtesy of MMA.

The Malaysian Medical Association (MMA) commended the SPM scheme, calling it a “step in the right direction”.

“The government should expand the initiative to include NCD (non-communicable disease) management, which we believe will further and more significantly reduce congestion in public healthcare facilities,” MMA president Dr Azizan Abdul Aziz said in a written response to CodeBlue.

“We are confident that more private GPs will participate in the scheme if NCD management is included among the services.”

The MMA president said that to achieve successful outcomes, the government will need to be more inclusive by conducting early engagements with stakeholders on public-private initiatives before implementing such schemes. 

“The top-down approach of past administrations which is still very much a practice in government departments is counter-productive.”

Before the launch of the SPM programme during Dr Zaliha’s tenure, MMA, FPMPAM, MPCAM, and the Organisation of Malaysian Muslim Doctors (Perdim) had asked for RM50 consultation fee under SPM in a meeting with ProtectHealth last May, before the launch of the programme in June. However, in spite of the request, the scheme was still launched with the RM30 consultation fee cap. 

While MMA commended the scheme’s aim to decongest public health care facilities, Dr Azizan said the MOH has yet to sufficiently address the maldistribution of health care workers — another contributing factor to overcrowding in public hospitals and clinics.

“There is also a need for short-term and long-term planning to address the shortages in specialists across the board. This too is among [the] factors contributing to long waits and overcrowding in public health care,” she said.

“We have heard that the government is discouraging the parallel pathway option for specialisation. If this is true, it will have a significant impact on planning of specialists for the future as the intake for the local masters programme for specialisation is limited.”

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