The health contract

Dr Steven Chow, FPMAPM via The Star

Though healthcare is increasingly driven by the prospect of profits, the patient-doctor social contract must prevail.

THE social contract between patients and doctors must prevail in Malaysia as it is a time-proven model for quality, affordability, and compassionate care for patients, said Dr Steven Chow, president of the Federation of Private Medical Practitioners’ Association, Malaysia (FPMPAM).
The traditional social contract governing the patient-doctor encounter guided by the simple dictum of Sir William Osler, ie, to cure sometimes, to comfort always, but never to harm, is increasingly eroded by the dictates of commercialised medicine, driven by bottomline turnover, profit, and return on investment.

Private practitioners in a dilemma
“Today, medical care is being touted as a lucrative business commodity to be bought and sold, with corporate visions of exponential growth and billion-dollar turnover,” observed Dr Chow.
In the current healthcare scenario, the basic needs of patients and the aspirations of compassionate doctors are no longer a contractual priority. Instead, the turnover generated by doctors and their corporate patients has become the implicit driver of business-driven contracts.
This is the cross-road that now faces both the public and doctors, he explained.
Paradoxically, the reason for the need for this change being marketed to the public is the so-called rising cost in healthcare, and the dire need for cost-containment to ensure sustainability.
On the contrary, the evidence paints a different picture – healthcare cost is on a rising trend that will seriously overtake our ability to provide basic quality, affordable healthcare for the less fortunate, Dr Chow emphasised.
Over the years, we have seen the progressive commercialisation of all aspects of healthcare, starting with medical education, all the way to the delivery of tertiary and primary healthcare. In tandem with this is the alarming rise in the cost of providing medical care, which affects both private and public sectors, he said.
“There is, thus, some important fundamental issue regarding the way our healthcare system is being regulated. It is important that this issue is addressed urgently. FPMPAM finds this trend extremely alarming.”
The public is of the perception that a high hospital bill is due to hefty doctors’ fees. Hence, they call for more regulations to oversee the practitioner, rather than the business of medicine.
However, in reality, the professional fees for doctors have already been capped by law. It should also be noted that the average doctor’s professional fees account for about 10% to 15% of the overall private hospital bill.
In contrast, there are no provisions in the Private Healthcare Facilities and Services Act (PHFSA) 1998 and Regulations 2006 to regulate hospital bills, Dr Chow said.
“Doctors trained in the traditional mould of medical care will have problems coping with this change. The new laws and regulations regulating the so-called business of medicine, with its countless threats of massive fines and imprisonment for non-compliance, do not augur well for the traditional genuine, compassionate social contract-based patient-doctor relationship.”
Thus, he called on the Ministry of Health (MOH) to uphold the spirit of the PHFSA 1998 and Regulations 2006, which states that medical care should be in the hands of doctors, eg, Part XIV states that the Board of Management of any private hospital is the ultimate authority governing all aspects of medical care in that hospital.
Two members of this board must be doctors appointed from the Medical/Dental Advisory Committee (MDAC), which is supposed to represent all doctors practising in hospitals and whose function is to ensure that the medical management of patients vests in registered medical practitioners.
“Hospitals have many ways and means to dilute the implications of this requirement,” said Dr Chow.
Moving on to Part XV of the PHFSA, Dr Chow said contracts between healthcare facilities and managed care organisations (MCOs) must not alter the power of the doctor in providing medical care. Most doctors in the private sector are bound by contracts with hospitals or MCOs, or directly with employers and companies.
The dilemma now is that when doctors start work at private hospitals, the hospitals themselves may have already entered into contracts with MCOs, in which some of the contractual provisions are in contravention of the PHFSA. The doctors themselves have no access to these contracts, but nevertheless, are involuntarily bonded to them by virtue of their contract with the hospital.
“We advise doctors that it is their right to refuse any contract that interferes with their independent medical care of patients. Should they be coerced, FPMPAM will fully support their action to refer such contracts to the MOH,” Dr Chow emphasised.
“The onus is on the MOH to act its part as the regulator. However, the major hospitals are now mainly owned by government-linked companies (GLCs), ie the government, being the regulator, is also an operator in the industry via its GLCs. In a situation like this, there is clearly a blurring of the line between the regulator and the operator,” Dr Chow commented.
In addition, as a measure to boost profits, some hospitals, MCOs and other third parties in healthcare have resorted to extracting mandatory discounts from doctors’ professional fees in their contracts.
The FPMPAM calls this “fee-splitting”, an exercise which is in contravention of the PHFSA and Regulations. “FPMPAM is committed to initiate all action necessary against any party trying to extract such discounts from our doctors.”
In the past, Dr Chow said, the FPMPAM had highlighted to the MOH the difficulties doctors were facing with contracts. “We hoped that the MOH would act swiftly and decisively.
“In 2006, we also proposed important regulations to the PHFSA and Regulations so that all the business components of healthcare are regulated synchronously to protect the public from over-exuberant commercialisation.”