Healthcare costs will keep rising without proper regulation

 

The Malaysian Medical Association (MMA) calls for the regulation of third-party administrators (TPA) to curb unethical practices such as fee-splitting and to protect the healthcare system against commercialism.

As the issue affects healthcare delivery for the population, we call on MPs to address the matter in the upcoming parliamentary session.

TPAs are privately owned managed care organisations, hired by companies to manage their employee health benefits.

These intermediaries in private healthcare earn from providing managed care services to employers and from charges to private general practitioner (GP) clinics listed as panel clinics.

The majority of private GPs rely on TPAs for the network of clientele (companies) they provide and administrative services managing the various employers (companies).

Private GPs will not be able to sustain their practice by solely relying on out-of-pocket paying patients. As much as 50 percent of private clinic patients come under the category of managed care.

One of the issues that have been brought to light is the practice of fee-splitting, where TPAs take a percentage from the total bill charged to patients, leading to increased costs incurred among private GPs and specialists who are involved. This can potentially compromise patient care.

The MMA has pointed out that some TPAs have been known to deduct 10 to 15 percent from the total bill.

Over time, this can affect the sustainability of the private clinic and the quality of patient care being provided as the GPs involved might be forced to make cost-cutting decisions or even adjustments in charges to cover losses.

We wish to remind all private medical practitioners that under the guidelines set by the Malaysian Medical Council (MMC), fee-splitting is an unethical practice.

If left unchecked, these unethical practices in our healthcare system will lead to a further escalation in healthcare costs, in particular private primary care services.

Since the Health Ministry claims that it does not regulate TPAs, we urge the government to take action against private medical practitioners involved in fee-splitting. By doing so, TPAs will be pressured to comply with ethical standards.

Despite the MMA’s engagements with the Health Ministry on the matter since 2015, there has been no regulatory action to address the issue.

The absence of regulation and oversight of TPAs has been a lingering problem even though it has been highlighted in the Malaysian Productivity Council Report 2016.

Even Bank Negara Malaysia (BNM), which regulates insurance providers, has remained passive concerning the regulation of TPAs, despite the fact that they handle claims for insurance providers.

High registration fees

TPAs also charge private GP clinics high registration fees of up to RM5,000 just to be listed as a panel clinic.

We find this fee to be unreasonable as the TPAs already earn a substantial amount from providing services to their clients (employers). It is also unfair for GPs who are just starting their private practice. Many of these private GPs were former contract doctors in the public healthcare system.

Delayed payments and claim rejections

Many GPs are faced with financial challenges as a result of delayed payments and the rejection of claims by TPAs.

Sometimes GPs are notified of these rejections long after the service has been provided, creating a backlog of unpaid services that clinics depend on for their cash flow.

While this may seem to be an administrative issue to be sorted out between the private GP and the TPA, it affects clinic operations. Staff salaries, rentals, and other commitments need to be paid on time.

Issues in employee health benefit claims at private specialist centres are also leading to delayed treatments. Healthcare costs can increase when health conditions worsen as a result of these delays.

Operational inefficiencies

The unstandardised registration and verification processes among different TPAs cause confusion and inefficiency at GP clinics, further compounding the administrative burden when more time and attention should be given to patient care.

The inconvenience caused to patients can affect the reputation of the clinic as well.

Lack of transparency

Most TPAs prohibit private GPs from disclosing information from their contractual agreement such as eligibility and coverage, with the enrollees.

This lack of information hinders the registration process and the delivery of care, leaving many patients unaware of their coverage limitations. It often leads to misunderstandings between patients and private GPs.

Pricing and fee cap issues

While TPAs enforce fee caps set by employers as a cost-control measure, it is also the responsibility of employers to ensure that their employees receive quality care.

These caps can impede effective treatment, especially for cases involving multiple diagnoses and medications.

Many TPAs, through their contractual agreement with clients, also prohibit private GPs from accepting co-payments from patients even if the patient is willing to pay for any additional treatment required.

This too, can have an effect on the quality of care being provided, which should be based on patients’ needs. Many patients end up making multiple visits to the clinic as a result because their complaints could not be fully addressed on their first visit, due to the fee cap.

Regulatory inaction and recommendations

Despite ongoing concerns from medical associations and practitioners, regulatory bodies like the Health Ministry and BNM have shown a lack of decisive action regarding the regulation of TPAs.

Although there are provisions in the Private Healthcare Facilities and Services Act for managed care in Part XV of the law, the Health Ministry has clarified that TPAs are not defined as healthcare facilities under this act, hence there is no regulation and enforcement for TPAs even though the act has been in force since 2006.

Additionally, BNM only regulates insurance companies, leaving TPAs outside their jurisdiction.

Given these regulatory gaps, it is crucial for the government to establish a mechanism to effectively oversee TPAs and ensure compliance with healthcare standards.

As solutions to these issues involving TPAs, MMA proposes:

1. Addressing fee-splitting in contracts.

2. Establishing an authoritative body to regulate TPAs and enforce ethical practices to protect patients and private medical practitioners.

3. Standardising processes and creating a unified clinic registration system.

Conclusion

The ongoing absence of regulation for TPAs in Malaysia has led to serious concerns among private GPs and private specialists.

This issue necessitates an urgent review and overhaul of the system to ensure ethical practices, duty of care, high care standards, and financial fairness.

The business of TPAs involves patient care, therefore, the Health Ministry must ensure they are regulated. - Mkini

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AZIZAN ABDUL AZIZ is president of the Malaysian Medical Association.

The views expressed here are those of the author/contributor and do not necessarily represent the views of MMKtT.