Urgent need to regulate managed care

THE Medical Practitioners Coalition Association of Malaysia (MPCAM) is happy to note that the Malaysian Medical Council (MMC) has directed its Ethics Committee to deliberate the issue of managed care organisations (MCOs) and third party administrators (TPAs) which made headlines recently.

The Ministry of Health has taken the lead to solve this impasse by meeting MPCAM and other doctors associations last week.

Managed care has been a feature of our healthcare landscape for about 22 years now. They provide intermediary services to various stakeholders such as insurers, corporations, healthcare providers and patients. Initially this was sporadic. However, for more than a decade now it has become a norm rather than an exception.

The time has come for MMC to review the Ethical Code and Ethical Guidelines, which already address fee-sharing between doctors, to also address fee-sharing between doctors and TPAs. The guidelines must address the issue of financial arrangements in managed care which may lead to any compromise in the care of the patient.

With the MMC said to meet as early as next week to deliber- ate this issue among others, we recommend its Ethics committee and its Councillors zero in on the following issues, to safeguard the rakyat and to guide doctors.

> Inconsistent expectations of

the patient

Patients seeking treatment from companies usually have higher expectations of their medical benefits than what the managed care system allows. Most of the time, patients do not know the limitations of the doctor, as dictated by the employer or by the MCO/ TPA.

There ought to be legislation to make it compulsory to disclose to policyholders and employers any financial impositions made on the doctor. This will avoid unnecessary misunderstandings when one seeks treatment.

> Kickbacks and fee-splitting

masked as administrative fees

Some schemes impose arbitrary administrative fees ranging from 10% to more than 15% of the total billing for a patient, which on closer examination appears to indicate that most often, the higher the claim, the higher the arbitrarily imposed administration fee.

There are others who take a fee per patient seen per day, and more recently, a form of inducement to be appointed to be a panel doctor of the MCO, a one-off commission fee ranging from RM2,500 to RM5,000 (excluding a yearly renewal fee). So now we have an administration fee, cheque deposition fee, transaction fee, annual fee, commission for appointment fee and terminal fee. We don’t know what other fees are in store for us.

> Limitations on the doctor Primary care medical service providers are paid paltry consultation fees, with the least being RM15 (before the administrative fee is deducted) and we can be imposed unreasonable limits on medicines, investigations and procedures.

We have to juggle between giving the best to the patient, rising cost of medicine and overheads, and to do all that within a limit imposed and also with very much delayed payments.

> Incentive for cutting cost Different managed care schemes pose different challenges. In general practice, for example, certain schemes provide a fixed remuneration of say RM40 per patient visit, inclusive of cost of medication and consultation. Reimbursement for medicines and investigations is sometimes pegged at such a ridiculously low price that it can even be below cost to the clinic in some instances. We need the regulators to regulate.

> Patient has no choice, loss of

continuity of care

TPAs determine which hospital/ clinic a consumer would be able to go to by only appointing certain clinics as panels. If the employer decides to appoint an MCO/TPA which is not the regular doctor of a patient, the patient loses out on his choice of doctor or hospital/clinic.

This fundamental right of the patient is being compromised. > Begging for payment Reimbursement can take place anytime from three to 12 months after the doctor has seen the patient. Some MCOs/TPAs only pay when prompted, while others “inadvertently” miss a payment or two in between. The doctor then has an arduous task to audit and trace pending payments and in extreme cases, beg for payment.

These business practices appear to demonstrate a lack of respect for the medical profession.

The Ministry of Health and the MMC could study the following suggestions from the fraternity on how best to address this issue:

1. All MCOs/TPAs must be subject to the same principles that regulate medical practitioners, and should not be allowed fee-splitting or kickback schemes, or be allowed to arbitrarily charge varying amounts of “administrative charges”.

2. All fees should be charged to the employer/user/subscriber of the TPA and not the healthcare provider participating in the scheme.

3. Contracts between MCOs and insurance companies, and insurance companies and their clients, must be transparent and abide by laws governing the medical profession.

4. All healthcare contracts and how they are administered and delivered should be subject to stringent audit.

5. The Health Ministry and the Malaysian Medical Council should consider legislative changes to be implemented to truly guide doctors and safeguard patients. Regulation of MCOs/TPAs by the ministry is inevitable and critical.