In a past article, we emphasised the need to implement the National Healthcare Financing Scheme (NHFS) to ensure Malaysia complies with Universal Health Care (UHC).
Several organisations appeared to be unclear about the scope of NHFS. Some think it is a limited agenda for tertiary care (hospital) services. NHFS must be comprehensive, covering 360 degrees of medical and paramedical services, including general practitioners (GPs).
Existing and newly created GPs under NHFS can improve and facilitate patient care. Post-hospitalisation and chronic illness management should be outsourced to GPs. This will reduce hospital patient loads and optimise hospital sizes and services.
GPs Are The Frontline To Cost Containment
The government should no longer hide that, among other goals, NHFS aims to contain health care costs and shift the government’s financial burden directly to the population by having the population contribute to a National Health Fund (NHF).
For nearly 30 years, the government has given different reasons for the need for NHFS and never mentioned the need to shift health care funding from the government coffers to the population.
The Diagnosis-Related Groups (DRG) payment system is a critical component in medical cost containment but is not the only instrument. Not all patients need continuous specialist follow-up at hospitals for the rest of their lives.
GPs can manage many post-hospitalisation illnesses. As GPs’ professional charges are a small fraction of the specialist and hospital charges, it makes sense for the government to transfer follow-up care to the GPs.
This is especially true for the management of chronic illnesses like diabetes, hypertension, hypercholesterolemia, and others. GPs’ drug and laboratory charges are a fraction of the hospital-based charges.
In Malaysia, breast cancer has ascended to the third most common cause of death (15.2 per thousand cases) in 2022, moving up from the fourth position in 2021. They are a major contributor to health care costs.
From 2007 to 2018, two five-year reports were published to illustrate the financial burden of cancer in Malaysia. Among women, breast cancer had the highest incidence, followed by colorectal cancer and lung cancer. Half of breast cancer patients are diagnosed below the age of 50 years.
The situation is the same for cervical cancer. The percentage of cancer cases detected at stages 3 and 4 has increased to 65.1 percent from 2017 to 2021 from 63.7 per cent from 2012 to 2016. A paper on the Malaysian Study on Cancer Survival, published in October 2018, highlighted the lower survival rates of patients with delayed cancer detection.
Cancers are one of the common causes of the rising causes of hospitalisation and contribute to mortality and morbidity statistics in this country.
Through early detection, GPs can reduce the number of late-stage cancers, lower mortality, and improve morbidity statistics. GPs are well-trained to perform breast examinations and pap smears.
If needed, simple additional training can be provided to GPs through the Continuing Medical Education (CME) programme to enhance their skills in conducting breast and pap smear screening and breast lump biopsy (trucut biopsy).
After all, medical students and doctors in their early careers in public hospitals are exposed to such procedures. Similarly, they can treat chronic illnesses as hospital-based specialists recommend.
Why should all the above therapies be the exclusive domain of private hospital specialists? Are GPs not good enough to do disease screening?
MOH Overregulation Of GPs Contributing To Higher Costs
As highlighted earlier, GPs are the frontline service providers under the NHFS. The regulatory cost must be kept low to ensure GP services remain sustainable.
Unfortunately, due to Ministry of Health (MOH) overregulation, the cost of GP services is rising. Apart from premise rental, utility charges, and local authority charges, they are subjected to other specific laws and processes under MOH.
To set up a medical practice, the intended professional must register with the Companies Commission of Malaysia (CCM) under the Limited Liability Partnerships Act 2012 or incorporate a local company under the Companies Act 2016 (CA 2016).
They have the same privilege as lawyers in setting up a partnership without registering with CCM, and Malaysian lawyers have retained this privilege until today.
The CCM requirements require doctors to have a company secretary and to submit an annual financial report. Why does MOH need to enforce such a regulation? How does this legislation benefit MOH or service quality?
Previously, doctors who wanted to set up a GP practice only dealt with the local authority. There is a duplication of processes where doctors have to apply CKAPS (Cawangan Kawalan Amalan Perubatan Swasta).
The legal domain for renovating any business premises is with the local authority, and it involves architects submitting drawings. MOH should engage local authorities and guide them on the requirements instead of duplicating the business license processes.
What is the difference between GPs and other businesses that MOH needs to micro-regulate clinics and GPs through CKAPS? It is just another business.
Architects are well-versed with the local council requirements and the Uniform Building By-Laws (UBBL). MOH even micro-regulates the signage and door sizes. It should limit itself to clinical waste management and using radioactive X-ray machines.
