Friday, November 28, 2014

HEALTHCARE SHOULD BE GST EXEMPT AS PROMISED IN 2013.

MEDIA STATEMENT
FOR IMMEDIATE RELEASE

Healthcare should be GST-exempt as promised in 2013
Kuala Lumpur, 27 November 2014 In response to the statement from the Minister of Health, Datuk Seri Dr. S. Subramaniam, that not all drugs will be zero rate, the Federation of Private Medical Practitioners’ Associations Malaysia (FPMPAM) calls for the Government to assess the GST implications for healthcare and fullfill its pledge made in October 2013 on the Budget 2014 that both public and private healthcare services will be GST exempt.

On October 10, 2014, at his Budget 2015 speech, our PM further added that medicines on the National Essential Drug List (NEDL) would be zero-rated thus giving the impression that the sick who are already burdened will need not be further burdened by additional tax for what is needed to treat their illness.

However, the guidelines and many briefings by the Jabatan Kastam DiRaja’s GST team now tell a different and rather complicated story.
1.        Not all medicines (including many essential ones) will be GST-exempt.
Patients and the public may not be aware that the NEDL is not the complete pharmacopeia or Wish List for treatment of all the important diseases and all its complications.
Of the so-called 2900 items on the NEDL, there are actually only 208 different medications. Many of the 2900 items includes repetitions of various preparations (different brands) of the same medications.[1]
Imposing GST on the many essential medications that are not on the NEDL will increase the cost of treatment and will be a burden to the sick. Prior to GST all duly registered medications were exempt from sales and service tax, in other words, zero percent. With the impending GST the cost of all these medications have already shot up. It will go up further when the cost of administrating the GST is passed down the line. Even patients from the government sector who require these medications will end up paying more.
Treatment using the restrictive NEDL will be cause a fall in productivity, with increased sick-leave due to dissatisfaction, morbidity and mortality arising from use of, and change to different medications, or patients' choice to forego medicines due to increased costs.
The Federation urges the Government classify “Zero-rated” on all duly registered medications (Schedule Poisons Group B & C) including clinical disposables and essential treatment items like stents, prostheses and to immediately form a broad-based panel to review the deficiencies and inadequacies of the NEDL.
2.             Healthcare services including surgery and procedure fees provided by doctors in        private hospitals will incur GST [Ref: Royal Malaysian Custom GST Guidelines on      Healthcare Item (12)]
For healthcare provision in private hospitals, it is clearly stated in the above that GST exemption is only for services provided by doctors employed by private hospitals/private healthcare facilities.
This is a major mistake.  The majority of the doctors especially the specialists in private hospitals are not employed but work as “independent contractors”. The situation is made even more complex with the many different individual versions to this legal concept of “independent contractors”  in different private hospitals and the existence of multiple layers of middle-men agencies like MCOs, TPAs, and insurers etc. collecting and processing fees before payment is finally paid to the hospital and only subsequently to the doctor. Each transaction at each level is fraught with GST implications and complex computations.
With this complicated scenario, imposing GST on private doctors’ consultation, treatment procedures, surgical and other essential treatment fees will not only be administratively costly and complicated but will also escalate the cost of providing private healthcare generally.
Patients will end up paying significantly much more next year for the same treatment. The multiplier effect will have a major adverse impact on the national expenditure on healthcare.
3.         Other Ancillary items for operating a clinic are also not exempted.
The other ancillary items in the running of a private clinic like medical indemnity insurance, utilities, rental of clinic space, servicing, leasing and rental of medical equipment  including other non-medical professional fees will also incur GST. Accountants have already informed doctors that if GST is imposed on medications their accountant’s professional fees is expected to increase 50% to 60% due to the increased work because of its complex structure.
4.         Healthcare needs more help, not more taxes
As a non-subsidized, self-paying provider, the private sector is already taking a major load off the public healthcare system. Even at this time, the public healthcare system is already not able to cope with the present demand for medical care despite the fact that a substantial load of out-patient primary care is being provided by the private sector.
It is not true that patients opt for private care because they can afford it and hence should pay GST. The fact of the matter is that the long queues and waiting time in public facilities is a major reason why many choose to opt for private care. They need to get well fast so that they can go back to their jobs and be productive.
The private doctors are already severely burdened by the administrative provisions of the PHFS Act 1998/Regulations 2006. GST imposition is a further burden and a distraction from the basic objective of providing affordable, accessible and quality care.
GST for healthcare in its present form is an administrative nightmare and financial burden to the provider as well as the recipient. Healthcare is a basic right of every rakyat. No Rakyat chooses to be sick and if they do become sick, taxation should not be imposed on an involuntary condition.
We hope the Government will abide by the PM’s pledge and implement GST exempt across the board for healthcare services as promised in October 2013. The Trust of the Rakyat must not be breached.
DR. STEVEN KW CHOW
President
FPMPAM                      

