Third-party administrators ‘squeezing’ GPs

From Dr RA Lingeshwaran

In Malaysia, the healthcare system is one of the pillars that support the well-being of our population.

Among the key players in this system are the approximately 11,000 general practitioners (GPs) who serve as the first point of contact for many seeking medical care.

Their role is indispensable in ensuring that quality healthcare is accessible to all Malaysians.

However, these healthcare providers are finding themselves increasingly constrained by the regulatory framework and business practices imposed by third-party administrators (TPAs).

TPAs act as intermediaries between healthcare providers, insurance companies and patients.

They manage the administration of healthcare services, including claims processing, billing and payments.

While TPAs are supposed to streamline these processes, many GPs face significant challenges due to the manner in which TPAs operate.

A key grievance is unfair fee structure. GPs are often forced to accept lower than reasonable or sustainable consultation fees, undermining their ability to cover operational costs while maintaining the quality of care.

These fees, sometimes set without adequate negotiation, do not reflect the rising cost of running a clinic such as staff salaries and cost of equipment and medication.

Another problem GPs face is delayed payments. They are frequently left to wait for months to receive payments for services rendered.

Such cash flow problems can be crippling, especially for smaller clinics that rely on timely payments to stay operational.

Complex and often opaque processes imposed by TPAs add to the administrative burden of GPs.

This bureaucracy takes time and attention away from patient care as GPs are forced to navigate layers of paperwork and red tape to receive payment for their services.

This is particularly frustrating given that the core focus of healthcare providers should be on their patients, not on managing administrative hurdles.

TPAs often make unilateral decisions that affect the operations of GP clinics. This includes decisions on which treatments or medications are covered under insurance plans and at what rates.

Such practices undermine the clinical autonomy of GPs and can compromise the quality of care provided to patients.

Steps to improve the ecosystem

The current system must undergo significant reforms to ensure that GPs are treated fairly and can continue to provide high-quality care to their patients.

The following steps can be taken to improve the ecosystem:

1. Transparent and fair fee negotiations: It is crucial that TPAs engage in transparent negotiations with GPs to set fair consultation fees that reflect the true cost of providing care. This should involve a standardised process that considers the varying costs of running a clinic in different regions.

2. Timely payment policy: The government should enforce stricter regulations on payment timelines to ensure that GPs receive their dues within a reasonable period. Penalties for delayed settlement should be imposed to discourage TPAs from withholding payments.

3. Reduction in bureaucratic processes: The processes imposed by TPAs should be streamlined and simplified to reduce the administrative burden on GPs. This can be achieved through the adoption of digital platforms that automate claims processing and reduce the need for excessive paperwork.

4. Empowering GPs with autonomy: GPs should have greater autonomy in making clinical decisions without TPAs overriding them. This can be made possible by establishing guidelines that protect the rights of GPs to determine the best course of treatment for their patients, without undue interference from third-party administrators.

5. Regulatory oversight: The health ministry, along with other relevant bodies, should establish a regulatory framework to oversee the practices of TPAs. This framework should include mechanisms for resolving disputes between GPs and TPAs and ensuring that the latter do not exploit their position to the detriment of healthcare providers.

GPs are the backbone of primary healthcare in Malaysia, and their ability to deliver quality care should not be compromised by unfair practices.

It is imperative that we address the challenges posed by TPAs to create a more equitable healthcare system.

By implementing these reforms, we can ensure that GPs are adequately supported, allowing them to focus on what they do best – caring for their patients. - FMT

Dr RA Lingeshwaran is a senator and an FMT reader.

The views expressed are those of the writer and do not necessarily reflect those of MMKtT.