Why GPs can’t be compared to kuey teow sellers

When the Private Healthcare Facilities and Services (Private Hospitals and Other Private Healthcare Facilities) Regulations 2006 was revised in 2013, fees of medical officers in private hospitals were upgraded to between RM35 and RM125. However, medical officers i.e. general practitioners (GPs) in clinics were left out of this exercise. Their consultation fees remained between RM10 and RM35, a price that was set 27 years ago.

From media reports, it looks like the Cabinet is hesitating to allow this standardisation (as the current terminology goes: harmonisation) exercise to take place due to the large number of GPs who would then be allowed to raise their consultation fees.

Health Minister Dzulkefly Ahmad raised the issue in Cabinet via a memorandum but from the media, communication is that the issue is stuck at another committee level called the National Cost of Living Council before it will be brought up again for the Cabinet’s consideration.

Even at the mention of the words “fee increase”, you can already see the knives coming out. In this time of economic difficulty, when we Malaysians are having so much trouble coping with the increase in prices, how can doctors even think of something like this, one might ask.

Let me explain a little about why this perception of a fee increase is false and why this harmonisation exercise is not only warranted but required.

Since the harmonisation exercise in 2013, medical officers working in private hospitals have been charging RM35 to RM125 as consultation fees for each consultation. Remember, this is for medical officers and not specialists, so these are the doctors you see at the outpatient, emergency, wellness or health screening departments in a private hospital or even the inpatient procedures that may require the consultation of a medical officer.

Many of us are just not looking at the itemised bill for this when we get a hospital consultation done since the overall bill is what we pay and, most of the time for private hospital admissions, the entire bill is taken care of by insurance coverage. So we pay for this without even being aware of it.

Now, why the reluctance to impose this for clinic GPs working out of shop lots or stand-alone premises? Simple. The perception is that because more patients pay out of pocket at clinics, it looks like they are paying so much more. So, “we should not increase the consultation fee for GPs” is the language everybody uses when actually it’s about giving the GPs the same as what their private hospital counterparts are already getting.

The next question everybody asks is: “Why do these GPs need so much money for consultation? Can charge up to RM35 what. Why you want to charge so much, up to RM125? If you allow them to charge so much, they will charge lah. So expensive then!”

Allow me some leeway to elaborate on this a little. What a lot of people don’t realise is what consultation fees are about. Consultation fees are the fees that you pay to a professional in the field to gain their advice or opinion on the subject in which they are an acknowledged, professionally qualified expert.

Professionals include teachers, lawyers, accountants, engineers and doctors, among others. There are also many others who have upgraded themselves to “professional” status in terms of fees.

My neighbourhood electrician charges a consultation fee of RM80 to step into my home to find out what’s wrong. My plumber charges the same amount (I think that all home service industry professionals have had association meetings to standardise their rates, but that’s a story for another time). Bear in mind that these fees don’t include the costs of actual repair which are a separate charge altogether.

Now let me share with you the story of an average GP. After speaking to some GP colleagues and stall-owners, I summarised some of the monthly costs of running a clinic in the table below:

(Disclaimer: Information is anecdotal information collected from a total of 18 GPs and 14 stall owners selling fried noodles and not just kuey teow. This reflects the average cost breakdown. Annual recurring costs are not included.)

This table may not be as accurate as those published in scientific journals, but it is only intended to illustrate certain pertinent points.

At a consultation rate of RM10, GPs need to see a total of 90 patients a day to cover their fixed costs. A kuey teow seller has to sell 67 plates a day to do the same. There is a huge difference between them, however. Frying 67 plates of kuey teow takes a fixed amount of time, with the same number of ingredients and the same amount of effort (I’m sure that some purists argue that no two plates of kuey teow ever taste the same, but again, that’s another argument for another time). In fact, in some places, they fry a couple of plates together in the same wok (whether this is morally justifiable is again another argument for another time).

For the GP, however, each consultation is different. Even some medical colleagues tend to think that GP consultations are simple and do not require any form of effort. “You only see cough and cold what, how difficult can that be” is an oft-maligning statement many members of the public make.

I take offence. On behalf of my GP colleagues, please let me assure you that nothing could be further from the truth. What looks like a fever may turn out to be a complicated case of dengue, and that simple looking cough is sometimes lung cancer.

The careful effort and time spent in meticulous examination to unearth the true medical and sometimes social issues underlying the patient’s problems are what a GP does – and the time to do this is significantly longer than it will ever take to fry a plate of kuey teow!

There are also huge responsibilities and risks that GPs bear that kuey teow sellers don’t. GPs are liable to being sued if the patients don’t think that they have received the right treatment. This is why the government now mandates that all doctors, GPs included, pay and buy indemnity insurance which is another additional annual cost. I don’t think that there is a kuey teow indemnity insurance out yet and neither have I read about a lawsuit being taken up in Malaysia for being served a lousy plate of kuey teow (I googled this to check; you can, too).

There are also many laws regulating the establishment and administration of GP clinics including the above-mentioned Private Healthcare Facilities and Services Act which require GP clinics to fulfil a multitude of specifications in order for them to receive their operating licences and commence operations.

Renovations to make the clinic compliant with these regulations alone goes into hundreds of thousands of ringgit which include the purchase of equipment and other necessities which are part of the licence requirements. Again, these costs are not reflected in the monthly fixed costs required to run a clinic.

I am sure that some of my GP colleagues may take offence at being compared to kuey teow sellers. Forgive me. As a Malaysian, most of us relate only to food examples which is why I chose this particular comparison.

More importantly, I hope that the point I am making comes across. GPs are not the equivalent of kuey teow sellers. Some quarters have voiced opinions along the lines of this, theorising that since GPs are businessmen, they should be as competitive as they can and if they charge the lowest consultation fees they can get more customers, i.e. patients.

But they are not businessmen. They are highly skilled professionals providing a critically needed service, subject to multiple regulatory requirements. So why do we persist in trying to pay consultation fees that are little better than that of a kuey teow seller?

Dr M Murallitharan is a public health physician and medical director of the National Cancer Society Malaysia.

The views expressed are those of the author and do not necessarily reflect those of FMT.