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[1] We must note that the World Health Organisation has two EDL one for adults and one specifically for children. After combining both lists and eliminating replications, there are 359 medications (by generic names) in the WHO EDL compared to our Malaysian NEDL which has only 208 items. Our NEDL has 151 medications less than the combined WHO EDL notwithstanding the fact that the WHO list has only 6 medications which is specifically for diseases (African trypanosomiasis & American trypanosomiasis), which is not common in Malaysia. Thus there are major deficiencies in the Malaysian NEDL.
If one looks closer our NEDL is clearly not designed to cater for all the important diseases and complications of the various disciplines of primary and specialist care. Specific treatment for many common diseases are not in this NEDL.

Tuesday, November 25, 2014

SHOULD WE STILL FOLLOW "MONA"?

We use to advocate that the ER ( Emergency Room ) or pre-hospital phase on management of Acute Myocardial Infarction should begin with MONA, an acronym which allows junior doctors to quickly remember what should be done. MONA stands for Morphine, Oxygen, Nitrates and aspirin. Well over the course of the last 10 years, we have seen the use of "nitrates" being challenged. Some say that nitrates may help, white others say that nitrates may harm, because nitrates may divert much needed blood from the vital infarcted segments to the more normal segments because of its unequal dilating properties for normal vessels and atherosclerotic vessels.
Well the "O" in MONA is also under attack now. A paper presented by Dr Dion Stub, formally of Monash Australia, presently of the St. Paul's Hospital ( Vancouver ), at the just concluded American Heart Association Annual Scientific Meeting, Chicago, seemed to show that giving O2 to people with normal O2 saturation post chest pains, may do more harm then good.
Dr Stephen Bernard ( lead investigator ) and group ( 9 hospitals in the Melbourne area ), studied 441 patients with STEMI. He divided these patients into the O2 group and the no O2 group. All of them ( inclusion criteria ), had suspected STEMI with chest pains of not more than 12 hours duration, and relevant ECG and enzyme changes. They all had O2 saturation ( by pulse oximeter ) of >94%. This was deemed as the normal. 218 of these patients received O2 at 8 L/min and the other group of 223 patients received room air ( avoid O2 ). This study was called AVOID ( Air Vs Oxygen in STEMI ). The primary end point was infarct size as measured by cardiac enzyme, and secondary endpoint was infarct size estimation by cardiac MRI. All of them upon admission received primary angiopasty.
At the end of hospital stay, those receiving room air ( avoid oxygen group ) has lesser CPK enzyme rise when compared with those receiving O2. There was no difference in mortality and morbidity endpoints, as the study was under powered for that. The 6 months cardiac MRI also showed that those receiving O2 had larger infarct size when compared to those who received room air.
What could be a possible explanation?
The theory is that after 15 mins of O2 at 8L/Min, the blood becomes hyperoxic. These will cause changes in the coronary microvasculature which may become vasoconstricted because of the instant hyperoxia.  This will increase free radicals in the infarcted zone, and the bottomline is that infarct size may increase.
Caution is required here as this study is small and there are studies showing that administering O2 cause no difference.
For the moment, the jury is still out on routine oxygen therapy post STEMI. Most of us will reflexly give it. Those who forgot to, now have some evidence to back them.
As for MONA, well we may end up with MOA or even MA.

Monday, November 24, 2014

MKINI OPEN HOUSE. AFTER 15 YEARS




I was at the Mkini Open House on 22nd Nov 2014, amidst a pouring rain. It was a small struggle getting there because of the rain and I also had some difficulty finding the place as Jln Tandung was not my usual haunt. Anyway find it I did after a couple of U turns. Arrived there at about 5 pm.


Nice place. Big multi storey building. I have never been to  a press center before, but they look fairly well equipped. Plenty of laptops al over the pace a some staff was working. Some visitors were going "on air" in one of the staged room. The crowd, well at 5pm was sparse, and the rain was a dampener. I am sure that it was larger once the dragon dance can and the entertainment began.