New applications involve complicated multi-jurisdictional processes, especially those involving CKAPS, which manages the applications. Most of the time, the issues highlighted are trivial but overemphasized, and they take a long time to be approved.
Meanwhile, doctors must pay rent while waiting for the long approval process. Simple things like changing the clinic’s operating hours require CKAPS approval. The basis of such regulations is unclear.
All these costs impact patients’ final treatment charges. New GPs are struggling, and established GPs are considering exiting as they have made their money and are no longer interested in facing MOH’s many existing and growing regulatory requirements.
MCOs Are Squeezing GPs
In theory, a Managed Care Organisation (MCO) is a company that contracts employers with a network of health care providers to deliver services to their corporate clients.
By doing so, employers no longer need to engage each clinic, manage its employee medical bills, and be burdened with the necessary administration.
Now, MCOs are charging clinics to be on their panels and encouraging employers to join them on the premise that they can control costs.
In reality, they control costs by gripping the medications doctors can prescribe and the amount of medicines they can issue to patients.
This affects the quality of medical care. MOH must look at MCOs beyond licensing and their practices that affect optimal medical care delivery.
At the moment, the cost-controlling approach taken by MCOs is affecting medical care.
Price Displays In Clinics And Dispensing Separation
Health Minister Dzulkefly Ahmad has stated that a medication price display policy will come into effect in 2025 as part of the initiative and will be implemented under the Price Control and Anti-Profiteering Act 2011.
Since when does the act of displaying prices control prices? Restaurants have been doing so for ages, yet food prices are increasing.
Price display is only relevant if the clinics display their products (medicines). When medicines are kept in cabinets or separate from the public eye, the requirement to display the price disappears.
The minimum number of clinics (like restaurants and other businesses do) is to provide itemised billing, including each medication’s prices, consultation charges, and taxes. This is adequate. The MOH policy on price display is inappropriate and burdensome for GPs.
Malaysian Community Pharmacy Guild (MCPG) president Lovy Beh has called for separating prescribing and dispensing medicines nationwide by 2025. The pharmacists’ call is purely economic. They want to expand their business interest in the pharmaceutical business, and patient care is not their main priority.
The current system has worked well, and GPs have served the nation since before independence. However, there is a need for a stronger justification for this separation.
If one was to walk into a pharmacy today, one would see the pharmacy diagnosing simple problems and offering treatments. CKAPS appears to ignore such practices.
The Medicine Advertisements Board (MAB), set up under the Medicine Advertisements Board Regulations 1976, discusses applications for medical products or health care facilities and services advertisements received. It decides on the applications at its discretion.
It is not required to explain why applications are denied. However, online medical services are mushrooming, and CKAPS does not regulate them, and it is uncertain whether the MAB governs their advertisement.
These are some of the regulatory cost contributions. The playing field is not leveled for GPs. They face many unregulated services and, at the same time, face unnecessary burdens from MOH overregulation.
Patients would be the ultimate beneficiaries if GPs’ regulatory costs are reduced.
What Can GPs Do?
Given cost escalation and competition, GP practitioners must abandon their soloist business attitude. They must explore mergers and acquisitions with other GPs and optimise care delivery.
Alternatively, they should explore developing a semi-autonomous care network. As part of a group, they can leverage their cost of doing business, merge their panels, and optimise their clinic locations.
They need to adapt and operate within the new rules and industry game.
As a network, it would be easier to negotiate with MOH and undertake outpatient care as a group. A large group can invest in IT solutions with AI capabilities.
Good centralised solutions would allow employers to manage their employees’ benefits and patients to manage their medical entitlements without the need for an MCO.
A large network can expand into other medical-related businesses. Rather than limiting earnings by being individualistic, GPs should move forward as a group, look forward to better and more exciting opportunities, and at the same time do what they like most, i.e., being a GP.
Conclusion
GPs are relevant and form a critical component in NHFS. MOH must be absolved of some of its processes and procedures and let local authorities handle them.
They need to look at the bigger picture and not hold on to empire-building. CKAP roles need to be repurposed to meet industry demands.
They need to facilitate rather than create additional bureaucratic processes. New policies must be based on care and needs and not favor groups that focus on business.
MOH must develop practical solutions for GPs that can lead to a level playing field with other paramedical service providers. It should not create regulations that give certain players in the health care sector an unequal advantage.
Dr Mohamed Rafick is a trained physician with 12 years of experience in military medical services and over 22 years of experience in the assurance industry. He retired as the CEO of a multinational reinsurance company in 2019 and remains active as an independent international assurance industry consultant.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
