The World Health Organization (WHO) recognises primary care as the best, cheapest and fairest way to improve health outcomes for countries.
A strong primary healthcare (PHC) system provides accessible, comprehensive and patient-centred services to the public, delivered by well-trained primary care physicians and their teams.
In Malaysia, the private PHC sector comprises approximately 8,000 general practitioner (GP) clinics, delivering RM4.5 billion of care in 2019.
To live up to the promise of PHC and in recognition of its size and importance, we look at three main challenges for private PHC in Malaysia and propose three ways to strengthen its delivery.
The first main challenge is that private GPs are not integrated with hospitals (public or private) or public sector primary care.
This leads to a lack of care continuity, which means that patients find it difficult to move from hospital to clinic, or from public to private healthcare facilities, and vice versa.
Care could also be duplicated, with multiple blood tests being performed every time the patient sees a new doctor.
Secondly, private GPs are not upskilling as comprehensively as they can and should.
Despite postgraduate general practice training being widely available in Malaysia, the uptake among private sector doctors has not been encouraging.
To date, out of the 700 qualified family medicine specialists distributed throughout the country, only 130-odd are practising in the private sector.
While there has been a paucity of data on the underlying reasons, it is believed to be due to the lack of tangible benefits to the GP beyond self-improvement.
Thirdly, private GPs are facing challenging interactions with third-party administrators (TPAs) and managed care organisations (MCOs).
TPAs and MCOs were established to help employers reduce their employees’ healthcare costs.
These entities monitor, receive, audit and consolidate medical bills from panel clinics, hospitals and insurance companies, on behalf of employers.
However, a 2016 report by the Malaysian Productivity Council found that TPAs and MCOs can be better governed to ensure that GPs are appropriately compensated for their skill and that patient outcomes are prioritised.
One records system
We propose three ways to strengthen the delivery of private PHC in Malaysia, which directly address the challenges identified above.
The guiding principles are to improve health outcomes for patients (like achieving diabetes and hypertension targets) and manage costs, while encouraging GPs to upskill.
Firstly, we recommend implementing a basket of solutions to improve care continuity.
In other words, a patient’s movement from the public to private sector, or from clinic to hospital (and vice versa), should be smooth.
These movements are called “care transitions”, and must be anchored by a universal, interoperable and portable electronic health record (EHR) system.
The government is the most ideal entity to set the standards for the EHR system.
They have the option of also being the owner and/or operator of the system, or leaving it to the private sector.
Having a lifelong and portable EHR system will allow smoother care transitions and a better patient experience.
Such a system can also reduce healthcare costs – mostly by reducing duplication of tests or procedures.
After several years, the data that is collected can be used to improve healthcare analytics, efficiency and healthcare outcomes.
Incentive to upskill
Secondly, we recommend that the Health Ministry (MOH) provides incentives for GPs to upskill.
Incentives can be easily created if the MOH mandates a minimum standard for GPs before they can participate in government-run programmes for co-management of chronic conditions like diabetes or hypertension.
For example, GPs could be required to have a minimum of the Graduate Certificate in Family Medicine (a two-year distance-learning program by the Academy of Family Physicians Malaysia, costing RM8,000), before participating in the PeKA B40 scheme.
A grace period of four to six years can be provided for new GPs to obtain this minimum requirement, with a grandfather clause for GPs who are already in the PeKA B40 scheme.
Incentivising GPs to upskill must be done in parallel with greater public-private partnerships with private GPs.
For example, government clinics can transfer their patients with diabetes or hypertension to private clinics for long-term treatment at a pre-determined rate.
We cannot demand upskilling in isolation, and it must be accompanied by an expansion of services by the government.
The United Kingdom provides a classic example of a well-trained PHC workforce.
Primary healthcare has formed the backbone of the UK National Health Service (NHS) since 1948.
The law requires every UK citizen to register with a GP.
These GPs act as “front doors” to the UK NHS, supported by allied healthcare professionals like nurses, dieticians, pharmacists and physiotherapists.
UK legislation has also mandated postgraduate GP training since 1979, which is delivered through the Royal College of General Practitioners (RCGP).
In other words, GPs are treated like a speciality equal to surgery, paediatrics or obstetrics, among others.
Overseeing third parties
Thirdly, we recommend a basket of solutions to improve the TPA/MCO landscape and their governance.
The aim is to standardise and improve the quality of healthcare provided to patients, while managing costs and being fair to private GPs.
There may need to be a stand-alone TPA/MCO Act to provide strategic leadership and regulatory oversight, above and beyond the provisions in the Private Healthcare Facilities and Services Act (PHFSA) 1998.
Such a TPA/MCO Act must address issues of professional fee reviews and schedules, the right for a TPA or MCO to intervene in the GP decision-making process, the right for delayed or partial reimbursements, and metrics to measure good performance.
A TPA/MCO Act should seek a new balance of power between GPs (who want to deliver good healthcare), employers (who want to cut healthcare costs) and patients (who want to receive good healthcare).
There is also the separate and delicate issue of the professional fee schedule for private GPs.
The Seventh Schedule of the PHFSA 1998 controls the professional service fee from doctors to patients, but it was abolished in December 2019 by the Pakatan Harapan government.
Abolishing the fee controls was intended to allow competition and to reward doctors for their skill and qualifications.
It was also because it was cumbersome to regularly review fee controls.
However, the abolishment of the private GP fee controls has not yet been implemented as the orders have not been gazetted due to the changes in government.
Therefore, there is an opportunity to set a minimum fee when the fee controls are finally abolished, in order to ensure that GPs are treated fairly by TPAs and MCOs.
In a nutshell, primary care reform in Malaysia can be achieved by ensuring care continuity, upskilling GPs, and managing TPAs and MCOs in more integrated and fairer ways.
Dr Na Wei Lun is a GP pursuing postgraduate training in family medicine and healthcare management. Dr Khor Swee Kheng is a physician specialising in health policies and global health, who tweets as @DrKhorSK. The views expressed here are entirely their own. For more information, email email@example.com. The information provided is for educational and communication purposes only. 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.