Doctors & Private
Health Care:
Challenges &
Conflicts within the Confines of Business in Malaysia
By Dr David
KL Quek
[Part of
oral presentation at APHM International
Healthcare Conference & Exhibition, June 4, 2014]
Accepted for
Publication in Asian Hospitals & Healthcare Management
Private Healthcare – Expanding Influence
Private
health care in Malaysia now commands some 22 percent of the total available
hospital beds in the country. What that began as small scattered urban
physician-led medical centres in the 1970s have now grown into huge conglomerates
of hospital chains, some of which are now public-listed. Some 40-50 percent of
these private hospital groups (IHH Healthcare, KPJ Healthcare, Ramsay Sime
Darby Healthcare, Columbia Asia, etc.) are controlled or owned by
Government-Linked Corporations and/or by our own national sovereign fund i.e.
Khazanah Nasional Berhad.[1] Healthcare
portfolios now account for some 10.9% of Khazanah Nasional Berhad.[2]
You
might ask what all this has to do with the practice and the ethos of hospital
care and its interactions with physicians? The private sector hospitals now
look after 1 in 4 of all acute hospitalised patients in the country. To most
people however, including government, media and citizens alike, private
healthcare has become quite expensive. Costs have been escalating year on year,
beyond the usual estimates of consumer price index for the country.[3]
From the tables
below, it would seem that for this small percentage of private care, 76.8% of
the payment mechanisms are out-of-pocket, totalling 34.2% of the Malaysia’s total
health expenditure![4] Nationally,
insurance and third party payers contribute less than one-quarter of private
health care costs, meaning that most patients using the private health sector,
pay on their own, out of pocket.
Of the total OOP
payments, some 46% are spent for hospitalisation costs, the other 54% for
ambulatory outpatient services. According to the recently updated WHO Malaysian National Health Accounts, 70% of health insurance expenditure is spent on
hospital care. Between 2000 and 2007, private hospital insurance funds in
Malaysia grew from 12.5% to 14.7% of private expenditure.[5] However, in many private hospitals these
days, 60-70% of private hospital bills are reimbursed by third party payers.
Health reimbursement – Growth of Third Party Payers (TPPs)
Hence,
greater attention are being paid to third party payers who command to some
extent, what, where and how much healthcare services, they would be willing to
pay for. TTPs therefore control reimbursements including exerting rigorous documentation
delays, possible denial of services, based on previous histories of poor
outcome or higher payouts (out of the norm) when compared with other like
facilities.
Competition
indeed is the benchmark of these increasingly savvy business-oriented managed
care organisations. They dictate which insured patient gets what treatment and
from where. Thus, it is understandable why hospital administrators bend
backwards to accommodate these bigger healthcare buyers, often offering bulk discounts
for purchases of services based on simple bargaining, goodwill, of give and
take, akin to many commercial undertakings.
Conversely,
physicians have construed these as fee-splitting particularly when their professional
fees have been bundled into the discussion for greater volumes of business.
But, it is hard to tease away this sort of contractual irregularity. Is this
some form of negotiated mutually-acceptable business contracted services or is
this outright fee-splitting?
Of
course there is a real danger that using these bigger payer-players, physicians
might be bullied into an unacceptable form of forced submission to accept the
worst possible terms of the contract—‘take it or leave it’ scenarios have been
exerted on those who baulk at such ‘negotiations’. Thus, this is also the
rationale why the Malaysian Medical Council stand has been, that physicians and
private hospitals must not engage in these sort of unfair bulk purchase
discount practices, because ultimately due to lower fees (for gains), lower
service quality could result, with the patients being at the losing end of this
bad bargain!
However,
some physicians at smaller private hsoptials have unhappily lamented that they
have been coerced into agreeing to collective discounted fees not withstanding
that they have been promised greater volume of services.
This
is where many physicians fail to recognise and grasp the financial niceties and
constrictions or the uglier business side of healthcare. Hence, conflicting
tensions between administrators and physicians continue to simmer… For bigger
private healthcare facilities and conglomerates, as the larger volumes are marketed
and ‘traded’ for ‘bulk’ purchase of healthcare services, more of these
negotiations, over and above the heads of physicians, would be the norm.
