The Malaysian Medical Council must decide if private agreements by doctors with managed care organisations and third party administrators are ethical.
By Dr Raj Kumar Maharajah
The Medical Practitioners Coalition Association of Malaysia (MPCAM), which has more than 10,000 doctors as members, have received complaints from doctors regularly through our online portal regarding managed care organisations (MCOs) and third party administrators (TPAs) responsible for handling the payments of consumers’ health bills from corporate bodies which have appointed these two parties to manage the health benefits of their employees.
The most recent complaints have been over a new trend by MCOs and TPAs, to force doctors to pay between RM2,500 (as in the case of a well-known institution of higher learning) and RM5,000 as a one-off payment to be appointed as a panel clinic and RM250 annually (the most recent case) in order to be appointed as a panel clinic.
These new requirements by MCOs and TPAs in the healthcare industry are very disturbing and we are unable to accept this “donation”.
The MPCAM has on numerous occasions urged the health ministry to streamline and regulate MCOs and TPAs under the provisions in the Private Healthcare Facilities and Services Act 1998 (PHFSA).
In fact, since last year, we have been engaging the Medical Practice Division of the health ministry to firm up the draft copy of the regulation, but to no avail.
We have about 30 TPAs currently managing the health benefits of employees, and all of them have their own set of fees and rules to be followed by doctors.
The number of TPAs keep growing as it is a lucrative business.
To be appointed as a panel clinic, some TPAs also require a “registration fee”, which can range from RM100 to RM5,000.
The consultation fees for doctors as mentioned in the PHFSA, is not adhered to and conveniently sidelined.
TPAs determine the registration procedure of a client in a clinic. Each of the 30 TPAs has their own procedures and requirements for a patient to register. Moreover, they also have different procedures for submission of claims; some even have mandatory terminals fitted to the clinics, for which the doctors are forced to pay a rental fee.
How many terminals are we supposed to have, and how many rentals do we have to pay? Can you imagine 30 TPAs having 30 different terminals, and collecting rentals for these?
We have registration fees on appointment as a panel clinic, administration fees to be paid to the TPAs every month, submission fees for each claim submitted, and payment fees when payments are made to the doctors (sometimes three to six months later).
Public health being compromised
These irregularities have led to the compromise of the healthcare of the public who visit private general practitioners in these following ways:
1. TPAs determine which health facility a consumer would be able to go to. The choice or selection of the hospital/clinic is that of the TPA. Hence, the consumer loses out on his choice of doctor, his choice of hospital/clinic and his choice as to where he would receive his treatment. This is a fundamental right of the patient and it is being compromised.
2. All added fees, as mentioned above, are paid by the doctor to the TPA.
3. Each of the 30 TPAs has their own regulations concerning the fee to be paid by the employer, and the fee to be paid by the doctor in the name of “admin fees” – which are determined by the respective TPAs alone. As we know, fee-splitting is illegal in the medical industry.
4. Some TPAs only allow a maximum medical fee that a patient is entitled to for their daily visits, whereas the charges for the day are also limited. Some even cap the number of medications that can be prescribed in a day.
5. By controlling the number of visits, as well as limiting the charges and number of medications, justice cannot be served to the sick. TPAs should not involve themselves in the care and treatment offered by the doctor to the sick. This puts the doctor under tremendous pressure and constraints.
The Malaysian Medical Council has not made a stand if it is indeed unethical for doctors to be involved in a private independent contract with MCOs and TPAs, which involves fee splitting at all levels, since the inception of this “middleman” idea in the 1990s.
With these brief accounts as to what issues doctors are facing, the Medical Practitioners Coalition Association of Malaysia strongly urges the Malaysian Medical Council to make a stand if it is unethical for a doctor to go into a private agreement with an MCO and a TPA.
We are prepared to throw our agreements into the waste paper basket if it is indeed unethical.
Dr Raj Kumar Maharajah is a member of the Medical Practitioners Coalition Association of Malaysia.
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