You are a government doctor and you want to move to the private sector. In the government service you get a fixed salary. You do not charge for your work that you do. In the private sector, you earn a living by charging a fee for your service. One decision you will have to make is when are you going to waive your fees or give a discount. Are you going to charge your colleagues, other doctors and the staff at your hospital? This issue is rarely discussed among doctors in Malaysia. Here I will describe my experience having worked in a private hospital for more than 25 years. This I hope, will give you some insight on the decisions you will need to make when you move to the private practice.
How I run my clinic
When I started work at Mahkota Medical Centre in 1994 , everything was owned by the hospital. At the outpatient clinic, I earn from the consultation fees, procedure fees and a percentage of the ultrasound fees. As for inpatients, I earn from the procedure fees. In the early days, there was no Private Health Care Act. The amount I charged was based on the market value of the procedure and this was decided by the doctors and the management of the hospital.
Everything changed when the hospital was sold in 1999. I was asked to buy or rent a clinic. I had to buy all the equipment I used in my clinic. I also have to employ my own staff. In summary I run my own private clinic in a private hospital. I have a large overhead for running my clinic.
How most doctors operate in Private Hospitals in Malaysia
In most other private hospitals, the doctor does not own a clinic. Usually the clinic is provided for or rented out to the doctor. The hospital may provide a staff or the doctor may employ his own staff. The equipment in the clinic especially the ultrasound machine may also belong to the hospital. In this scenario, the overhead cost for the doctor is lesser.
Should you charge your colleague and other doctors
When I started work 25 over years ago, 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 have to pay for the hospital portion of the ultrasound fees. They will need to buy the medication from the hospital pharmacy.
When I switched to my own clinic, I not only waived my consultation fees but also my ultrasound charges and at times the medication when it is not costly. Only when the medication is expensive, I will sell it to them at cost price. So in fact when I see a doctor in the clinic, I am losing money. This, I considered as professional courtesy.I adopted this approach for all doctors and their immediate family.
In patient procedure
When I started working in 1994, very few people including doctors had medical insurance. More ever being an obstetrician, obstetrics procedures including deliveries were never covered by insurance. So if the doctor is cash paying, I have always waived all my surgical and delivery fees. If the doctor has medical insurance and the procedure is covered by insurance, then I will charge for the procedure in full.
What about doctors’ relatives and acquaintances
When a doctor’s relatives and acquaintances consulted me, I had to make a calculated judgement as to whether to give a discount and if so, how much discount to give. Even though they usually do not ask for a discount or a waiver, I am always unsure whether a discount is expected. It is very difficult to discuss this with them. Sometimes I ask my staff to inform them that I have given a discount for the treatment. At other times I have charged in full hoping that they will understand.
How do doctors react to this waiver and discounts
My family members and I have been patients of many of my colleagues before. Most of them have waived their fees. Sometimes the amount waived can be large. We, like most other doctors appreciate this gesture. My wife usually gives a gift to the doctor for taking care of us. I have also received numerous gifts from doctors and their families for my free service. To decide on what gift to give and the amount to spend on the gift is not easy. Some years ago, I operated on the wife of a senior private specialist in town. His wife was not covered by insurance. He, being in private practice for a long time, was outright with me. Firstly, he asked me what I usually charge for the procedure. Then, he told me that instead of trying to figure out what gift to buy for me, it will be easier to give me cash on 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 this was interesting even though this practice is uncommon.
Charging hospital staff
Another category of patients that you need to deal with, is your own hospital staff. Even though they are not your employees, you work with them in the hospital. They are not very rich and most of them could not afford the fees that you and the hospital charges. Sometimes they would like an opinion from you before deciding whether they can afford treatment in a private hospital or go to a government facility. In my experience, they usually ask me how much I will charge and then decide whether they can afford it. I have rarely charged the hospital staff for outpatient consultation and even ultrasound charges. As for inpatient charges, if they do not have insurance, I have always waived all my fees. The hospital continues to charge them usually with some discounts. Some hospitals do take a group insurance for all their staff/employees and the insurance covers them for medical fees but the amount covered is usually small.
