As a government doctor, you get a fixed salary; you do not charge for the work you do.
However, in the private sector, you earn a living by charging a fee for your service.
One decision you will have to make occasionally is whether you are going to waive your fees or give a discount to certain patients.
One group in particular that you will have to consider are your colleagues, i.e. other doctors and the staff at your hospital.
This a rarely discussed topic among doctors in Malaysia, so I hope to give you some insight through my over 25 years’ of experience working in a private hospital.
A professional courtesy
In an earlier article, I described two different types of clinic systems in local private hospitals.
The most common type is where the clinic is owned by the hospital and the doctor just charges his consultation fees.
The second type is like the hospital I practice in where the clinic and all the equipment belong to me.
When I started private practice in 1994, I felt that it was an honour if a colleague or another doctor chose to consult me.
I waived all my consultation and procedure fees.
My patient still had to pay the hospital portion of the ultrasound fees though.
They also had to buy all their medications from the hospital pharmacy.
In 1999, when I bought over my clinic in the hospital, I not only waived my consultation fees, but also the ultrasound charges, and even the medications at times when they were not costly.
Only when the medication was expensive would I sell it, but even then, at cost price.
Even though I am losing money during such consultations, I consider it a professional courtesy to my colleagues and have adopted this approach for all doctors and their immediate family members.
When it came to in-patient procedures, very few people, including doctors, had medical insurance 25 years ago.
In addition, obstetrical procedures, including deliveries, were not covered by insurance.
Therefore, if the doctor was paying out of his own pocket, I waived all my surgical and delivery fees.
If the doctor had medical insurance and the procedure was covered by insurance, I would then charge for the procedure in full.
I still practice this today.
When a doctor’s relatives and friends consult me, I have to make a calculated judgment as to whether to give a discount or not, and if so, how much.
Although they usually do not ask for a discount or waiver, I am always unsure whether one is expected.
It is very awkward to discuss this with them.
Sometimes, I ask my staff to inform them that I have given a discount for the treatment.
Other times, I charge in full, hoping that they will understand.
Another category of patients you need to deal with are your own hospital staff.
Even though they are not your employees, you work with them in the hospital.
Most of them cannot afford the fees that you and the hospital charge.
Sometimes, they ask me how much I charge, then decide whether or not they can afford it.
I rarely charge hospital staff for outpatient consultations, not even the ultrasound fee.
As these patients usually do not have medical insurance, I always waive all my in-patient charges.
The hospital also usually gives them a discount on the fees.
Quid pro quo?
When I started private practice, waiving my fees was not only a professional courtesy, but as a relatively fresh specialist working in a new town, I was hoping that the doctors I treated would be satisfied with my service and consider referring their patients to me.
And indeed, many of them did, and still do, refer their patients to me.
Similarly, I have continued referring patients to my colleagues who have taken care of my family members and me.
However, I learnt in a difficult way that there is no obligation for them to continue referring patients to me in the long run.
You must understand that just because you did not charge a doctor for your services once, the doctor is not indebted to send patients to you forever.
I will give you an example.
I delivered the babies of one particular doctor and waived all my fees.
She continued to support me over the years until her good friend, also an obstetrician and gynaecologist, entered private practice.
After that, I never received any patient referrals from her.
I was disheartened, but soon realised that she was not indebted to me.
I should be grateful for all her previous referrals. Free service should be provided without any expectations.
Similarly, I too will not be obliged to continue referring patients to colleagues who have taken care of my family and me.
Gifts in lieu
My family members and I have been patients of many of my colleagues. Most of them waive their fees.
At times, the amount waived can be big. We, like most other doctors, appreciate this gesture.
My wife usually gives a gift to the doctor.
I have also received numerous gifts from doctors and their families for my free service.
To decide on the type of gift and the amount to spend on it can be difficult.
Some years ago, I operated on the wife of a senior private specialist.
She did not have medical insurance.
The specialist was straightforward with me.
First, he asked me what I normally charged for the procedure.
Then he told me that instead of trying to figure out what gift to buy, it would be easier to give me a discounted amount of the surgical fees.
We agreed on a figure and he paid me. Both of us were happy with the transaction.
I thought that it was interesting as it was uncommon.
IVF and delivery
Allow me to share a couple more personal experiences particular to my field of obstetrics and gynaecology.
A colleague who runs his own IVF (in-vitro fertilisation) centre, once asked me how I charge doctors who consult me for IVF treatment.
IVF treatment is expensive and not covered by insurance.
There are three charges: consultation, drugs and laboratory fees.
I do not own my own IVF centre. Therefore, I do not charge my consultation fee and the drugs are sold at cost price to most doctors, while the hospital charges the full laboratory fees.
My friend, who has his own IVF centre, told me that he gives a 20-30% discount on the whole IVF package to fellow doctors.
Another experience is related to legal liability.
When I first entered private practice in 1994, my medical indemnity insurance cost RM4,950.
(Medical indemnity insurance covers a doctor’s legal costs and any compensation they might have to pay if they are found guilty of medical negligence or committing a harmful error during work.)
Today, it ranges from RM50,000 to RM100,000.
The chances of getting sued for a delivery in 1994 was also so much lower than now.
I have always waived my deli-very fees for fellow doctors and hospital staff.
However, this changed after an unfortunate incident.
A couple, both doctors, underwent two IVF cycles and conceived on both occasions, but miscarried.
Fortunately, they then conceived naturally and planned to have an elective Caesarean section, but went into labour before that.
They decided to proceed with a normal delivery, which was conducted by my colleague as I was operating at that time.
Unfortunately, the baby had shoulder dystocia with a subsequent Erb’s palsy.
Soon after, I received a letter of demand from their lawyers.
I was upset for several reasons.
Firstly, I did not do the delivery.
Secondly, despite the fact that I had waived all my professional fees while treating them for several years, they still decided to send the letter of demand.
After this incident, I decided not do any more free deliveries at the hospital.
I advise all hospital staff who come to see me for their pregnancies to see my other colleagues who will not charge them instead.
In the United States, due to corporatisation of medicine, doctors are increasingly not allowed by their employers to give discounts.
The complexity of insurance claims and the pressure of hospitals employing their own doctors will make waiving fees more and more difficult in the future.
I suspect this will eventually happen in Malaysia as well.
I hope this article will give young specialists entering private practice some ideas on when to waive their fees.
With the current medicolegal environment and high medical indemnity insurance, your decision may be different from the decisions I made 25 years ago.
I feel the best way to deal with this issue is to discuss it upfront with your patient.
This can be awkward, but it clarifies the issue for both parties.
Waiving fees for colleagues and doctors is a nice professional courtesy, but as medical practice is becoming more expensive and complicated, new doctors might find it difficult to sustain this practice.
Dr S. Selva is a consultant obstetrician and gynaecologist, and fertility specialist, in private practice in Melaka. This is the 11th article in a weekly series about surviving private practice in Malaysia. For more information, email firstname.lastname@example.org. The information provided is for educational purposes only and should not be considered as medical advice. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.