THE Medical Practitioners Coalition Association of Malaysia (MPCAM) is happy to note that the Malaysian Medical Council has, at its most recent meeting, directed its Ethics Committee to deliberate the issue on MCOs (managed care organisations) and TPAs (third party administrator), which made headlines recently.
Incidentally, the Health Ministry has taken the lead to solve this impasse by meeting MPCAM and other doctors’ associations last week.
The MPCAM has been vociferous on this issue on numerous occasions, where we have highlighted feedback from members regarding MCOs or TPAs, entering into contracts with doctors, where the doctor would commit to pay a fee for each patient referred by the TPA.
Managed care has been a feature of our healthcare landscape for about 22 years now. They serve to provide intermediary services to various stakeholders, such as insurers, corporations, healthcare providers and patients.
Initially, these dealings were sporadic in nature. However, for more than a decade now, it has become the norm and is now an integral part of healthcare.
The time has come for MMC to review the Ethical Code and Ethical Guidelines, which addresses fee-sharing between doctors, to also address fee-sharing between doctors and TPAs.
The guidelines must address the issue of financial arrangements in managed care, which may lead to a compromise in the care of the patient. With the MMC Council said to meet next week to deliberate this issue among others, we recommend the Ethics Committee of the MMC and its councillors zero in on the following issues to safeguard the rakyat and to guide doctors.
OF THE PATIENT
Patients seeking treatment from companies usually have higher expectations of their medical benefits than what the managed care system allows for. Most of the time, patients do not know the limitations of the doctor, as dictated by the employer or by the MCO/TPAs. There ought to be legislation to make it compulsory to disclose to policyholders and employers any financial impositions made on the doctor. This will avoid unnecessary misunderstandings when one seeks treatment.
KICKBACKS AND FEE-SPLITTING MASKED AS ADMINISTRATIVE FEES
Some schemes impose arbitrary administrative fees ranging from 10 per cent to more than 15 per cent of the total billing for a patient, which, on closer examination, appears to indicate that most often, the higher the claim, the higher the arbitrarily imposed administration fee.
There are others who take a fee per patient seen per day, and more recently, a form of inducement to be appointed to be a panel doctor of the MCO, a one-off commission fee of between RM2,500 and RM5000 (excluding a yearly renewal fee). With administration fees, cheque deposition fees, transaction fees, annual fees, commission for appointment fees and terminal fees, what else is in store?
LIMITATIONS ON THE DOCTOR
Primary care medical service providers are paid paltry consultation fees, with the least being RM15 (before the administrative fee is deducted) and we can be imposed unreasonable limits on medicines, investigations and procedures.
We have to juggle between giving the best to the patient, rising cost of medicine and overheads and to do all that within a limit imposed and also, very much delayed payments.
INCENTIVE FOR CUTTING COST
Different managed care schemes pose different challenges. In general practice for example, certain schemes provide a fixed remuneration of, say, RM40 per patient visit, inclusive of cost of medication and consultation. Reimbursement for medicines and investigations is sometimes pegged at such a ridiculously low price that it can even be below their cost to the clinic in some instances.
PATIENT HAS NO CHOICE, LOSS OF CONTINUITY OF CARE
TPAs determine which hospital/clinic a consumer would be able to go to by only appointing certain clinics as panels. Hence, if the employer decides to appoint a MCO/TPA that is not the regular doctor of a patient, the patient loses out on his choice of doctor or hospital/clinic. This fundamental right of the patient is being compromised.
BEGGING FOR PAYMENT
Reimbursement can take place anywhere from three to 12 months after the doctor has seen the patient. Some MCOs/TPAs pay when prompted, while others others “inadvertently” miss a payment or two in between. The doctor has an arduous task auditing and tracing pending payments and in extreme cases, beg for payment.
These business practices appear to demonstrate a lack of respect for the medical profession.
The Health Ministry and MMC should consider legislative changes to truly guide doctors and safeguard patients.
An urgent regulation on MCOs/TPAs from Health Ministry is inevitable and critical.
Dr Peter Chan Teck Hock, Dr Raj Kumar Maharajah and the executive council of the Medical Practitioners Coalition Association Malaysia.