KUALA LUMPUR, Dec 1 — The Federation of Private Medical Practitioners’ Associations, Malaysia (FPMPAM) has criticised the “normalisation” of clinical interference from third-party administrators (TPAs) or manage care organisations (MCOs).
Referring to CodeBlue’s recent interview with PMCare Sdn Bhd, FPMPAM noted that the TPA openly acknowledged that referrals, investigations, medication choices, and even treatment quantities were subject to TPA validation and approval.
“No call centre or administrative officer should override or delay a doctor’s clinical judgement. This is unauthorised intrusion into medical decision-making, not benefit management,” said FPMPAM president Dr Shanmuganathan TV Ganeson in a statement today.
“Such interference places doctors in conflict with their professional obligations under the Malaysian Medical Council (MMC) Code of Professional Conduct.”
FPMPAM said managed care “achieves” lower costs only by restricting care, limiting clinical choice, and inserting non-clinical gatekeepers between patients and their doctors.
“These practices raise significant concerns about clinical interference, ethical infringements, and patient safety.”
The doctors’ group said typical managed-care arrangements raised “serious ethical red flags”, such as blanket consent clauses allowing employers access to workers’ medical information, restrictions on prescribing beyond narrow commercial formularies, and contractual provisions that supposedly prevented doctors from raising concerns.
“They undermine the sanctity of the doctor–patient relationship, reduce confidentiality protections, and place doctors in untenable positions when clinical need conflicts with administrative limits,” said Dr Shanmuganathan.
FPMPAM highlighted the risk of wrong medication, delayed diagnosis, and fragmented follow-up and increase of avoidable complications when referrals are delayed, investigations restricted, or chronic patients diverted to pharmacies instead of their treating doctors.
“Cost reductions achieved through these mechanisms cannot be claimed as ‘efficiency’. They are a form of care rationing that transfers risk to the patient.”
The doctors’ group further characterised the discrepancy between PMCare’s reported medical cost inflation figures and national indicators as reflective of “administrative price suppression, not true market behaviour”.
“Similarly, the continued anchoring of GP consultation fees around RM30 to RM35 is a direct result of decades-old fee ceilings and strict TPA reimbursement controls, not actual practice costs. This undermines the sustainability of primary care clinics nationwide.”
FPMPAM demanded regulatory safeguards to establish clear boundaries on what TPAs can and cannot control, rules that prevent non-clinicians from overriding medical judgement, stronger protection of patient confidentiality, and fair and transparent reimbursement practices.
In an interview with CodeBlue, PMCare, a 30-year-old TPA that pioneered managed care in Malaysia in 1995, explained that its claims or guarantee letters are usually handled by non-medical staff who are guided by parameters in the company’s proprietary system, based on the client’s policy or schedule of benefits.
PMCare chief executive officer Kamal Aryf Baharuddin also attributed the company’s low medical cost inflation of under 1 per cent for hospitalisation and about 10 per cent for general practitioners (GPs) last year to its cost control measures.
PMCare reported an RM131 average cost per GP visit in 2024.
The TPA’s cost containment measures included redirecting stable chronic patients to GP clinics or participating pharmacies to get long-term medications, instead of hospitals, in a bid to reduce tertiary care utilisation.
PMCare’s payments to panel GPs nationwide this year averaged at around RM134, comprising RM100 medication and RM34 consultation.
Kamal said PMCare exercised “strict controls” over medication pricing, medication–diagnosis appropriateness, and dispensing quantities “to prevent abuse, ensure clinical appropriateness, and minimise wastage”.
He added that Health Minister Dzulkefly Ahmad has yet to gazette the new RM80 consultation fee ceiling into law; panel GPs have not yet requested PMCare to raise their consultation fees.