Healthcare Conglomerates Call the Shots
So why
does larger private hospital ownership matter? They most certainly do, because they do need to justify their
larger existence and outlays, and guarantee their bottom-lines. These private
hospital chains to some extent, dictate the profit-orientated approach to
healthcare, often with corporate demands for higher double-digit returns on
investments (ROIs).[6]
Parkway Pantai
revenues grew by 13 % to RM3.9 billion, and EBTIDA by 32% to RM968.8 million in
2013.6 Therefore, CEOs in these privatised concerns are given notice
to achieve similar targets, year in, year out! Thus, not surprisingly, it has
been suggested that the recent inflationary trends of private healthcare have
been fuelled by GLCs’ forays into owning and aggressive investments in the
healthcare sector.
But high profile investments into the
private healthcare market leads to higher corporate expectations and costlier administrative
processes too. With greater expected Return on Investments (ROIs), ‘governance’
and bigger administrative oversight, higher platforms and standards of
fiduciary accountability, competitive amenities, acquisitions and other quality
safety mechanisms have to be enhanced in tandem.
So besides greater numbers of administrative
personnel and its inherent costs, capital and infrastructural expenditure,
there would have to be other unique healthcare-related quality assessment and
compliance oversight, through agencies such as JCI and/or MSQH, besides the
other technical ISO standards. These aspects are often oblivious to the
physician whose remit appears to be purely focused on work alone! Thus,
differing goals of healthcare stakeholders invariably lead to physician-management
conflicts!
Therefore, hospital conglomerates tend to
compete by dictating the terms and conditions of what physicians working under
their jurisdictions are expected to perform and to deliver. There’ve been
cynical if oblique complaints that huge investments into private healthcare
industry, have led to aggressive marketing and overutilization of diagnostic
and therapeutic amenities and services; these been openly encouraged, even incentivised!
Thus, this commoditisation and commercialisation of private health care creates
more conflicts between healthcare providers and the administrators / owners.
As healthcare services become more
complex and expensive, more and more people are resorting to third party payers
(TPPs): health insurance companies or employer-provided reimbursement managed
care organisations (MCOs). For private care hospitalisations these days, the
quantum of third party payers now approaches 70 to 75%. Self-paying only
contributes to around 25 to 30%.
Thus, more TPPs are demanding greater
scrutiny of healthcare requests, enforcing more denial of service or partial
payments, and mandating more elaborate if tedious auditable reporting, all
adding to the growing tension of private healthcare malaise for both the
administrator and the physician.
Changing Landscape of Patient Empowerment
As an
insider for more than 30 years in medical practice, my perspective is
understandably slanted toward that of the medical professional. But it would be
foolhardy to purely focus on just physician practices, rights and autonomy
alone.
The
current scenario of near-universal World Wide Web access to information has
created a climate quite different from just 2 decades ago. Then, physicians
rule the roost. Physician ‘knows best’ paternalism dictates what patients need:
to test, to treat, to operate, to cure. This information asymmetry or
doctor-patient knowledge gap is slowly but surely diminishing.
These days, patients are more
knowledgeable, increasingly demand their rights. They are not averse to second
or third opinions, and they place their own interests first and foremost. But
not only patients, the medical-legal fraternity, the healthcare payers are also
demanding for more accountability, on patient safety and quality issues.
Everyone now expects a fairer healthcare deal (at the best prices!), where
patient harm is frowned upon and expected to be as low as possible!
The axiom of ‘Primum non Nocere’ (first
do no harm) for physicians is now de rigueur![7]
Physician Scrutiny amidst Patient
Safety & Quality Assurances
So what are we to do? As the immediate-past 2-term Chair of
a Medical and Dental Advisory Committee and an elected Malaysian Medical
Councillor for the past 10 years or so, I’ve been given that rare if unpleasant
privilege to glimpse into the seedier side of medical miscommunications,
medical errors and mishaps including incompetent care. But this exposure has
helped me to focus more sharply on mounting patient grievances for
unsatisfactory healthcare experiences and outcomes; including physician lapses
and errors.[8]
Let’s face this squarely and bluntly.
Whenever we audit or scrutinise any processes (particularly when a fault has
been charged) there would be bound to be exposed worms in the cracked woodwork!
So I would readily admit that it is hard to pass muster on all counts, unless
our systems and processes are flawless! Thus, as inquiries mount to decipher
the arcane perspectives of medical practice, we (council members, experts and
medical litigation lawyers) have been forced to hunker down to scrutinise how
doctors, allied healthcare providers and their facilities have been functioning—looking
for avoidable errors, mishaps, weaknesses and failures, where preventable
negligence aspects might be exposed.
