KUALA LUMPUR, August 1 — Rakan KKM will need to expand its operations and charge rates equivalent to private hospitals if the programme intends to generate revenue, say health experts.
Mark Cheong, deputy head of school (education) at Monash University Malaysia’s School of Pharmacy, highlighted the contradiction in the government’s objective of using Rakan KKM private wings in government hospitals to raise money for the underfunded public health care system.
“It’s hard to imagine that Rakan KKM will actually be able to solve this huge problem that we have with regards to the underinvestment of our health care system,” Cheong said on Astro Awani’s Consider This, hosted by Melisa Idris, on Wednesday.
The public health and palliative care researcher cited reports that Rakan KKM would only operate after-office hours or weekends and provide a narrow scope of elective services. Hence, Rakan KKM would appear to be a relatively low-volume service.
“If that is the case, presumably then revenues aren’t going to be that high, nowhere near the amount of money we need to actually make up for the underinvestment in our health care system,” said Cheong.
“So even if everything goes right for Rakan KKM, it’s hard to see it as the silver bullet that will solve our national health care problems.
“Ironically, if it were then to try to achieve that aim, it would have to massively scale up its scope and operations, which would then really do away with the national health service system that we have right now.
“In that case, our worst nightmare will come true – we will truly have privatisation of our health care system.”
On the same Consider This segment, Galen Centre for Health and Social Policy chief executive Azrul Mohd Khalib similarly questioned the amount of revenue that could be earned by Rakan KKM.
“Is there enough money that’s going to be generated from Rakan KKM that it’s going to be able to go back into the system to build investments, to build new hospitals, pay our private wing better in terms of medical professionals, specialists, nurses, modernise equipment, digital health, modern infrastructure? Is there going to be enough?”
He noted that private hospital group KPJ Healthcare Berhad – which operates 29 hospitals in Malaysia – only posted RM57 million net profit in the first quarter of this year, just 5.9 per cent of its RM971.8 million revenue for that period.
“In order for Rakan KKM to demonstrate the kind of outcomes or outputs that we’re expecting, they have to make a lot of money. They have to make it very soon. And most importantly, they have to charge probably higher, much much higher than what we’re talking about right now, to maybe the point of being similar to a private hospital,” said Azrul.
He added that the most important pull factor for patients to Rakan KKM in competing with conventional private hospitals is time and quality of service.
“This thinking that private paying patients are willing to be charged and pay higher rates is true, but only to a certain extent,” Azrul said.
“Will it [Rakan KKM] provide quicker service, better service, and will it mean you have timely and effective access to treatment that works for you?”
He said “cavalier” suggestions that Rakan KKM would only operate after-hours, in a bid to address concerns of private wings affecting public patients, contradicted the government’s promotion of Rakan KKM as a “premium service”.
“You’re supposed to be able to get the attention of the consultants that you want, when you want it, and get it quicker. But if these guys are supposed to do it after they’ve finished all their public service, then when are they going to do it?” said Azrul.
“Who’s going to do an MRI or CT scan in the middle of the night, for example?”
Azrul also pointed out that Rakan KKM’s predecessor, the full-paying patient (FPP) scheme, only generated RM20 million revenue from 10 hospitals in 2017, averaging at RM2 million per hospital, according to the Auditor-General’s 2017 report.
“Now that sounds like a lot – until you realise that it’s not,” said Azrul.
“Our actual amount of need is actually in the billions, not single-digit or double-digit millions. The issue here is – have we learned enough from the FPP programme?”
The health expert noted that the scope of the FPP scheme declined over the years and mostly provides just obstetrics & gynaecology (O&G) services now, as specialists resigned from the public health service.
Low-Income Patients Most ‘Time-Poor’, What Are ‘Elective’ Procedures?
In response to Melisa who asked about ethical issues with patients paying to “essentially cut the queue”, Cheong said the biggest concern was the inequalities that Rakan KKM threatens to create.
“It really does start to create a difference between the haves and the have-nots,” he said.
He added that limiting Rakan KKM to elective procedures and offering shorter waiting times was “not completely harmless” either.
“When we think about shorter waiting times, it’s perhaps tempting to think it’s just a difference between a half-an-hour wait versus a two-hour wait. But if you consider especially Malaysians who are from poorer backgrounds, ironically they are the ones who are the most time-poor themselves,” Cheong said.
“For them, additional waiting time, longer queue, will mean another day of lost income. It may mean additional child caring costs, and it may very well lead them to decide, ‘it’s really not worth me waiting longer, and so I’m going to then skip my appointment’.”
The public health researcher also questioned the definition of “elective” procedures.
“Is an outpatient consultation with a cardiologist elective? If you’re waiting in queue to check whether or not you have some serious heart condition, a simple outpatient appointment like that may not actually be elective. It may actually have an impact on your health,” Cheong said.
“Another example that was thrown about – it might be a procedure for trigger finger. But if you’re a manual worker and you work using your hands, a trigger finger isn’t something that is inconsequential to your livelihood. So can you actually afford to wait longer for that?”
‘Incredibly Unclear’ Evidence Of Specialist Retention Under FPP
Cheong said the FPP scheme introduced in 2007 aimed to retain specialists and consultants by enabling them to earn extra income – the same objective for Rakan KKM.
“There have been a couple of studies done. The evidence is incredibly unclear as to whether or not it’s actually helped to retain more specialists than before,” he told Melisa.
He challenged the assumption that health care workers are leaving the MOH mainly because of low remuneration.
“We’ve heard from health care workers on the ground, colleagues of mine even, that it’s a mixture of culture, bureaucracy, issues with autonomy, the lack of career progression, and welfare.”
The AG’s 2017 report concluded that while the FPP scheme reduced specialists’ attrition rate, other factors contributed to their retention in public service, such as job security, professional medical indemnity, and support from more experienced specialists.
Azrul pointed out that the public sector currently faces a shortage of about 11,000 specialists, besides a dire lack of nurses.
“The thinking that maybe Rakan KKM can make use of surplus or excess capacity just isn’t really there.”
The four hospitals that Rakan KKM plans to launch at – Cyberjaya Hospital, Putrajaya Hospital, Sultan Idris Shah Serdang Hospital, and the National Cancer Institute (IKN) – are seeing a “huge number of patients”, especially Serdang and Putrajaya.
“Where are we going to get the manpower?” questioned Azrul.
“These are the same services that are going to be dependent on the same equipment, same expertise, same labs – when is this going to happen? When are Rakan KKM’s needs going to be addressed if they’re also competing with the public patients that are happening at the same time?”
