KUALA LUMPUR, August 2 — Private general practitioners (GPs) have called for an audit of ProtectHealth Corporation’s mechanisms and financial management, rather than focusing solely on private clinic doctors.
Federation of Private Medical Practitioners’ Associations Malaysia (FPMPAM) president Dr Shanmuganathan Ganeson said ProtectHealth’s recent discovery of abuses in the Madani Medical Scheme (SPM), including false claims and violations by private GP clinics, only “give glimpses” of the programme’s strengths and weaknesses.
“Audit must be an ongoing process, and a proper audit should involve all,” Dr Shanmuganathan told CodeBlue. “In fact, the initial data reflects poorly on ProtectHealth’s ability as it appears to be ill-equipped to manage provider moral hazards and possibly enrollee moral hazards.”
Dr Shanmuganathan’s comments follow Health Minister Dzulkefly Ahmad’s Dewan Negara reply last Wednesday, which revealed that ProtectHealth uncovered abuses of the SPM by private GP clinics.
Claims surged from about 20,000 to as high as 50,000 per day in late December 2023, revealing “violations of SPM service terms and conditions” such as using up SPM beneficiaries’ allocations despite their not being sick, unregistered GPs colluding with SPM panel GPs to make claims under the scheme, false claims (no medicines or services provided), and the sale of medications at the counter without doctor consultations.
Actions taken so far include the termination of two GPs from SPM and the suspension of 44 others, who are under investigation.
Dr Shanmuganathan said the findings suggest that ProtectHealth, a fully-owned subsidiary of the Ministry of Health (MOH), has not put adequate processes in place to prevent these moral hazards.
“Those involved in managed care would know better, as dealing with moral hazards is basic for these organisations,” Dr Shanmuganathan said. “A moral hazard occurs when one party in a transaction has the opportunity to assume additional risks that negatively affect the other party. The decision is based not on what is considered right but on what provides the highest level of benefit, hence the reference to morality.”
Medical Practitioners Coalition Association of Malaysia (MPCAM) president Dr Soo Tai Kang echoed the call for an audit by the Auditor General’s Department to assess the Madani Medical Scheme’s success and funding.
“ProtectHealth can audit its doctors, but the Auditor General’s Department should audit ProtectHealth on their mechanisms and financial management,” Dr Soo told CodeBlue.
When asked whether ProtectHealth should file complaints with the Malaysian Medical Council (MMC) to investigate suspected GPs and potentially remove them from the medical register if fraud or unethical practices are confirmed, Dr Soo said that the MMC oversees the ethical conduct of registered doctors.
“Complaints launched by patients or doctors will be investigated. Not third-party providers. Also, striking doctors off because of such practice is not supported because it is not serious malpractice,” Dr Soo said.
Dr Soo defined “serious malpractice” as wrongful diagnosis and treatment or causing harm to patients through incorrect treatment. In contrast, he categorised overclaiming reimbursement as a criminal breach of trust.
Dr Shanmuganathan added that managed care organisations (MCOs) typically address these issues through provider communication for correction. He noted that the MMC conducts inquiries upon reports, and fraud should be reported to the police.
Dr Shanmuganathan warned that failing to address potential issues in public-private partnerships in primary health care can lead to disaster.
“Before embarking on such ventures, due diligence must be done to screen provider applicants. The system must have checks and balances to reduce these hazards. As said earlier, ProtectHealth does not seem to have done the needful before launching these schemes. Are they ready to handle these challenges? While they say they have some checks, obviously it is not enough,” Dr Shanmuganathan said.
Dr Soo highlighted the need for transparent and sustainable partnerships. He recalled a meeting where MPCAM, FPMPAM, the Malaysian Medical Association (MMA), and the Organisation of Malaysian Muslim Doctors (Perdim) objected to the reimbursement and fee structure, as it was below regular charges.
“However, we were told that such market survey prices were from their reliable sources and this scheme was carried out,” Dr Soo said. “Such partnership should be win-win for both parties, and private GP should be allowed reasonable charges to sustain their practice.”