We’ve been tasked to look into standards
of care to see if these meet the ethical obligations of not just bare minimum
or competent care, but of empathetic but appropriate care and attention to
safety as well. So it behooves every physician to be extra vigilant, and get
his or her processes, expertise, knowledge and skills, communication and
clinical results spot on.
Don’t wait to be hauled up for an inquiry
and/or a medico-legal challenge! Which leads to the next surrogate performance
measure: quality and safety accreditations. These are not just acronyms for
pride, they are there for improving systems and processes, to reduce errors to
a tolerable minimum, to protect the patient, the physician and the healthcare
facility![9]
Hence, the mandated surrogate application
of hospital safety and quality accreditation exercises (Joint Commission
International JCI[10], Malaysian
Safety for Quality in Health MSQH[11]), so much
the bane and scorn for many a hospital physician. Of course it’s true that we
already have the very restrictive and punitive private health care facilities
and services Act[12] and
Regulations[13]
that has stifled our medical practice, so say many a practitioner! Why do we
need so much oversight?! We are being too straitjacketed by too many rules, it
is lamented. Physician frustration has been growing globally.
Physician Angst
Recently, an orthopaedic surgeon, Dr Daniel Craviotto has
lamented that: [14]
“We as physicians continue to plod along and
take care of our patients while those on the outside continue to intrude and interfere
with the practice of medicine. We have let nearly everyone trespass on the
practice of medicine. Are we better for it? Has it improved quality? Do we have more of a voice at the table
or less?
Are we as physicians happier or more disgruntled then 2 years ago? 5
years ago? 10 years ago? Once we're gone, who will speak up for our
profession and the individual physician in the trenches? The politicians? Our
medical societies? Our hospital
administrators? I think not. Now is the time for physicians to say enough is
enough.
“I don't know about other physicians but I am
tired—tired of the mandates, tired of outside interference, tired of anything
that unnecessarily interferes with the way I practice medicine. No other
profession would put up with this kind of scrutiny and coercion from outside
forces. The legal profession would not. The labor unions would not.”
Our physician autonomy has indeed been
corroded… it is hard to be a physician these days! True, but sadly current reality
bites must be considered. Although the angst expressed by Dr Craviotto is
understandable, his various points of contention can be debated. Allowing the modern
physician these days to a totally free run of his practice is no longer a
given, nor is this the best option to assure quality care, at best lowest costs.[15]
Unfortunately. Our carefree days of doing everything our heart desires, no
longer count for much when quality assurances and longer term outcomes are
measured, systematically.[16]
Physician Responsibility &
Oversight vs Patient Safety
Physicians free from oversight are more likely to deviate
from tested clinical pathways based on his or her individual idiosyncrasies,
belief in their own inflated personal skills and their dubious selective
memories. And it has been shown over and over again that physicians like any
other human professionals are as likely to perform based more for personal gain,
than that for the patient, i.e. this warped vested interest, moral hazard, needs
to be tempered by some Leviathan code of ethics![17]
So, like it or hate it, these ‘standards’,
quality and safety policies and exercises will be here to stay. Not just because
hospital owners want this, but health authorities worldwide too expect this to
be the norm. In fact during the Bush administration in 2006, Senator Hillary
Clinton and Barack Obama wrote just that paper for endorsing greater patient
safety initiatives to help reduce medical litigation costs.[18]
The ultimate goal, of course, is patient
safety, which should never be second guessed, least of all by the physician or
healthcare provider who is conflicted by virtue of their profession. Therefore,
there must be a reorientation in our ethos toward healthcare. We have to create
a new paradigm shift in the spirit of our healthcare culture, community
aspirations that places patient safety and interests first! But clearly there would
be conflicting aspirations and goals between one party and the next, between
physicians and administrators/owners!
Physician-Administrator/Owner
Conflicts & Changing Dynamics
Hospital administrators would often resist reforms that they
feel would impinge on their bottom-line to cover large fixed costs, while they
would be averse to trying too hard to change physicians’ behaviour toward
appropriateness use of medical technology or medications or reducing costs, for
fear of reducing turn-over revenue.
Physicians themselves are also self-interested for financial
and non-financial reasons. Physicians fear that talk of accountability and
appropriateness of care would standardise their approaches to care, to restrict
them to rigid clinical practice guidelines, subject themselves to too much
outcome measurement and peer review, thereby reducing their autonomy, as well
as capping their income.[19] Thus both
are invariably opposed to too much ‘reform’ for better more cost-effective
healthcare models and innovations![20]
-->
But increasingly many physicians working in the private sector feel extremely
frustrated at being hamstrung by what appears to be the widespread inadequacy
and incompetence of employed allied health personnel. Hospital administrators
appear to be blasé about this, preferring to function on ‘make-do’, ‘just
enough’ cost-efficiencies and bottom-line ROIs, which just rankles the
physicians all the more!
