Sunday, May 14, 2006

PHFS: The good, the bad and the ugly

This article was written for the Star specifically it's Sunday healthcare supplement on the 14th of May. It was also linked by Materia Medica Malaysia.

The Private Healthcare Facilities And Services Act 1998 And Regulations 2006 – more harm than help?

MALAYSIA prides herself in having a good healthcare system, left over as a legacy of the British administration. There was a public system of healthcare, which provided healthcare to the public for nominal fees, or even for free, and the private healthcare system, which was largely “fee for service”. Since 1971, private medical care was governed by the Private Hospital Act 1971 and the Medical Act 1971. The system worked well, but there were problems.

It is true that in some private clinics, there were a minority of doctors who were unwilling or unable to provide emergency care, but these few received a lot of bad press. The many that did provide emergency care had grateful patients, who did not make it a point to provide the good doctors with any publicity. Thus the many good deeds by the majority (the good), were lost and have been forgotten.

It is true that there were some bad doctors who “overcharged” their patients. When these patients complained, this minority (the bad) duly received front page publicity in the national press.

On the other hand, the many who charged reasonable and affordable fees, provided free treatment, helped hospices or other voluntary organisations and did their work for free, did not receive press coverage in most instances. I suppose, they are expected to have their rewards in the hereafter.

Yes, there were doctors selling codeine cough mixtures, MCs, and psychotropic drugs. These were the bad-apples (the ugly). As the Minister declared when he launched the PHFS regulations 2006: “We could do nothing. We could not enter their premises, we were called toothless, and so we needed a new act and regulation,” to punish these few bad-apples.

He does have a point. However, do we need this PHFS Act 1998 and Regulations 2006 to be able to do this?

The duties of a doctor

We are all taught to take care of our patients using the “Hippocratic oath” as our guiding light. We teach all our young doctors “to cure sometimes, to relieve often, and to comfort always”. We know that we can only cure the minority of disease conditions, but our doctors should always be compassionate, to relieve suffering and to comfort all in suffering and grief.

That spirit of caring is a good spirit to inculcate in all our young doctors. This is the softer side of us that no law can inculcate or encourage. In fact, the letter of the law may have the opposite effect, making doctors calculative and detached.

The doctor-patient relationship

When I was in government service, I sometimes received food and fruits from my grateful patients. It gave me a certain sense of pride. They trusted me and knew that I worked hard for them. I am sure many of my colleagues have also experienced the same. Nowadays, this is getting increasingly less.

I hope that in the future, it shall not be all about fees for services. “I am paying you so I expect you to do this, or else I will complain and you will be in a spot”. Sadly, the trust element in a doctor-patient relationship is slowly waning. The relationship is now developing into one of customer-service provider. In fact in some private medical centres, their mission statement proudly declares their patients as customers, as if they are the neighbourhood supermarket.

The rising cost of healthcare

With regards to healthcare, from the patient’s point of view, he would want the best possible care (no one must suffer and no one must die) and at the cheapest possible cost. He would want the best doctor, with the most experience to treat him, with the best equipment possible (state of art equipment that may cost millions of dollars). Can all these requirements be bought with the fees that we used to charge 20 years ago?

We are always reminded that the cost of healthcare is rising. Twenty years ago, life expectancy was 65 years, and healthcare formed 2-3% of the national budget. Twenty years later, the average life expectancy is about 75 years, and the healthcare cost is about 5% of our national budget.

People do live longer and better with better professional care and healthcare facilities. These facilities and care come with a cost. If the government will not bear that cost, then the individual will have to.

Making private doctors look mercenary, by constantly highlighting their charges, is undermining the doctor-patient trust more and turning it into a customer-service provider business relationship. Patients are constantly reminded to look at doctors as businessmen.

The medical landscape is changing, albeit for the worse. The new PHFS Act, in the current form, can only make this worse. It will spawn a new generation of businessmen doctors, with little compassion for patients, and all fee for service, as businessmen do, guided by stringent regulations.

This new PHFS act calls for more record-keeping and paper documentation. Everything has to be in black and white. This will mean more staff and invariably a rise in cost. Whatever you do or failed to do, you will be held accountable and can be severely punished, including going to jail. So doctors will become defensive and calculative. It is all about legal requirements and abiding by the law.

When he sees a patient, he takes a history and does a physical examination (all this is cheap). In the old days, with these findings, he used his experience to come to a working diagnosis. He may carry out a few simple tests to confirm his diagnosis, and he may begin treatment, based on his experience. There is no substitute for clinical experience. But experience is never always 100% correct all the time.

In the old days, with enough trust that “doc knows best”, experience was acceptable and it worked well in the majority of cases. Now, with the “lack of trust attitude” and business approach, trust and experience is not enough – everything must be done and seen to be done.

When someone complains, and the grievance committee meets, the doctor should jolly well have a whole barrage of tests to support his opinion. These committees have hindsight, which is usually more perfect, while the doctor looking after a patient in front of him has only prospective sight, and that is not always perfect (we are only human after all).

The stage is thus set for the practice of defensive medicine. Write everything down, make the patient sign for everything, do plenty of tests (usually more than you need to) to support your case, even check for rare conditions, so that you don’t miss anything, should the committee ask. This will surely bring about added cost.

With a whole new set of laws, there will be a whole new set of rules for dissatisfied patients and lawyers to work on.

Medical insurance rates will go up. The medical protection insurance societies will undoubtedly say that the increased risk of litigation does justify the increased cost of cover.

At the end of the day it is the public that will have to bear the increased cost. In all countries where laws and lawyers increase, medical suits increase, and cost of medical care increases.

Hospital bills

What is even worse is, the major part of rising healthcare costs is not taken care of by the Act, although it purports to do so. All who have been attended to in private healthcare facilities, especially private medical centres, will know that their final bills come in two main sections, the doctor’s professional fees (usually about 15-20 % of the total) and the private hospital fees (usually about 80-85% of the total).

The new Act has a section on doctor’s fees and how much they can charge. That is good. But what is missing is a list of charges that the private hospital can charge for the treatment given. This does not seem to be fair to patients.


I think it is important that the public be made aware that the Act, in its current form, will certainly increase healthcare costs.

The specific motivation for this new law was to provide powers to act on bad and errant private practitioners and healthcare facilities. Couldn’t this aim and objective be achieved in another way?

Unfortunately, this question has come too late. The Regulations are already in motion. Looks like the Act and its Regulations may need appropriate amendments so that it can achieve its general noble objective.

One thing for sure, the private healthcare landscape in Malaysia has changed as of May 1, 2006. We can only hope that it will be for the better.

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