Chua – have a heart

by LKN

Perhaps Lee Kuan Yew is right and we should indeed pay Ministers more if we are to expect a better dose of governance.

I read with bewilderment the MOH’s appeal to private hospitals to provide affordable heart surgery to the poor failing which it will invoke the Private Healthcare Facilities and Services Act 1998 (PHFSA) to direct these hospitals to carry out “their social responsibility.”

Chua appears to have been suddenly inspired with this brilliant idea following his visit to the Narayana Hrudayalaya Institute of Cardiac Sciences in Bangalore and speaking to its “world-renowned director” Dr Devi Shetty where 14 Malaysians have been treated.

He further reasoned that the MOH may “arrange for the poor to be treated in Bangalore at a minimum rate if presumably prices in Malaysian private hospitals are not “reasonable”.

The Health Minister appears to demonstrate either inconceivable fiduciary irresponsibility or complete economic ignorance as to why cardiac costs and its concomitant services are high in the private sector.

He further seems oblivious as to why the government’s own hospitals cannot be more efficient in treating these patients ignoring completely that costs in government hospitals are probably the same if not more save for the fact that the tax-payer instead actually pays the same bill for government patients.

More astonishing is the lame duck response of the Federation of Private Medical Practitioners’ Association of Malaysia president Dr Steven Chow who apparently says the federation supports the minister’s call. Doctors should perhaps review who they elect to run their organizations as statements of this nature are really counter-productive to the betterment of health services in this country.

The heart unit at the Christian Medical College headed by Stanley John in Vellore was at the forefront in the provision of cardiac services in India in the 1960s but modern heart services really came into being in India when the cardiac unit at the Railway Hospital in Perambur, Madras was established by T.J. Cherian to not only cater for the 4 million railwaymen and their dependants but also for the general public.

Following this, many heart units mushroomed throughout India and the majority of them are in the private sector.

The cost of an angiogram in India is about 10,000Rs (RM700) and an angioplasty for a two-vessel disease is usually less then RM10,000. Contrast this with a Malaysian private hospital including IJN, where an angiogram can cost anything between RM3000-4500. Angioplasty and stenting can cost between RM12,000 to RM25, 000 depending on number of arteries blocked and/or stented.

If you need a bypass, a patient in the general ward of a private Indian hospital pays about Rs100,000 (RM7000). If you are admitted to a deluxe ward the price is about RM10,000 or if you are in the super-deluxe ward the package price is around RM12,000.

These prices can be cheaper if surgery is done in smaller cities such as Coimbatore, Trivandrum, Madurai, Cochin, Vishakpatnam, Pune or Noida. They are pretty much standardized if they are done in Madras, Bangalore, Bombay, Hyderabad or Delhi.

Why are prices in India much cheaper? They have the same mortality and morbidity results and use the same equipment. The reasons are:

  • The private heart units cater to a large middle class population estimated to be around 200 million and growing. Costs therefore are lower.
  • India has constant and active cardiology and cardiac surgical programs that produces surgeons and cardiologists to cater for these illnesses.
  • They have an even more active program that generate support staff such as cardiac cath lab technicians, echocardiographers, perfusionists, physiotherapists, critical care nurses, biomedical technicians and nutritionists.
  • India’s medical technical base is so established that it manufactures even Siemens CT scan machines under licence at a much lower cost.
  • Many private hospitals in India, to save costs, invest in equipment from the refurbished market rather then buy new as high tech medical equipment has the potential of becoming obsolete within months as a result of rapid medical advances.
  • Pharmaceuticals and consumables are almost entirely generic and manufactured locally.
  • Land and construction costs of hospitals are far cheaper and are not handicapped by anti-business regulations such as the PHFSA.

In Malaysia:

  • The market is far smaller although it has the potential to grow bigger.
  • We don’t have established programs to train surgeons, cardiologists or paramedics. Even the specialists that we bring in quit our government hospitals fairly quickly and politics in government heart units is so bad that administrators in the MOH have reportedly lost control over these units although they are of national importance. The Minister himself has admitted in the mainstream media that more heart units are required but manpower is a serious problem.
  • Thanks to us signing patency laws we can’t even do parallel pharmaceutical imports forcing our hospitals to purchase medicine and consumables at euro or dollar prices.
  • A private hospital in Malaysia is still deemed a commercial venture and land purchased is subject to commercial premiums. Approvals can take as long as 3 years and are now further restricted by the anti-business PHFSA. Even if approvals are given by local councils, they have the potential of being overturned by politicians or health officials as in the Telok Gadong hospital in Klang causing severe holding cost losses to the investor.
  • Water and electricity at private hospitals are subject to commercial rates and bills are further subjected to service taxes.
  • Private hospitals who borrow to set up hospitals are subjected to commercial 8% interest rates. Multimillion-dollar equipment hire-purchase loans are further subjected to shorter repayment periods of usually 5 years as a result of depreciation.
  • Protectionist policies by the MOH and MMC have ensured that the void of specialists in the private sector cannot be filled leaving patients without specialists in both government and private sectors in many secondary towns. Even in newer hospitals such as Petronas’s Prince Hospital both Apollo Hospitals and Austria’s Vamed faced the brunt of this protectionism at the expense of escalating holding costs to our own Petronas.