After finding my "brick" and those of a couple of my friends, and after a self tour of the whole building, I decided to leave. Took a drink and then left at about 6pm into a severe traffic jam along Fed Hwy. It took me a hour to get from the Jln Templer traffic light to Subang. When I reach the Subang entrance, I discovered that the whole Fed Hwy was closed at the Subang exit. Now I know, it was because of a new landmark in Subang, called " the leaning LRT beam of Subang". What kind of contractors do we have in Malaysia. After so many deaths and accidents, ( with instant promises of no repeats after each incident ), we now have the leaning LRT beam of Subang. When will we ever learn.

I could get home with the relatively minor detour, to USJ, but I pity the Klang folks who were not so conversant with the detour routes. The crude signage just say ( arrow pointed left ). So the Klang foks have to find their way to Klang either through Subang ( free tour of Subang ) or through the old airport road. There was no signage to help them.
This is Malaysia. Malaysia Boleh.



Thursday, November 20, 2014

HEALTHCARE COST SURELY TO RISE FROM NOW TILL APRIL FOOL’S DAY 2015

This statement was send to Star yesterday, as letter to the editor. Let's see if they will print. I am very concerned that the Custom's Dept have no clue as to the workings of the private doctors. While public hospital supplies and services are all zero rated, 1-2% of private healthcare supplies and services are zero rated, and the bulk ( 98% approximately ) are standard rated. The PM's call for Healthcare to be exempted ( in a very broad term ) we know now to be a farce and simply untrue.

The YB MOH announced last week  that not all drugs will be zero rated. In fact, a quick calculation revealed that probably less than 10% of commonly used drugs will be zero rated. Following  the numerous briefings , seminars,  Q&As, notes, documents and meetings with Customs Department, a few things are very obvious in this GST for Healthcare due for implementation about 6 months for now. Firstly, that Customs Department did not realize how many types of disciplines and categories there are in Healthcare. They must have thought that there is a doctor who sees patients and  who charges patients. Little did they realize that there are GPs, family physicians, specialists in solo practice, specialists in private hospital practice, etc  etc  etc. Secondly, it is also fairly obvious   that Healthcare is GST exempt means that only the doctors consultation fees is GST exempt. Not his fees for surgery and procedures, not 90% of his medications, not his professional indemnity fees, not if hospital collects the fees for the consultant ( which is the majority of the private hospitals ). Since that is what the government wishes, and since doctors have family and responsibilities he will have to increase his fees to cover whatever GST will take away. I am sure that the private hospitals will do the same.
The sum total being, healthcare cost will surely rise. It is only the quantum of rise that is yet unknown.

In order to avoid this, we call upon the government of Malaysia, to make Healthcare GST zero rated all along the supply and service chain. If that is not possible, then be prepared to face a severe rise in Healthcare Cost for the patients come 1st April 2015. It may be best to shelve this GST all together, until proper studies are done and the customs understand the working of private healthcare system.

The public must wake up. and take the government to account.

Tuesday, November 18, 2014

1MDB : WHAT THE GOVERNMENT DOES NOT WANT YOU TO KNOW.



Please come and attend this 1MDB public forum. See what Rafizi and Tony Pua have discovered.. I understand that Dr Mahathir is speaking too.
Tomorrow night at THE CLUB, Bandar Utama

Monday, November 10, 2014

HELP. HELP HELP FOR CLEAN FREE AND FAIR ELECTIONS




The Election commission has announced that they intend to table in Parliament the new electoral boundaries for GE 14  However, they would not allow Tindak Malaysia or Bersih to have copies of the new electoral boundaries, even if they wish to pay for it. Just to make it difficult, these new maps will be presented to Parliament and placed in the various constituencies where they can be viewed. There is no soft copy.
So both Tindak Malaysia and Bersih have launch a campaign to look for volunteers to form groups of 3-4 people, to visit all the electoral constituencies and physically take pictures of all the new maps and bring them back to HQ, where they can be studied to see where the Gerry Meandering is so that we can go to court to dispute the new boundaries. All these work within 30 days.
This is all in line with the Federal Constitution.
We must uphold the Federal Constitution, especially 13th Schedule.
We need volunteers who can spare 3 days to help do this work. It helps if you have a driving licence and is good at photography.

If you are interested, please contact me at

Thank you. In any democracy, we must have clean, free and fair elections.

Thursday, November 06, 2014

GE13: Clean and Fair? The verdict of the People’s Tribunal

I spend last night at the Bersih forum on " Verdict of the Peopl's Tribunal"  on GE 13. I also bought a hard copy of their report.


