Charge according to ability to pay

I REFER to the press statement by Health Ministry secretary-general Datuk Seri Dr Chen Chaw Min on Friday (see statement at tinyurl.com/star-costs) touching on the latest treatment charges imposed on Malaysian cancer patients based on the Fees (Medical) (Amendment) Order 2017 that was issued by the ministry’s finance division in February 2017.

In his Aug 24 statement, Dr Chen said that the increased charges practised currently by all government hospitals are lower than the charges for similar treatments in private hospitals, and that the revenue collected last year from patients seeking treatment in government hospitals was only 2.64% of the total cost borne by the government. This was in reply to The Star’s Aug 13 report (online at tinyurl.com/star-medicine) on patients referred from private hospitals to public hospitals complaining that they were paying more for cancer treatments and drugs in public hospitals than in private ones.

There are two pertinent issues that have been missed by the press statement.

I applaud the effort by The Star to highlight one issue, which I believe stems from the Fees (Medical) (Amendment) Order 2017 that categorises patients into different classes of fee schedules that are not based on their ability to pay but on the mode of referral. If a private practitioner in primary care practice or a private hospital refers a patient to a government hospital, the patient will be automatically billed at a higher rate. This includes outpatient fees, drug costs, and blood and imaging costs as well as inpatient charges.

The first issue is: Why is private referral treated like this? Patients and doctors alike feel as if it is a way of punishing them for going to private practice first before seeking care at government facilities.

A patient’s son was shocked when he discovered that a drug company sold letrozole (a generic brand used in cancer treatment) to the government at a cost price of RM33.60 per box for four weeks’ supply, yet his mother, who had switched from a private to a public hospital, was billed RM400 at the public hospital. The cost price had been inflated 10 times for patients referred by private practitioners!

Also, it would not be correct to attribute that care was provided in a fair and just manner to the revenue collected from patients seeking treatment in government hospitals stated to be only 2.64% of the total cost borne by the government. There are many other contemporary factors and developments that would also have had distributional consequences. Hence, the reasons that were given in the press statement were spotty and not comprehensive in so far as it attempted to quash the perception that government hospitals are raking in profits from patients.

The second issue is placing old and very common but important drugs used to treat cancer, such as tamoxifen or letrozole, together with other antineoplastic (antitumour) agents such as chemotherapy combinations, in a single fee category that costs more.

Tamoxifen is an oral drug and does not require the use of a facility, blood tests monitoring or higher expertise like the other treatment modalities. It shouldn’t be lumped in with those other modalities in a generic manner. Furthermore, patients in early stage breast cancers who require tamoxifen may be prescribed this drug monthly for as long as five to 10 years.

Not all patients who seek initial investigation at private hospitals are rich. Some are forced to pay or exhaust their life savings in order to get quicker treatment before continuing further care at government hospitals. They should not be penalised for going to private centres prior to the government hospitals.

The Health Ministry’s Client Charter states that “every client will be appropriately served, regardless of gender, ethnicity, religion or status, socially and economically”, therefore patients should be billed or categorised according to their paying ability.

Cancer is now a chronic disease that affects many people we know. Even though many people like to think cancer cells are identical and cancer is one disease, in fact not every cancer story is the same, and there are many differences in people’s journeys within the healthcare system in a country.

We as oncologists are working in an increasingly challenging world to overcome cancer, which is a lot smarter than we ever realised. However, sometimes decisions are made which are so rigid they become implausible. While people use cancer as a metaphor for the worst things in life, there are no metaphors dreadful enough to describe differential treatment for cancer patients seeking treatment at a public facility entrusted to provide access to care.

To ensure patient safety and improve the quality of healthcare services (other than staff competency level, leadership style, organisational cultures, working environment, team cohesiveness, compliance with international standards, patient-provider relationship), client needs and expectations must not be ignored or belittled.

I sincerely hope the Health Ministry can review the Fees (Medical) (Amendment) Order 2017.