At least four associations representing private medical practitioners in Sarawak, Sabah, Penang, and Selangor/ Kuala Lumpur have already, are planning, or are considering recommending new clinic fees for patients.
Sarawak practitioners took the lead on May 1 itself by introducing three additional charges to the standard doctor consultation fee, when the Ministry of Health’s (MOH) drug price display policy came into effect under the Price Control and Anti-Profiteering Act 2011 (Act 723).
The Society of Private Medical Practitioners Sarawak (SPMPS) has recommended that Sarawakian general practitioner (GP) and specialist clinics charge a prescription fee (RM5-RM10), registration fee (RM5-RM10), and regulatory compliance charge (RCC) at RM5-RM20.
The Association of Private Practitioners Sabah (APPS) has recommended 3+1 new fees for private medical clinics in Sabah: facility fee (RM5-RM15), patient registration fee (RM5-RM10), RCC (RM5-RM20), plus an optional prescription fee (RM5-RM10) for prescriptions issued without in-clinic medicine dispensation.
The Penang Medical Practitioners’ Society (PMPS) is planning to recommend a service fee for private GP and specialist clinics in Penang, with the range to be decided later.
The Private Medical Practitioners’ Association of Selangor and Kuala Lumpur (PMPASKL) will decide next week on whether to advise members to charge patients new facility and registration fees; there is “very strong interest” in introducing new fees.
Rather than wait for the government to fulfil its promised review of GP consultation fees, doctors have taken immediate action to protect their interests, especially after Health Minister Dzulkefly Ahmad broke his promise to raise consultation fees before mandating medicine price display last May 1.
Private clinic GPs’ consultation fees have stagnated at RM10 to RM35 for more than three decades under Schedule 7 of the Private Healthcare Facilities and Services Act 1998 (Act 586).
To illustrate, if Sabahan and Sarawakian private practitioners already imposed the maximum new recommended fees, they’d be earning an additional RM55 and RM40 respectively for each patient they see today.
These amounts exceed the RM35 that they might receive sometime in the nebulous future, should the government double GPs’ ceiling consultation fee to RM70, a significant 100 per cent increase.
Hospital-based GPs’ consultation fees are set at RM30 to RM125 under Schedule 13 of Act 586. Equalising Schedule 7 with Schedule 13 translates to a 257 per cent increase for clinic GP consultation fees.
By implementing new additional fees for patients immediately, the balance of power shifted from the government to doctors. Using a decentralised approach also strengthens the medical profession’s bargaining position in its fight against price transparency.
Actually, there’s nothing for doctors to bargain over since they already acted unilaterally across multiple states, without waiting for unnecessary “permission” from the government, just like how Putrajaya unilaterally mandated drug price display.
According to the Department of Statistics Malaysia’s (DOSM) Basic Expenditure of Decent Living Index, it is most expensive to “live decently” in Selangor at RM5,854 a month, followed by Kuala Lumpur (RM5,468), Labuan (RM5,376), Melaka (RM5,291), and Putrajaya (RM5,249). Malaysians need RM4,414 in Sabah and RM4,167 in Sarawak to “live decently”.
Should private medical clinics use this index as a guide in charging new fees and to compare to the maximum RM40 of three additional clinic charges in Sarawak, practitioners in Selangor and KL may choose to charge patients up to RM52 to RM56 in whatever new fees they want to introduce.
The nightmarish stagnation of GPs’ consultation fees originated from a fee schedule proposed by the Malaysian Medical Association (MMA) in the 1980s. This was a pre-emptive move by the largest doctors’ NGO in the country in the event that a national health insurance scheme was to be introduced.
The RM10 to RM35 in GP consultation fees was an MMA fee schedule released in 1992. Without strong opposition from the medical profession then (doctors didn’t stage a demonstration), the government legislated this rate into a statutory scale under Schedule 7 of Act 586 in 2006.
Legal fees for lawyers are not fixed by a statutory scale, except for non-contentious matters like conveyancing. For contentious matters like litigation, lawyers and clients have the flexibility to negotiate fees for individual cases, guided by rules like the complexity and novelty of the issues involved.
Whatever new clinic fees implemented in Sarawak, Sabah, Penang, Selangor/ KL, or other states are likely to be legal, since Act 586 only regulates doctors’ professional fees. GP clinics are simply beginning to mirror what private hospitals have been doing by imposing multiple charges beyond a doctor’s consultation or procedure fee.
So the government won’t be able to stop GP clinics from introducing various new charges, unless it places the same prohibition onto hospitals.
Using a state approach will also probably make it harder for the MOH to persuade – not legally compel – doctors to scrap these new fees, since the government will have to negotiate with multiple associations, rather than a single national organisation like MMA or the Federation of Private Medical Practitioners’ Associations Malaysia (FPMPAM).
In fact, learning from MMA’s experience with the stagnant consultation fee, doctor groups will likely prefer to keep additional charges unregulated instead of proposing more statutory fee schedules that could remain unchanged for decades.
Without legal authority to strike down new fees by GP clinics, the MOH may rely on potential public anger to force doctors to the negotiating table.
But merely touting the moral high ground has limited utility because it is the provider, not consumer, who holds the cards in Malaysia’s dual health care system.
As proven by the actions of Sarawak, Sabah, Penang, and Selangor/KL doctor groups, a Nash equilibrium is in play, where private practitioners mutually cooperate by collectively introducing new charges, instead of racing to the bottom in a price war.
Unlike hospitals in which patients are willing to travel out-of-state for specialised services, Malaysians are highly unlikely to go outstation for primary care just to avoid paying additional fees of RM50, for example, in a GP clinic.
Threats of boycott won’t work either — because of the availability of the public health care system and panel coverage.
Nothing can beat RM1 for two months’ worth of medications. The reason why Malaysians visit GP clinics in the first place is because they’re willing to pay a lot more to get seen by a doctor in just a few minutes and to collect their drugs at the same place, instead of waiting for hours in a congested klinik kesihatan. Time, not money, is the GP clinic’s unique selling proposition.
The MOH’s price transparency effort received massive public support, which is rare for health care policies that are typically discussed only within the profession or sector. Malaysians deserve to know the price of things before deciding whether to make a purchase. This is a common-sense consumer right.
Ironically, a policy meant to curb medical inflation may have inadvertently opened a Pandora’s box with new market-driven charges by GP clinics, creating the opposite effect with more expensive clinic visits.
Drug price display mainly targets primary care clinics, even though public conversations over the past year about medical inflation have been about large itemised hospital bills and health insurance premium hikes.
Despite the MOH’s best intentions in protecting consumers with price transparency (yes, patients are consumers), perhaps it should have heeded this idiom: “If it ain’t broke, don’t fix it.”
Boo Su-Lyn is editor-in-chief of CodeBlue.
