This five-part series was initiated as the result of current discussions on medical inflation. Our earlier essays had captured the major contributors of rising medical costs, which include the laissez-faire, skyrocketing insurance premiums that are planned to increase by a whopping 40 to 70 per cent, and unregulated, hefty private hospital bills.
Others include investments in new technologies, new expensive medicines, expectations of increasingly informed patients, star quality hospital ambience, branding and the frills of comfort, and premium private hospital services.
Examples include options in the brave new world of medicine such as radical resection, targeted radiotherapy and/or chemotherapy, and new monoclonal antibodies that form personalised medicine.
Our conclusion is DRG is not the be-all and end-all, nor is it the panacea for rising medical inflation. It, however, has its appropriate and specific role in the overall transformation towards a sustainable health financing scheme.
Getting Priorities Right
Every Malaysian acknowledges that the unity government inherited a broken public health care system. The health care issues we face today are primarily due to irresponsible and immoral previous political policies and governance.
Yet, it makes no sense for the government to come down hard on a flourishing and profitable health care industry, when many pivotal “reformasi promises” have yet to be realised, let alone gestated.
Therefore, we urge the Prime Minister and his unity government not to act impulsively, or issue rash statements, on matters that have been beleaguering Malaysians for decades, such as medical inflation.
They need to stay calm, reflect, analyse, and accurately diagnose the primary problem in our unique, dual, separate, polarised, and public and private health care ecosystems, before jumping on what appears to be a quick fix.
Pinning Down The Problem
With any major health reform programme, we must endeavour to find a win-win engagement. This demands a lot of training and change management in ensuring quality care and patient safety are not affected in the transition.
Any drastic changes with major ramifications to the present health care ecosystem that affects clinical practice is surely going to cause a different set of issues at the expense of best patient care if done without proper engagement, agreement, and training of the main players (private hospitals and private specialist) and without getting more hands-on support.
Unfortunately, the recent townhall conducted by the Ministry of Health (MOH) on diagnosis related groups (DRG) had unearthed more questions than answers. Health policy experts are not specialists nor surgeons, and they may not understand the complexities of diagnosing, treatment and decision making.
Eighteen countries in the OECD, piloted the DRG system, ranging from a one-year DRG pilot programme in Poland, up to 18 years in Chile. The average pilot DRG period was 7.4 years.
In Malaysia, we are still struggling with the DRG case-mix to comply with a passable grade after many years. There are just not enough good clerks or clinic assistants. Eventually, the data entry falls back to the doctors to fill it up correctly. And guess what, they too don’t do a good job, and they hate it.
We need to refine the system until it covers virtually every diagnosis, every severity, and every situation. This is quite clearly a tall order, because clinical medicine is neither precise nor certain all the time.
While the main objective of DRG is to manage costs, it may instead lead to supplier-induced demand, where volume of services goes beyond what is medically necessary.
It is potentially open to abuse, when unscrupulous hospital operators can modify treatment decisions to fit the DRG category, which can compromise patient care and outcomes.
Similarly, patients may be upcoded even sicker than they actually are for hospitals to increase payments, putting patients and families through unnecessary distress and anxiety.
Stepwise Approach
MOH must recognise that the pushback from private hospitals and private specialists is real and not unwarranted. One can think of many points of systems failure and potential unethical practices from major shifts like this be-all and end-all DRG mindset of the political governance.
Therefore, the MOH must not rush DRG implementation due to pressure from the highest in political office. In bad hands, even a good system will churn out bad outcomes.
We recommend a stepwise approach of gradual implementation of the DRG into the healthcare ecosystem, a plausible roadmap towards addressing medical inflation.
In our opinion, the DRG is best piloted in select MOH hospitals and university hospitals under the Rakan KKM programme, and/or a few voluntary private hospitals. Each major hospital group may volunteer one or two of their hospitals for this DRG pilot programme.
DRG may be a good tool to manage rising medical costs, but it requires further analysis for practical implementation involving people, process, and technology.
Hybridisation may be necessary, a combination of different tools including value-based care, for a health care system that truly leaves no one behind.
Read Part 1, Part 2, Part 3, and Part 4.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
