KUALA LUMPUR, Oct 21 — A CodeBlue survey among private specialists indicates perennial and perhaps even systemic interference by the insurance industry with the practice of medicine, said the Academy of Medicine of Malaysia (AMM).
AMM master Prof Dr Hanafiah Harunarashid, who is also a surgeon, said the AMM, an umbrella body that represents 13 medical specialties in the country, felt strongly about clinicians’ autonomy.
“Clinical decisions must always be made by those directly responsible for patient care. When administrative or financial controls begin to influence medical judgment, we risk compromising both safety and trust. Patient welfare must always come first,” Dr Hanafiah told CodeBlue today when contacted.
He also noted that Malaysia’s private health care sector has expanded rapidly within a few years, along with the country’s economic growth, particularly the finance and insurance sector.
“This rapid change has overtaken the slow pace of legislative and regulatory maturity that any modern society needs to balance the fragility of the investment market and the need for protecting consumers,” he said.
“We should all start with agreeing there needs to be safeguards for patients and practitioners in insurance practice, and genuine cooperation among all stakeholders, payers, providers, regulators and consumers for mutual benefit must be sought in order to find a good sustainable solution in the long run.
“This is most important to open the way for responsible health care financing that is fair, equitable, accountable and efficient for all levels of society.”
In a series of four articles on a nationwide poll run by CodeBlue among more than 850 specialists across specialties in private hospitals, CodeBlue reported that 99 per cent perceived interference from insurers and takaful operators (ITOs) or third-party administrators (TPAs) with their clinical decision-making.
Specialist doctors participating in the survey also wrote at length about the pervasiveness of health insurance tactics of “Deny, Delay, Revoke” in Malaysia that are beginning to mirror American health care, affecting patient care and outcomes.
“Deny” refers to outright refusals of care, including by invoking “pre-existing conditions” like chronic diseases that are unrelated to the admission diagnosis. Insurance also denies coverage of various diagnostic tests, procedures, and drugs or therapies, as well as inpatient care by only insisting on daycare or outpatient treatment instead.
“Delay” is bureaucratic stalling by insurers that leads to postponed surgeries, admission, or critical interventions for medical emergencies.
“Revoke” refers to the retraction of guarantee letters (GL) after admission or completion of a procedure or treatment, forcing referrals to government hospitals or leaving patients stuck with private hospital bills and doctor fees unpaid.
“The Academy of Medicine believes accountability should extend to all who shape patient care,” said Dr Hanafiah, when asked if legislation should be enacted to hold ITOs or TPAs liable for medicolegal implications from denials or delays of patient care.
“When administrative directives delay or deny treatment, it is only fair that those issuing them are also held answerable for the outcomes.”
AMM supported calls from the Galen Centre for Health and Social Policy and Bayan Baru MP Sim Tze Tzin for the establishment of an independent statutory Private Health Care Commission to regulate ITOs and TPAs, as well as private health care providers.
“Conceptually, the establishment of an independent statutory Private Health Care Commission could be a strong governance move, provided it is designed properly. We need more details and it has to be fairly represented by appropriate stakeholders,” said Dr Hanafiah.
The AMM master cautioned against a “one-sided, heavy-handed” approach to regulation, saying that neither Bank Negara Malaysia (BNM) nor the Ministry of Health (MOH) should be the unilateral enforcer on private health care costs or financing, due to their different mandates.
MOH, the largest health care provider in the country, is also “already encumbered by existential crises of overburden, resource shortages, and challenging threats.”
Health director-general Dr Mahathar Abd Wahab recently warned ITOs and TPAs against interfering with doctors’ clinical decisions that he said could be illegal, citing Sections 82 and 83 of the Private Healthcare Facilities and Services Act 1998 (Act 586).
The operations of ITOs and TPAs in health care are mostly unregulated, aside from fraud regulated by the central bank. A CodeBlue editorial has demanded the enactment of legislation, similar to the United States’ Patient Protection and Affordable Care Act (ACA), to prohibit ITOs in Malaysia from denying coverage or charging higher premiums due to pre-existing conditions.