This is especially so with the perennial problem of questionable
quality nurses. Nurses form the ‘elegantly silent’ backbone of the hospital
experience—the face-to-face encounters, the monitoring and their first contact
interpretations, hence the timely and appropriate informed referral to further
physician interaction, are critical in any hospitalisation experience.
Poor or inaccurate documentation or interpretation of
patient features, delays in recognition of changes in vital signs or
deterioration of monitored data, or failure of nursing attention, all affect
patient safety and increase medical mishaps leading to poorer outcomes. However,
in the eyes of many physicians, this conundrum appears to be consistently
underplayed and compromised by the inactions or excuses of management.
It appears that most urban areas teeming with hospitals have
severe problems with adequacy of competent staffing, particularly of good
nurses. Hence the frequent movement and pinching of nurses from one centre to
another contributes to discontinuity of consistent care and standards of care,
that endangers patients.
But are health improvement measures just one-way regulatory
or systems processes affecting the hapless physician, who just happens to be
the easiest whipping boy for regulatory or administrative action? Are hospital
administrators and owners exempt from the regulatory and punitive reach of the
law, in order to improve safety concerns?
Would JCI and/or MSQH accreditation be sufficient to
exculpate these corporate managers, who might seemingly be at odds with the
complaining or whistle-blowing
physician, by sweeping the proverbial dusts under the carpet?
This appears to be addressed in some recent judicial rulings.
Recently, a judge has imputed that hospital medical directors in charge would
be held answerable and vicariously liable to charges of negligence when systems
failure occur, particularly when these result in poor patient outcomes or
deaths. An ill patient transferred in from a neighbouring hospital was left
inappropriately attended to at an emergency department for many hours, and not
properly triaged, resulting in gross delay in treatment, leading to her
preventable demise. The entire broken process of triaging and systems of
referral or management pathways would now be scrutinised for negligent care.[21]
Hopefully with this new sort of ruling, hospitals
particularly private sector ones, would be more amenable to get their systems
in place and not shirk behind the oft-repeated excuses of staffing shortages
and unavoidable shared common experiences!
Below are two self-explanatory tables
depicting the conflicting tensions that invariably exist in the dynamics of
hospital practice between physicians/healthcare providers and
administrators/owners.
So there must be continually
evolving basic bottom-line agreements and clearer roles for doctors, administrators
and/or policy makers of the private health care sector. There must be greater
understanding as to the dynamics of this provider-administrator tension and
conflict. Administrators and managers should explore with physician leaders on
how private hospitals can best harness the intellectual potential of doctors,
particularly in instilling committed leadership toward greater involvement and
attention in improving patient safety. They should mutually agree upon how they
can garner all-party support toward developing more inclusive patient safety
and quality measures, scorecards and policies.
Conclusions… a reorientation of ethos?
Doctors in
private health care settings must re-align themselves and their outlook beyond
just declaiming their competence, autonomy and of course, their right to make
money and make a living! We must work toward better institutional partnership, ownership
and shared common identity.
But management
must make greater efforts to accommodate the needs and aspirations of doctors
beyond merely providing them a place to practice in peace. Similarly physicians
need to become more involved and immersed in more patient-focus practice and
quality-assurance system processes, to ensure high quality and appropriateness
of care, amidst the changing dynamics of more stringent health policymaker oversight
and greater more demanding patient expectations!
It is essential
that we develop more inclusive physician-collaborators in quality and patient
safety strategies to include as many, if not every one, of the healthcare
provider work force—tapping into our usual nursing support staff, technicians
and other allied personnel, even clerical documentation executives.
We need to get as
much feedback from all stakeholders to become willing collaborators and
partners in institutional policy making. Piece-meal, ad hoc, knee-jerk,
disparate or confrontational approaches only derail the commitment toward
better overall outcomes for all concerned.
As physicians we
need to re-orientate and reformulate our professional and ethical obligations,
beyond our own vested interests! We need to refocus on the patient and his or
her interests, because ultimately, patients are our sine qua non or raison
d’être for the practice of medicine!
Finally, it would
be appropriate to conclude as Reinertsen has6
“We are losing
our clinical autonomy in part because the public has learned that the basis for
it, the full power of our scientific knowledge, is not being consistently
applied for their benefit. We will not regain that autonomy by lamenting its
loss, or by making shrill cries to preserve it.