A colleague of mine who is running his own IVF centre, once asked me how I charge doctors who consult me for IVF treatment. As you know IVF treatment is expensive and is not covered by insurance. There are 2 charges namely: the drugs and the laboratory charges. I do not own my own IVF centre. I do not charge my consultation fees and the drugs are sold at cost price to most doctors. As for the laboratory fees, the hospital will charge in full. My friend who owns his own IVF centre told me that he gives a 20 – 30 % discount on the whole IVF package.
What is my expectation for waiving my fees for doctors and colleagues
When I started private practice, being a young doctor working in a new town, waiving my fees was not only a professional courtesy but I was hoping that the doctors I treated will be satisfied with my service and will consider referring their patients to me. This was my wishful thinking. Fortunately, it was usually the norm.. Many of them do refer their patients to me and continue doing so. Similarly, I have continued referring my 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 you. You must have the attitude that, it does not mean that you did not charge a doctor for a service, the doctor will be indebted to you and send patients to you for the rest of their lives. I will give you an example. I had delivered the babies of a doctor and waived all my fees. She continued to support me over the years until her good friend came out to private practice. From then on I never received any referral from her. I was disheartened: I am only human. I have to realise that she is not indebted to me. I have to be grateful for all her previous referrals. I learnt that when I provide free service to anyone, I should not have any expectations from them. Similarly, I don’t have any obligation to continue referring my patients to my colleagues who have taken care of my family.
When I first started working in private practice in 1994, my medical insurance cost me RM 4950. Today it is more that RM 100,000. The chances of getting sued for a delivery in 1994 was so much lower than now. I have always waived my delivery fees for my colleagues, doctors and hospital staff. However this concept changed after a doctor sent a lawyer letter to me recently for an unfortunate incident.
A couple, both doctors consulted me for fertility problems. She underwent 2 IVF cycles and conceived on both occasions but miscarried. Fortunately, she conceived on her own and was planned for an elective caesarean section. She came in spontaneous labour before the date of the elective caesarean section. They decided against Caesarean section and deliver the baby naturally. The delivery was conducted by my colleague because I was operating at that time. Unfortunately the baby had an Erb’s palsy. A received a letter of demand from their lawyers. I was upset for several reasons. Firstly the delivery was not done by me. Secondly, despite the fact that I have waived all my fees managing her for several years, she still decided to sent this letter of demand. I learnt that a patient will sue you for a bad outcome how ever well you have taken care of her and however much you have waived your fees previously. After this incident, I decided that I will not do any more free deliveries in the hospital. I have told my clinic staff to inform all the hospital staff of my decision. We advise all the hospital staff who wanted antenatal followup and deliveries to see my other colleagues in the hospital.
I tried to do some research on this topic on Google. “Quora” a question and answer website had some answers to this topic. Many respondents said that it is common to waive or give a discount to other doctors. However, one respondent replied that in the USA, due to corporatization of medicine, doctors are increasingly not allowed to give discounts by their employers. The complexity of insurance claims and the pressure of hospitals employing their doctors will make waiving fees more and more difficult in the future. I am postulating that this will happen in Malaysia in the future.
I hope this article will give a young specialist starting private practice some thoughts on when to waive your fees when treating colleagues, doctors and hospital staff in the hospital that you work. With the current medicolegal environment and the high medical 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 uncomfortable but it clears all expectations from both parties: you and your patient. In that way there will not be any misconceptions and misunderstanding. Another option is for your clinic staff/manager to discuss fees and you separate the medical professionalism from economics. Waiving fees for colleagues and doctors is nice and it is a professional courtesy but as medical practice is becoming expensive and complicated, new doctors will find it difficult to sustain this practice.
I will appreciate your opinions and comments. Thank you.