But our incidence of heart disease is rising and we need to address these issues rather quickly and blackmailing the private sector with the PHFSA or threatening to send patients to Devi Shetty in Bangalore is not going to help neither patient nor country.

The Minister first needs to get his ship in order and this he can do by making certain that training programs for cardiologists, surgeons and paramedics are consistent and well established.

In this respect the Ministry should emulate the exemplary work of Datuk Abu Hassan of the Ministry’s Emergency services who instead of building a giant trauma center and monopolizing it has instead created more then 50 emergency physician posts throughout the country so that emergency services in all government hospitals are upgraded.

He has, in addition, established multiple training programs and conferences to further improve emergency services in this country.

The MOH must have similar programs for cardiac training.

The Minister in earlier media reports declared that finance was not a problem but manpower was in the provision of cardiac services in this country.

If such is the case, the MOH should open the unused unit at Serdang, possibly the new unit at Alor Star and should further upgrade ICUs and unused theaters in other general hospitals and contract out services to private specialists or hospitals.

In doing so the Minister should rein in the usual nonsense and obstructive policies that would generally be placed in his path by his own self-serving specialists to prevent private specialists in helping in the treatment of heart patients in this country.

Despite Chua’s rhetoric that private specialists don’t help out in government hospitals, the truth of the matter is his own government doctors are the ones who have placed endless barriers impeding private specialists from helping out.

But more importantly the Minister must bury his unconcealed animosity for the private sector and find ways and means to work with them for the betterment of this country’s healthcare. For a Malaysian minister, he appears to have no such inhibitions in working with the Indian private healthcare sector and Devi Shetty.

  1. #1 by palmdoc on Saturday, 14 April 2007 - 10:31 am

    On might also be interested to read a Caridiologist-blogger’s viewpoint:

  2. #2 by Not spoon fed on Saturday, 14 April 2007 - 10:41 am

    The side effect for Malaysia to pay high salary to those ministers would be great.

    Unless Malaysia has attained the status like Singapore – advanced country, low corruption low, etc.- otherwise, you would see the side effects.

    With high salary plus the culture of granting datuk, dato’, tan sri, tun, could you imagine what the Malaysian ministers would be ?

  3. #3 by madmix on Saturday, 14 April 2007 - 11:12 am

    Most things in India are a lot cheaper than Malaysia. Incomes are a lot lower. Why compare with India wher you can live like a lord on RM10,000 a month. Obviousy, hospital charges and cardiac surgery will be a lot cheaper in such a situation, otherwise how is the average citzen abble to get decent health care. If you compare with rich countries like the US, Japan or the EU, Malaysia seems a bargain.
    The reason why private cardiac surgery costs so much here is because the private hospitals want to make huge profits to justify their investment. If they are run on by charitable organizations on low profit or non profit basis, I am sure the charges can be slashed in half.

  4. #4 by undergrad2 on Saturday, 14 April 2007 - 11:26 am

    “I read with bewilderment the MOH’s appeal to private hospitals to provide affordable heart surgery to the poor failing which it will invoke the Private Healthcare Facilities and Services Act 1998 (PHFSA) to direct these hospitals to carry out “their social responsibility.”

    It is time employers offer insurance to their employees. The cost of insurance is then shared between employer and employee. It would be cost effective that way -and affordable to the employee.

    In the United States the cost of such insurance could be expensive and not all employees could afford the premiums – but at least employees are given a choice.

    The cost of an open heart surgery in the U.S. is about USDLS55,000.00 and allowing for the difference in the cost of living in both countries, that works out to some RM50,000.00 . Few could afford the cost unless they have insurance. Those who could afford insurance only pay some USDLS 500.00. Just imagine the difference!

    If you have no legal status like an illegal alien, you would still not be refused surgery if you appear at the ER. You would be treated like any other patients with insurance. The costs are billed to some charity which pays 80% of the cost of the surgery for qualified individuals. Individuals who are indigent are qualified to apply.

    I dread to think what would happen to ordinary citizens in Malaysia without any form of insurance who is in need of heart surgery to save their lives not next year or next month or even next week but today and right away – not to mention the fate of illegal aliens in the country.

  5. #5 by PureMalaysian on Saturday, 14 April 2007 - 2:27 pm

    “The reason why private cardiac surgery costs so much here is because the private hospitals want to make huge profits to justify their investment. If they are run on by charitable organizations on low profit or non profit basis, I am sure the charges can be slashed in half.”