“The most
effective approach, the professional approach, would be to join together with
our colleagues, in venues large and small, to decide on and apply the best
science together, as a profession. The Zen paradox of clinical autonomy is that
by giving it away to our colleagues, we gain it as a profession.”
References:
[1]
Quek DKL. Private-Public Partnership in Healthcare for Malaysia. Jan 16, 2009.
http://dq-essays.blogspot.com/2009/01/private-public-partnership-in.html
[2]
Khazanah Nasional Berhad. Creating Value
through our Investments. http://tkr.khazanah.com.my/2012/creating-value/
[3]
Chee Heng Leng. Ownership, control, and contention: Challenges for the future
of healthcare in Malaysia. Soc Sc Med 2008;66:2145-2156.
https://www.academia.edu/3840924/Ownership_control_and_contention_Challenges_for_the_future_of_healthcare_in_Malaysia
[4] Safurah Jaafar et al,
Malaysia Health System review (Health Systems in Transition, Vol. 3 No.1,
2013)– WHO Western Pacific 2013.
[5]
World Health
Organization (WHO) (2011) [website]. National Health Accounts: Country
Information. World Health Organization, Geneva. Accessed June 2014
[http://www.who.int/nha/country/en/index. html]
[7]
Reinertsen
JL. Zen and the art of physician autonomy maintenance. Ann Intern Med.
2003;138(12):992-995.
[8]
Thomas H.
Gallagher, David Studdert, Wendy Levinson. Disclosing Harmful Medical Errors to Patients. N Engl J Med
2007;356:2713-9.
[9]
Health care at
the crossroads: strategies for improving the medical liability system and
preventing patient injury. Joint Commission on Accreditation of Healthcare
Organizations, 2005. (http://www.jointcommission.org/NR/rdonlyres/3F1B626C-CB65-468BA871-488D1DA66B06/0/medical_liability_exec_summary.pdf.)
[10]
JCI.
http://www.jointcommissioninternational.org/improve/create-effective-policies/
[11]
MSQH.
http://www.msqh.com.my/msqh/manual-and-guidelines
[12]
Private Health Care Facilities and
Services Act 1998 (Act 586). PCNB, Malaysia, 1998.
[13]
Private Health Care Facilities and
Services Regulations 2006 (P.U. (A) 137/2006). PCNB, Malaysia, 2006.
[14]
Daniel Craviotto Jr. A Doctor’s
Declaration of Independence. Wall Street Journal, April 28, 2014.
http://online.wsj.com/news/articles/SB10001424052702304279904579518273176775310
[15]
Ezekiel
J. Emanuel, Steven D. Pearson. Physician
Autonomy and Health Care Reform. JAMA, January
25, 2012 (307) 4:367-8.
[16]
Thomson-Reuters.
The 2011 National Physicians Survey: frustration and dismay in a time of
change.
http://mikemeikle.files.wordpress.com/2011/01/2011-thomson-reuters-hcplexus-national-physicians-survey.pdf.
Accessed June 12, 2014.
[17]
ABIM
Foundation; American Board of Internal Medicine; ACP-ASIM Foundation; American
College of Physicians-American Society of Internal Medicine; European
Federation of Internal Medicine. Medical professionalism in the new millennium:
a physician charter. Ann Intern Med. 2002;136(3):243-246.
[18]
Clinton HR,
Obama B. Making patient safety the centerpiece of medical liability reform. N
Engl J Med 2006;354:2205-8.
[19]
Richard A.
Culbertson, Philip R. Lee. Medicare and Physician Autonomy. Health Care
Financing Review 1996 (18) No. 2:115-130.
[20] Victor R. Fuchs, and Arnold Milstein. The $640 Billion Question — Why Does Cost-Effective Care Diffuse So Slowly? N Engl J Med 2011; 364:1985-1987 May 26, 2011, DOI: 10.1056/NEJMp1104675
[21] Pengarah Hospital Selayang & Ors v. Ahmad Azizi
Abdullah James & Ors. CLJ 2013, 3:833-842. [Civil Appeal No:
W-01(IM)-388-2011] February 2012
[This is part of a Plenary
Lecture entitled: “Doctors & the Hospitals they work in. Are they
True Partners? Challenges of Ensuring Clinical Governance within the Confines of a Business” presented at the Association of Private Hospitals of Malaysia
Conference 2014, at Sunway Pyramid Convention Centre, on 4 June 2014.]
