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Doctors at the Crossroad - Commercialization of Medicine and the Practice of Medicine

Message to the Penang Medical Practitioners’ Society 2014

Dear Colleagues,

“Doctors at the crossroad - Commercialization of Medicine and the Practice of Medicine”

In writing this message I have been reminded that the mission statement of the Federation was just simply “to serve”.

Over the years since its formation, the Federation have taken this to mean to serve our patients, community and fraternity for a better healthcare for the nation. Decades ago when life was simpler, patients and community had direct access to their doctors at nominal cost. There was MCOs, no third party payors and virtually no health insurance. Without the interferences of commercial parties, market forces was able to keep out-of-pocket private healthcare cost low and affordable. In the mid-80s the MCOs and TPPs made their appearance. Today, the landscape have changed. Cost have shot upwards and gate keepers of all sorts and forms are now in the business.

Commercialization of medicine today is in full gear, from the very production of doctors and allied healthcare professionals all the way to delivery of healthcare and eventually even the dispensing of medicines. The professed public policy today for healthcare speaks clearly only for the interest of commercial medicine. The focus of change is in favor of the business of medicine. There is regular talk about health tourism, mega-public listed hospital chains, MCOs, health insurance and valued-added healthcare related investments.

Today, we, the doctors at the crossroad of the Business of Medicine and the Practice of Medicine.

The principles of the business of medicine is simple. Medicine is a tradable commodity, disease is an opportunity, utilizing the patient is a standard operating procedure, an epidemic is a goldmine especially when there is something to sell e.g. the so-called pandemic of the A1H1 flu, high end investigations like CT scans are money spinners (the more slices the better), ROIs and P- E ratios are the performance indicators of the healthcare industry.

On the other hand, the practice of medicine embraces compassion, empathy and the nobility of the profession which unfortunately, when the opportunity arises is conveniently used for doctor bashing.

The call of the profession to heal sometimes, comfort always but never to harm makes no major economic sense. In the past, this was translated in monetary terms as earning a decent living and at the same time enjoying the romantics of the call of medicine.

There is no big money here, only service, long hours and unreasonable capitated fees for fixing up the sick whilst your class mates in the business world drive off in their Ferraris and Lamborghinis, flying from one end of the globe to the other in private jets .

Looking back to 1990s, the private GPs, mainly independent solo practitioners accounted for only about 40% of the primary care provider workforce but they were able to handle 60% of the outpatient load at nominal cost. This took off a significant load from the public hospitals leaving them to focus on secondary care and training. Today this has drastically changed and indeed, tomorrow, with the proposed transformed healthcare be it 1-Care or whatever it may be called, this independent solo practitioner system will be a thing of the past.

Public hospitals are now increasing clogged up with the massive task of sorting out the walking sick. A&E facilities are jam-packed with non-emergencies and hospital beds are filled to the brim. Off-loading these patients to the RM1 per visit 1-Malaysia clinics have not solved the issue. We are now worse off than when we started.

Since 2000, the earnings of GPs have fallen significantly. MCOs, TPAs and insurers have taken a firm grip offering pittance for doctor’s fees and in the same breath, have the audacity to demand discounts from the doctors. The bottom line of this business model is the fee for the middlemen. Today, to see doctor, one must pay a middlemen fee. The same goes, for the doctor. To see a patient, there will also be a middlemen fee.

The golden goose in healthcare was first laid on the table for slaughter in 1990s.The first cut was the privatization of government medical stores to a private company which has since then changed, sold and resold all for a profit. From that time onwards, the carving have continued.

Well connected, monopolistic entities have stepped in to cherry-pick the best parts. What is now left, are the remaining morsels that disease and the sick has to offer, and that is, the money in primary care. Hence one can now see the logic for all this push for a transformed primary care system (as in 1-Care) and its eventual separation of prescription and dispensing. The independent solo practitioner’s clinics are closing one after another. Doctors are retiring for good.

The new, young and those remaining are looking at more lucrative, less demanding and non-medical endeavors. They no longer look at the practice of medicine.

The golden age of the practice of medicine is indeed over. Commercial medicine is here to stay. The new textbooks for doctors are those of marketing and not medical science.

The challenge for us is tremendous. We are losing our younger generation of doctors to the call of commercial medicine, aesthetic practice, multi-levels health and wellness programs. Soon, the profession may have to relook at the relevance of the Hippocrates Oath in this 21st century.

Unless the public opinion and action intervenes,the previous primary care system manned by the solo independent practitioner that had looked after 60% of our outpatients in their simple cost-effective one-stop clinics will be in danger of total collapse very soon. We must treasure and consolidate this system. To replace this with corporate

style oligopolistic mega-chain clinics is the sure recipe for an unmitigated disaster. To add in the privatization of public hospitals and single payer healthcare insurance into this recipe will hasten its occurrence. This is not to mention the unchecked massive wastage and leakages of the system as highlighted by the Auditor General’s Report year after year.

Our constant message to the government since 1998 have remained unheard. We have always been reminded of the increasing cost of healthcare is doctor-driven and why we must change and reform. The truth of the matter is that doctors are no longer in charge. Commercial forces are the driving force behind these reforms and transformation. The contradictory policies that are now implemented are the cause of the increased healthcare cost in the first place. In the UK today (which is supposed to be the model that we will be following) there is already a frank public admission of the failure of healthcare reform policy but yet here in Malaysia, we are still pushing ahead on this same track.

The juggernauts of the business of medicine are in the corridors of power in PutraJaya daily to push their business agenda whilst doctors remain stuck for long hours micromanaging patient's disease. More and more laws and regulations are loaded on the practice of medicine whilst the business of medicine flies freely like a bird.

It has been said that money is the ultimate driver of public policy. Follow the money, so it is said. The gold is in healthcare reforms. This is certainly very true in healthcare in Malaysia.

We believe that Malaysia can afford to put more money into improving our healthcare system. Currently we spend a mere 4.3% of GDP on healthcare. Despite this low cost, we had been able to provide universal access and a safety net for the poor and those who are unable to pay for their healthcare. The allocation of RM 23B for 2015 works out to a mere RM 730 capita per year. The increase of RM1.23 B(less than our wished 1% of GDP) in the Budget 2015 is insufficient in view of the increasing serious threat of infectious diseases, both old and new.

It is now time that we present our wish list albeit in a different platform i.e. via our patients and the public.

We are always reminded to be ready for change and that change is good, hence the need for transformation. However, change is only good if it is for the better. What we seeing is a process that is trying to re-invent the wheel and breaking down something that is not broken and then trying to fix it. This process seemed to be already pre-determined in spirit and in form.

Doctors and patients can be an effective lobby to modulate this process. In an average year there is at least 30 million separate doctor-patient face-to-face engagements in the private sector. This size of this exposure is better than the average print media. It is not that the doctors-patient lobby is ineffective. It is the issue of FEAR to voice the TRUTH. Being in the comfort zone, have the tendency is not to rock the boat.

The collective power of doctors talking to patients across the Nation with a single message so that the rakyat’s aspiration can resonate in into the corridors of power is immeasurable.

On our inaugural Doctors’ Day on 10th October this year, we have reflected with our fraternity and the public on what our healthcare system was and what it will be. We hope our friends, patients, the rakyat and our leaders in both sides of the House have taken heed because one day in the future they themselves, their families and their children will be patients in the very system that they have allowed to be created. They have to voice their caution before it is too late.

Once again, a big Thank You to the Council of the Penang MPS and all its members for the support in the Federation’s mission and vision.

With best wishes.

Steven Chow
President, FPMPAM.

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