Here is the question that keeps me awake: the same specialist treats the same illness in a public hospital for far less money. Move to a private centre, and the price shoots up. Apart from nicer rooms and better coffee, what really changed?
The Sleepless Question
In government hospitals, we learn to do more with less. We reuse, we plan, we stretch supplies. In private hospitals, the very same doctors work with premium devices, fast scanners, and the “latest” drugs. Patients are happy—until the bill arrives.
If we remove the hotel ambience, what explains the gap? It isn’t one bad actor. It’s a loop: how we pay, how we buy, what insurers cover, what tech we choose, and what patients expect. We clinicians are also inside that loop.
What Really Drives The Bill
Specialist fees are a small slice, but a big signal. Schedule 13 is usually not most of the bill. The big costs come from operating theatre time, room and board, implants and devices, scans and tests, and medicines.
Still, when we update Schedule 13 to add new techniques (e.g., robotics), the whole episode can drift up, unless we also change how we pay for the whole case.
The missing foundation: primary care. If we want DRG or case‑based payments to work, we must first strengthen primary care. The general practitioner (GP) fee schedule (Schedule 7) has been delayed for years, even though GPs are the gatekeepers for prevention, chronic care, referrals and post‑discharge follow‑up.
You cannot run DRG well without strong GPs. Underpay primary care, and more problems get pushed downstream into costly specialist and hospital care.
Buying and transparency. Opaque buying (public or private) breaks the link between price and value. If a generic or an equivalent ends up costing more than the original, trust collapses, and we waste money that should fund real innovation.
Facility economics—land, loans, compliance, and SST—also load into beds, devices, and theatre time. Patients rarely see these inputs; they only see the final total bill.
Utilisation management : Insurers use approvals and treatment limits as part of the policy contract with patients. The issue isn’t the rules themselves but that many doctors and patients don’t fully understand the coverage they paid for.
Clear education, plus published criteria, set response times, and a simple appeal process, can keep costs predictable without delaying care.
The Therapy Arms Race We Don’t Measure
In the public system, one laparoscopic set may serve a whole week. We still get good results. In private care, another force takes over:
- Hospitals compete on big machines and new toys—another robot, a faster CT, a wider menu of premium implants.
- Brand choices grow, but prices are often unclear to patients.
- We switch to single‑use items for ease, even when reuse is safe and common in the public sector.
New medicines, especially innovator drugs and breakthrough drugs, can save lives. But many new biologics, cell and gene therapies, and cancer drugs come with very high list prices.
Without strong health technology assessment (HTA), outcomes tracking, and smart contracts (like price‑volume or pay‑for‑results), we end up in a world where the drug is the bill. Public formularies and tenders help control use.
In private care, the idea that “latest is best”—among doctors and patients—feeds an arms race. Premiums rise. Patients pay more out‑of‑pocket. Sometimes for only small gains over standard care.
Insurance Is a Safety Net, But Even Nets Tear When Costs Soar
Insurance is a hedge against big medical bills. It only works if the bill is predictable. As costs climb, the net must get stronger — higher premiums, tighter approvals, smaller drug lists.
When that keeps rising, the market starts to crack:
- People drop their plans or buy cheaper ones.
- Companies cut staff benefits or exit, so TPAs also lose volume.
- Insurers face riskier pools, have to raise prices again, and add more rules.
Wha this means: Less affordability → less coverage → fewer insured cases → lower hospital volumes → tighter margins → delayed investment. Less fuel → less care → less revenue → less profit → unhappy shareholders. A vicious cycle that hurts patients and providers.
The fix is not to attack insurers for doing mathematics. It is to cut the root costs, bring back predictability, and keep the hedge affordable.
Shared Responsibility And Five Fixes
Clinicians are not guilty, but not blameless.
We choose the implant, the guidance system, the drug. We decide the scans and the length of stay.
In the public system, we learnt value per ringgit. In private care, the system often rewards speed and novelty, not value.
We have been vocal about the business side of private health care — and that also admits our place in the inflation loop. If we want to lead, we must show stewardship first: use a wider lens, remember our roots, and be efficient again. Remember your Ministry of Health (MOH) days.
Here are five practical fixes (control cost, keep quality):
- Back GPs first: Update Schedule 7. Pay for chronic‑care bundles and post‑discharge follow‑ups. Reward results (e.g., HbA1c, blood pressure), not just visits. DRG and case‑based models only work with strong primary care.
- Change how we pay hospitals: Pilot DRG / case bundles with quality checks for common conditions across public and private sites. Pay for outcomes, not throughput.
- Make advanced therapy earn its keep: Require HTA and value‑based contracts for high‑cost devices and innovator drugs (risk‑sharing, price‑volume, pay‑for‑results). Track real‑world outcomes so price follows benefit.
- Shine light where we can: Publish reference price bands for implants and high‑cost drugs and case bundles; build towards a robust data driven financing model; make insurer approval rules public and increase awareness among doctors and patients towards keeping Protection affordable for ALL.
- Teach health care economics: Put cost‑effectiveness into training and CPD. Use shared decision tools that show benefit and cost. Write guidelines that balance efficacy and affordability.
Medical inflation is not the ultimate fate. It comes from choices we made and can unmake.
Regulators should not delay ensuring that primary care is paid fairly. Hospitals should match big spending to real outcomes.
Insurers should make their rules clear and fast. And clinicians should lead by being efficient again.
Do these, and the same surgeon doing the same surgery can deliver value for all Malaysians in both the public ward and the private suite.
Dr P. Raju is a clinician, digital health care advocate, and former board member of the National Poisons Board. His work spans providing primary care through corporate health programmes with enterprise health care technology, aiming to bridge the gap between patient care and modern digital medicine.
The views expressed in this article are solely those of the author and do not represent the opinions or policies of any organisation, institution, or entity. The information provided is based on publicly available data and personal analysis.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
