With the introduction of the 13th Schedule of the Private Healthcare Facilities and Services Act 1998 (Act 586), a solution to the woes of private health care organisations and insurers has hopefully presented itself.
The old schedule is outdated because it does not reflect how things have progressed. The Ministry of Health (MOH), Ministry of Finance (MOF), and Public Service Department (JPA) are also victims here as they are subject to the rules stipulated in the previous schedule. I do not blame them for not being able to formulate a better way to be progressive, react faster, and do what is needed.
As doctors, we do what is best for our patients, not our egos. MOH must acknowledge they are not doing right with regard to serving patients, doctors, and insurers.
The 13th Schedule Act is outdated in many ways, since back in 1998, no one talked about having subspecialties. Today, a carpal tunnel release procedure can be done by a general practitioner, plastic surgeon, neurosurgeon, and hand surgeon, who will all charge the same fee.
The old Act may not adequately reflect differences in complexity, duration, risk, expertise, and resources required to delivered the best care.
Carpal tunnel release done by endoscopic release and open surgery is also subject to the same charge. A static or periodically amended fee schedule cannot adequately accommodate the rapid evolution of medical science and technology.
The considerations that should matter in the fees are specialist and subspeciality training, years of experience, complexity of the procedure, and duration of the surgery.
If a patient has a one cm laceration wound and another patient has a 20 cm laceration wound, the charge to clean and repair the wounds is the same. Clinical risks and responsibilities are also masked due to the complexity of the procedure.
However, is a femur fracture in a 35-year-old vs a 75-year-old the same? The Act sees it that way and so will insurance companies.
Another issue, of which I am also a victim, are after-hours additional charges. If a procedure like replantation of a severed thumb starts just before 6.00pm, it may only be finished four hours later.
In this case, I am not allowed to charge emergency charges. This ruling really saddens me as it does not take in account the time and effort taken, and also time away from family.
The old Act also deprives doctors from being compensated for time on Saturdays, since we have to charge normal fees until 1.00pm. I really cannot understand why this is allowed in the first place. When the government switched the working week to five days, the MOH should also have followed suit.
For more complex cases like tumour excisions, the oncology surgeon is allowed to charge full fees, but the plastic reconstructive surgeon can only charge half their fees.
There is no clear mechanism on fee disputes between doctors, TPAs (third party administrators), and insurers. On many occasions, we find ourselves trying to answer non-medical questions from them.
Unfortunately, as hand surgeons, we do get complicated cases sometimes. When this happens, the previous Act views a multiple level fractured bone as the same as a single level fractured bone.
The last time the Act was amended was in 2013. Our earning capacity as private surgeons has reduced cumulatively by about 28 per cent since then, due to inflation.
Insurers and private health care establishments know this fact very well but still turned a blind eye to our plight. Insurers still demand discounts from hospitals and doctors.
Despite the Health director-general calling out this practice, insurers are still demanding discounts on doctors’ charges.
When it comes to medical premiums, I think they should be regulated, as affordable insurance can effectively reduce the burden on public health care facilities. Insurers are getting away with many things that need proper regulation, including definitions of preexisting conditions, claims, and other issues.
The framework of the new Act should also include overall facility fees. The introducton of DRG is a step in the right direction here.
Another issue that the Act must include is medicolegal litigation and appropriate compensation. The impact of a single case has an overall impact as it can be applied to future cases and to insurance premiums.
The MOH Annual Report 2024 records that a draft amendment to the Thirteenth Schedule proposed adding 1,268 procedures and notes. This illustrates the scale of the updating exercise, but there has been no change to the system. It has taken more than 10 years and five health ministers, MOH, MOF, and many other government agencies.
Our government apparatus is too slow to deal with recurring issues like ageing facilities, lack of manpower, long waiting lines, dying patients, and inadequate treatments.
I have the honour of working with some hardworking and amazing people in the government, but they are being let down by poor management of resources, and worse still, their lives are placed at risk when they work in inappropriate work conditions.
In short, we need a new Act that will be able to address all the current shortcomings of the system. Fee structures and mechanisms should be amended to deal with the current health needs of the population, and the issue of rising costs should also be tackled.
The author is a hand, microsurgeon and orthopaedic surgeon in private practice.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