The Tribunal's report is published and the findings I am told is posted in the Bersih website ( www.bersih.org ) and you can also buy a copy. The conclusion ( or verdict as they called it is obvious. There was widespread fraud, almost at every level. The only level left unhindered was that you could go, and cast your vote, fairly freely. All other stages of the electoral process was flawed and there was good evidence. Non of the court cases challenging ever got to open court. They were all thrown out at the preliminary stages through some technicality and excuse.

The following in the final verdict, found in pg 65 of the Report.
                 OVERALL, TAKING INTO ACCOUNT THE 'MACRO-LEVEL' OF APPORTIONMENT-THERE IS REASON TO BELIEVE THAT THE 'WRONG PARTY' WAS DECLARED TO HAVE WON THE 2013 ELECTIONS.

So what can be done. GE 13 was stolen from the people.

Of course most of the discussion last night at the forum was, What then shall we do? Especially with GE 14 facing us, and the electoral delineation exercise about to take place before the end of 2014.

Some were focusing on how to garner people's support to object to the proposed delineation ( DART program ), noting that ALL previous delineation have always resulted in boundaries favouring the ruling party, and thus resulting in landslide victory for the ruling party at the next GE. Some were in favour of greater publicity for electoral boundaries that were free and fair ( Tindak Malaysia ). Some were in favour of asking opposition MPs to be more vigilant in Parliament, as delineation with increase in seats would require the support of 2/3 in Parliament ( meaning support of the opposition ). I was in support of getting the people's support through peaceful street demonstration ( people's power ), to get the ruling party to listen and not mess around with the delineation.

Whatever it is, we have to uphold the Federal Constitution, 13th Schedule.

Whatever it is, we should all return to the Rukun Negara and uphold it, together with the Federal Constitution.










Tuesday, November 04, 2014

DAP Fund Raising Dinner. 3rd NOV 2014.

I spend last night attending the DAP fund raising dinner. A very big affair boosting 110 tables booked for the evening at PJ Civic Center. Thank God there was no rain, so trafficwas smooth. I carpooled and we reached at 7.15pm and there was no longer any parking space at the Civic Center and we had to park by the houses on top of the hill. I had organised to fill 2 "Gold" tables, with my medic colleagues and some business people.

It was speeches after speeches. Saudara LGE spoke well, highlighting the "Bible Burning Issue" an of course the new MB of Selangor Azmin Ali spoke and he outlined his plan for Selangor during his term. All in the poster spoke, so the meeting lasted till 11.30pm. Tong Pua ( organising chairman for this dinner ) spoke last, outline the 1MDB issue. Gosh, how did a responsible PM and Chairman of IMDB advisory board, allowed 1MDB to accumulate so much debt. If Tony is correct, we will be paying this debt till the next generation. Some more no accounts for the last 2 years. A company holding debts of billions with no accounts shown. How can this be? ROC where are you? Nowadays, we hear of borrowing by the billions, and eating by the billions. Some more money park in Cayman Island where are the darling company accounts cannot be scrutinised. Sounding more and more like a scam, except that the Government of Malaysia stands guarantor ( thru some legal papers ). I am really worried for 1MDB.

Anyway, it looks like DAP is trying to groom up a new set of younger leaders. Still very raw, I must say. Last night was a good effort. I hope that DAP managed to raise a lot of money. I must say that the floor collection was ( to me ) disappointing. About RM 20+K only.

I expect that from now till GE 14, there will be about 5-6 more fund raising. It gets more challenging as the economy gets slower and times get harder for the man in the street.

All in all it was a good time. I learn many new things, prime of which is " How can a responsible government allow one of its crony companies to accumulate so much debt? I thing I am right to say that they have not shown an profits yet, after 4 years in operations. They sure have shown plenty of debt.

Monday, November 03, 2014

CAUTION. BEWARE THAT ANTIBIOTICS IN COMBINATION WITH CERTAIN ANTI-HYPERTENSIVES MAY KILL

Hypertension is a growing problem amongst the Malaysian population. ACEI and ARBs are commonly used as they are proven to be very effective in the treatment of hypertension and also confers additional benefits with respect to renal protection.
"Flu", cough and cold is also a very common ailment afflicting us Malaysians. Co-trimoxazole ( commonly called Bactrim ) is also a commonly used antibiotic for treatment of common infective disorders.
There were some reported deaths in people taking Bactrium, who were also hypertensives on ACE-I. So the Canadian Researches looked into this issue. This resulted in a paper published in the BMJ 30th Oct issue. The paper is entitled, " Co-trimoxazole and sudden cardiac deaths in patients taking inhibitors of Renin Angiotensin system.". The study was led by Dr Michael Fralich From the Canadian Drug Safety and Effectiveness Research Center. They review the hospitalisation data and discharged data of the Ontario Health District from 1st April 1994 till 1st Jan 2012. There were all together 39,879 sudden cardiac deaths. They analysed those who had received ACEI / ARB  and also antibiotics Co-trimoxazole and also ciprofloxacin and two other antibiotics. These SCD were matched against 3,733 patients of the same age and sex group and who also have the same co-morbid factors of T2DM and kidney disease. These were used as matched controls.

