We presume that the CodeBlue article titled “APHM Denies Health Insurance Buffet Table Syndrome, Says Malaysians Getting Much Sicker” represents the official views of the Association of Private Hospitals Malaysia (APHM).
(Editor’s note: That article was published in March 2025, based on an interview of APHM officials by the Keluar Sekejap podcast).
While there is truth in the underlying health crisis, APHM’s dismissal of all insurance overutilisation as a “myth” paints an incomplete picture.
It is a classic case of seeing the world through rose-coloured glasses, ignoring a significant and well-understood driver of medical inflation in favour of a single, more sympathetic narrative.
Rising Claims Due To Genuine Sickness Versus Over-Utilisation
To claim that over-utilisation is a complete myth is to throw the baby out with the bathwater. While the non-communicable disease (NCD) crisis is real and severe, it does not negate the parallel reality of insurance-driven consumption.
In health economics, “moral hazard” is a fundamental concept where individuals consume more healthcare because they are insulated from the true cost by insurance.
To deny this exists is to ignore a basic driver of demand in any insured market. The “buffet table syndrome” is the local manifestation of this global phenomenon.
The article quotes APHM’s honorary secretary, Anwar Anis, who stated, “The increase in claims in Malaysia after Covid-19 has indeed been quite high… we are among the highest.” This high claims environment naturally creates fertile ground for both necessary care for the sick and unnecessary care driven by the presence of a medical card.
APHM president Dr Kuljit Singh’s argument that “nobody finds being in a hospital cool” is a red herring. The issue is not about finding hospitals “cool”, but about seeking perceived “value” from a paid-for insurance policy, opting for convenience, or pursuing diagnostic peace of mind at no immediate out-of-pocket cost.
To suggest that the only game in town is severe illness is misleading.
Disease Severity For Pneumonia And Dengue
APHM stated that, “In the past, pneumonia was just pneumonia, but now they come with bad pneumonia… And even if they get dengue, it is severe, to the point of being fatal.”
This characterisation presents a distorted picture that does not align with standard medical practice or national health data.
The claim implies a blanket shift in severity that justifies all hospitalisations. In reality, established Clinical Practice Guidelines (CPG) clearly defines “severe” pneumonia or dengue requiring hospitalisation versus milder cases that can be safely managed as outpatients.
The vast majority of dengue cases, for instance, are and should be managed without hospital admission, guided by clear clinical and laboratory criteria. The dengue CPG describes clearly on the need for daily follow-up, especially from day 3 of illness onwards until the patient is afebrile for at least 24 to 48 hours without antipyretics.
The patient is provided with an Outpatient Dengue Monitoring Record and Home Care Advice Leaflet for Dengue Patients. And the treating doctor is informed and alerted of the warning signs which would necessitate admission to hospitals.
Unlike the Base Medical and Health Insurance/Takaful (MHIT) Plan, many insurance plans do not cover the cost of outpatient management of dengue, thus patients are admitted to private hospitals to avoid having to pay out-of-pocket for outpatient blood tests and consultations.
The decision for outpatient management of community-acquired pneumonia (CAP) is guided by validated clinical severity scores, most commonly the CURB-65 score. Patients classified as low risk are candidates for safe and effective treatment at home with oral antibiotics.
This approach is strongly supported by major international guidelines from bodies like the American Thoracic Society (ATS) and the British Thoracic Society (BTS), and is endorsed in Malaysia’s own Clinical Practice Guidelines on Adult Community-Acquired Pneumonia.
The latest updates (December 2025) in the National Antimicrobial Guideline (NAG) contain the clinical pathways in primary care (outpatient) and the therapeutic recommendations by the Ministry of Health Malaysia.
The Malaysian guidelines explicitly state a key objective is to “reduce unnecessary hospital admissions,” reaffirming that outpatient management is a standard, first-line approach for clinically stable, low-risk patients.