    There is NO such thing as “charitable”. Have u heard of lawyers or accountants from big consulting firms doing charity work? Nope. They will squeeeeeze every single cent from the client, and nobody does a losing business in this world. To run a private hospital costs millions and millions, if not billions. An MRI machine costs millions, another 64-slice CT costs another million, laboraties support another few millions etc…

    With more and more lay people wanting to sue the doctors and hospitals, even over “trivial” matter; or without having the full knowledge of why the relatives die, they put on the newspaper headlines wanting to sue and sue and sue…

    So now u have it, doctors and hospitals need a higher premium to insure lest anything goes beyond human control. And with the possiblity of changing Bolam to Whitaker, it is even more important to have a good amount of premium insured. Hence, as the chinese proverb goes “the fur from the sheep will only originate from the sheep” — so the end-users (ie lay people) will have to pay for the cost! Just so simple analogy.

    In fact, I agree with undergrad2 that employers should offer their employees insurance and medical coverage. That way everyone will be happy — be it the people, or the doctors/hospitals. U come for cardiac surgery, the doctors and hospitals get paid the agreed sum, and the employees dont need to pay a single cent (or probably a minimal fees only).

  6. #6 by PureMalaysian on Saturday, 14 April 2007 - 2:36 pm

    Oh and by the way, I always hate those poor people who want to go private hospital for treament (as if they dont know its an expensive place), then later complain to Mr Michael Chang from MCA that they cant afford the bills. C’mon… Gimme a break!

    If u r poor, admit it — and go to public hospital and start queing up. There are very good public hospitals in every state, so dont act “cool” and walk into private medical centre without having enough $$$.

    Even my parents go to public hospital too.

    Only if there is a need to refer to private medical centre for certain procedure (which is very rare), that is totally another story then.

  7. #7 by Jururawat on Saturday, 14 April 2007 - 6:28 pm

    The next thing you know is that the MOH will be whispering to the private sector something like ” if you work with us, we will give you what you want in return “. But hi tech equipments aside, you do hope that you are in the safe hands of a skillful doctor. The equipments themselves are not everything. In the end the one who is doing the operation is the one who decides how good the operation will turn out to be. He or she can just simply do a slipshod job and in the end, you find your life shortened by half the time. Ever wonder why Tun Dr Mahathir did not have his heart surgery here in Malaysia nor India, but in the well known, hi tech, skillful U.S.A.? If the poor have to be treated in India, the government should foot all the bills for both the patient and at least one of the relatives. Don’t expect the poor to approach the loan sharks and to defend themselves when the time for paying up is due. So just what is the real motive when the government advises all its’ citizens to exercise, eat right and take care of their heart ?

  8. #8 by undergrad2 on Saturday, 14 April 2007 - 8:20 pm

    “Ever wonder why Tun Dr Mahathir did not have his heart surgery here in Malaysia nor India, but in the well known, hi tech, skillful U.S.A.?”

    One has to be fair to the old man! He did have his heart surgery locally i.e. at the Heart Center, in Kuala Lumpur. For that you must give him credit for his confidence in local heart surgeons.

  9. #9 by undergrad2 on Saturday, 14 April 2007 - 8:26 pm

    In the mid-80s some of his adversaries were lamenting the fact that the local surgeons involved in the heart surgery did the country a disservice by not stopping his heart whilst they had the chance to so! And they were right because not long after that, the country suffered an unprecedented national leadership crisis which led to UMNO being declared illegal.

  10. #10 by Winston on Sunday, 15 April 2007 - 4:17 pm

    Some of you have talked about health insurance as if that is the panacea for all Malaysians.
    Our health insurers will only insure a person until age sixty-five although there are some who will extend it to age seventy.
    However, you must get insured at age sixty at the latest. Anyone over that age will not be accepted.
    So, it can be seen that when you need them most, that’s the time they’ll drop you.
    In addition, the premiums are according to an age range. The movement from one range to the next involves steep increases in premium.
    So, the older you get the higher premiums you have to pay. For a retiree, this can be very challenging to say the least.
    Now, I would like to ask about the so-called National Health Insurance Scheme which was in the works for umpteenth years. It’s quite apparent that all those who write to this blog have forgotten about it.
    Malaysians have very short memory which makes it very easy for the government to rule them! That’s one of the greatest malaise affecting this country! The opposition parties must do something about it.
    As for those who visit private hospitals without first checking their pockets, let’s put it this way – there’s a huge queue at public hospitals. Also, the will to live is very strong.
    There is a Chinese saying that illnesses should be treated when they are not yet at a serious stage. In fact, when the appointment rolls along, what is basically a minor problem may become a serious one.
    So, instead of blaming each other, the blame should go to the government for wasting the taxpayers’ hard earned money on projects that benefit only a few and ignoring the health problems of the people. Not only health problems, many other problems are also ignored!
    In a way you all deserved it because you gave the mandate to this government!

  11. #11 by undergrad2 on Sunday, 15 April 2007 - 10:20 pm

    In the United States, health care issues win elections.

  12. #12 by undergrad2 on Sunday, 15 April 2007 - 10:22 pm

    Malaysia sadly is all about economic survival and who gets what and who gets more. I believe we’ll get there eventually but when?

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