Table 3 
 Antibiotic use and risk of sudden death within 14 days
Antibiotic useNo (%) casesNo (%) controlsOdds ratio (95% CI)Adjusted odds ratio (95% CI)*
Amoxicillin (reference)418 (22.9)2021 (29.8)1.0 (reference)1.0 (reference)
Co-trimoxazole474 (25.9)1262 (18.6)1.80 (1.54 to 2.09)1.54 (1.29 to 1.84)
Ciprofloxacin603 (33.0)1888 (27.9)1.50 (1.30 to 1.72)1.18 (1.00 to 1.39)
Norfloxacin158 (8.6)832 (12.3)0.89 (0.73 to 1.09)0.83 (0.65 to 1.05)
Nitrofurantoin174 (9.5)768 (11.3)1.08 (0.88 to 1.32)1.03 (0.81 to 1.30)
*Analysis adjusted for disease risk index.

They found that those taking Co-trimoxazole and also an ACEI / ARB had a significantly higher SCD rate than match controls, especially if used till 14 days.  Ciprofloxacin also carries a slightly increase SCD rate, though not as high as Co-trimoxazole.
The reason for this may be the effect of Co-trimoxazole to increase serum potassium is some people.
There were earlier evidence that the use of ciprofloxacin was associated with a risk of SCD.

I suppose the message should be that when we use ACE-I / ARB, we should beware of the problem of hyper-kalemia and we should also be careful of antibiotics used. Co-trimoxazole use should be restricted to patients not taking ACE-I / ARB.






Thursday, October 23, 2014

IS VIAGRA GOOD FOR THE HEART?


Viagra is a popular drug, frequently used in Malaysia as treatment for erectile dysfunction. That is the medical indication. However, many young men are using it as a tonic for sexual enhancement.
Now, they are asking , if I should take Viagra often ( chronically for some ) will it harm my heart.
Well, a recent study by the Italian group seemed to suggest that it surely does not harm the heart but in fact may help the heart. It that true?
This issue was highlighted in the lay press recently showing that it is of public interest. So I thought that I should have a look at it.
The study is an Italian one, published in the BMC Medical, 19th Oct 2014. The Article is entitled " Is chronic inhibition of Phosphodiaesterase Type 5 cardioprotective and safe? A meta-analysis. This Italian group from the Sapienza University of Rome, went into the medical data base of Medline and Embase to look over 24 RCT involving PE 5 inhibitors usage from 4 weeks to 1 year, where cardiac indices were also measured. There were 1,622 patients deemed suitable. 954 were on PD 5 inhibitors and 772 were on placebo. They were enrolled from March 2012 till Dec 2013.The indications for PD 5 usage was not clear. They researchers only wanted all patients to have placebo control and also to have taken PD 5 inhibitors chronically. Most of the patients were taking sildenafil citrate ( viagra ). Fewer were taking Levitra and Cialis.
They concluded from their meta-analysis ( which had a lot of statistics ), that PD 5 was safe to use chronically. That there was some improvement in LV function indices, that it helped the heart with LVH to remodel better, that with usage in patients with heart failure, the pro-BNP estimation improved, and there was also better peripheral vasodilation.

So I had a look at the paper. It must have been a big ask to take so many diverse study and try and match them together. There were many variables. I did not know how the investigators were able to analyse the data coherently. Yes, there was improvement in LVEF but it was in the region of 3-4%, and they were using echocardiogram as a means of determining the LV function. Surely, 3-4 % may not be significant. The methodology to measure vaso-motion was not detailed.
All in all, in my opinion, a rather weak study, using statistics to mesmerise us. Drawing big poster concusions based on rather flimsy data.

I am quite sure that it is safe to consume PD 5 inhibitor chronically but remember NOT to use it together with GTN. If used chronically, it may reduced Pulmonary artery resistance and improve RV function somewhat. As for improvement in LV function, we should take that with a large pinch of salt.

To be certain, we will have to wait for more data, and more evidence.