PUTRAJAYA, Jan 13 — Dr Abu Bakar Suleiman, clinical advisor to Health Minister Dzulkefly Ahmad and the Ministry of Health (MOH), has lambasted the MOH as he questioned the direction of Malaysia’s health care system.
At a town hall on diagnosis-related groups (DRG) in MOH’s headquarters here last Thursday – which was attended by over 100 senior ministry officials and external stakeholders – the former Health director-general delivered a stunning rebuke of the MOH in a soft-spoken voice.
“You need to get your priorities right,” Dr Abu Bakar told the town hall moderated by MOH deputy secretary-general (finance) Norazman Ayob.
“If you don’t know where you’re going, any road you take will not get you there,” he said, paraphrasing from Lewis Carroll’s Alice in Wonderland.
Dr Abu Bakar described DRG as a “very helpful” tool in a health care budgeting process, but asked, “What do you hope to achieve? You are stuck in the health system of the last century.”
The clinical advisor to the health minister and MOH said he hasn’t heard anything about value-based care or how DRGs will help in the transformation of the health care system.
“You’re not doing DRG for the sake of DRG, for goodness sake,” he said, adding that value-based care is about creating value, measured in the quality of human interaction, clinical outcomes, and the cost of care.
“Value is not cheap care.”
Dr Abu Bakar stressed the need to provide health care services outside hospitals, “which you’re not doing.”
The clinical advisor said he made certain recommendations on this after Covid-19, but “MOH just ignored it. MOH did not learn from the Covid pandemic.”
Even as Malaysia aims to provide 2.2 beds per thousand population (2.01 was achieved in 2020), Dr Abu Bakar said more hospital beds are needed “in the right places” and that most specialists should work in non-hospital based services, such as day surgery. Home care should also be developed.
“You talk about DRG when you don’t do that? DRG is not just for hospital care; you’re talking about the treatment of patients. You need to do DRG for chronic disease as well, otherwise it doesn’t make sense,” said Dr Abu Bakar.
In a traditional DRG model, patients are classified based on diagnosis and procedures to determine costing or budgeting. But DRG (or casemix) has evolved into a classification of a “patient episode of care”, including chronic conditions and both inpatient and outpatient care, according to health economist Prof Dr Syed Mohamed Aljunid Syed Junid.
“Can you see the disaster of Ministry of Health?” Dr Abu Bakar said. “Hospital in silo, primary care silo, pharmacy silo, nursing silo.”
“You all want to stay in the health system of the last century. I’m very concerned for my grandchildren – what kind of health system is going to be there for them?” added the 80-year-old.
Towards the end of the three-hour town hall, Dr Abu Bakar sought to modulate his tone.
He noted that Dzulkefly wants value-based care to be the core of Malaysia’s future health care system, but Dr Abu Bakar called for DRG to be implemented gradually, not in a “big bang.”
“I think the Ministry of Health has done a lot of good work in that respect, despite my provocations earlier on,” said the former Health DG, who served from 1991 to 2001.
The MOH piloted the DRG model in six MOH hospitals in 2010, before expanding it to 38 MOH hospitals in 2016.
In 2023, the DRG model was fully expanded to all 149 MOH hospitals under a MyCMX system development. Despite having had the DRG system in place at dozens of hospitals for nearly a decade, the MOH has only ever used historical budgeting for its ministry-wide allocations.
Dr Abu Bakar pointed out that private health care providers love the fee-for-service model, in which they are paid or reimbursed based on the amount of services provided. But countries around the world are moving away from fee for service.
“If you look at fee for service, 100 per cent risk is borne by the patient or the funder. The provider takes zero risk. Is that fair? DRG, with average cost, they give room for you to make your margin.”
The MOH has formed a Provider Payment (DRG) Working Group, as Prime Minister Anwar Ibrahim’s administration seeks to develop a national DRG payment model following public outrage over rising medical insurance premiums.
The Steering Committee of the Provider Payment (DRG) Working Group, appointed last October 25, is co-chaired by the MOH secretary-general and the Health director-general.
Universiti Malaya health economist Prof Dr Maznah Dahlui was appointed last November 12 as chairwoman of the Technical Advisory Committee under the Steering Committee.