The Base MHIT Plan covers the cost of treatment in outpatient settings for diseases like dengue, influenza A and B, bronchitis, pneumonia and bronchopneumonia.
While any death is tragic, national health statistics do not support a new, unexplained epidemic of fatal dengue or pneumonia post-pandemic that would explain a systemic surge in all related insurance claims. Using the most severe, fatal cases to justify a trend is comparing apples to oranges when discussing general admission rates.
In a fee-for-service private hospital environment, there is a natural financial incentive to classify a case as “severe” to justify admission, especially when an insurance card is presented. This creates a potential ethical conflict where clinical judgment and financial opportunity can become two sides of the same coin.
Patients In Private Hospital Emergency Rooms Being ‘Genuinely Sick’
APHM’s statement – “If you look at private hospitals, most of the patients you’ll see in ER, they are genuinely sick… and we have that data” – is an overgeneralisation that ignores the daily reality observed in many private emergency departments.
It is common knowledge among health care providers and the public that private hospital ERs are frequently used for non-urgent conditions—such as cough and colds, fever, body aches, or minor ailments—especially after-hours when regular clinics are closed.
Patients often present with these conditions and insist on admission after investigations, driven by the desire to “claim” from their insurance.
The dynamic described by the APHM president is only half the story. The full picture includes patients who, upon being told their condition does not warrant admission, request or pressure the attending doctor to admit them so their insurance will cover the cost of the ER visit, diagnostics, and a night’s observation.
This turns the medical decision on its head, putting the insurance tail in a position to wag the clinical dog.
The APHM’s claim to “have that data” is unconvincing without transparent, audited publication. A hospital’s record will, by definition, list a diagnosis that justifies the visit.
Such data cannot distinguish between a patient who came in with a genuine emergency e.g. acute abdominal pain suggestive of acute appendicitis and one who came in with a mild headache but, through insistence and selective symptom reporting, ended up with a billable admission for “observation for migraine.” The data they cite likely doesn’t tell the whole story.
A 2013 study of the Emergency Department (ED) at Universiti Kebangsaan Malaysia Medical Centre (UKMMC), found that 62.1 per cent of the total 66,603 patient attendances were classified as non-critical cases. The majority of these patients attended with non-urgent, minor issues, with 76.7 per cent of all patients being discharged immediately after treatment, reflecting a high rate of potential misuse of emergency services.
We think that the ER situation in private hospitals is not much different from UKMMC and our professional experience working in private hospital settings since 1997 and the post-Covid pandemic suggest similarly, and if anything, more minor cases were being seen.
The available clinical data and experiences directly challenge the blanket assertion that these diseases now universally present with greater severity.
Besides, the existence of clear, criteria-based protocols demonstrates that hospitalisation is medically indicated only for a specific subset of patients exhibiting defined risk factors. Therefore, a rise in total insurance claims for these conditions cannot be automatically attributed to a mysterious increase in disease severity without first examining whether the admissions aligned with these objective clinical benchmarks.
Conclusion: A More Balanced Perspective Is Needed
APHM’s narrative, while containing elements of truth about Malaysia’s NCD burden, is a half-baked explanation for the insurance crisis. It conveniently shifts the entire blame for rising claims onto disease patterns and absolves the private health care delivery system of any role.
The reality is that you can’t have your cake and eat it too. The combination of a genuine population health crisis and a systemic incentive for over-utilisation driven by insurance is what creates the perfect storm of “medical inflation”.
Ignoring either factor is a disservice to an honest conversation about health care sustainability. A sustainable solution requires addressing both the root causes of sickness and the structural incentives that encourage unnecessary care—not simply choosing one narrative over the other.
This letter was written by:
Dr Rajeentheran Suntheralingam, Urologist, Damansara Specialist Hospital (DSH)
Dr Musa Mohd Nordin, Paediatrician, DSH
Dr Ahmad Faizal Mohd Perdaus, Respirologist, DSH
Dr Sng Kim Hock, Neurologist, Pantai Medical Centre (PMC)
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
