In January 2017, new guidelines recommending appropriate tests and investigations for the "Top 10" causes of patients being admitted into public hospitals will be implemented. This is one of the strategies introduced by the government to keep Malaysia's healthcare costs down for patients.

Test and investigation "bundles" would be recommended for pneumonia, diabetes, chest pain and heart failure as these were common causes of medical ward admissions, Ministry of Health (MOH) deputy director-general Datuk Dr. Jeyaindran Sinnadurai said.

The "bundle system" which has been introduced in Australia and New Zealand - based on recommendations in Clinical Practice Guidelines (CPG) - refers to actual cost and care provided for a medical condition across the entire care cycle.

Studies by the WHO show that 30% of global healthcare costs can be saved by being more judicious in ordering tests, prescribing medications, diagnosing correctly the first time, and cutting down on utilities.

Bundling system to reduce cost of healthcare

The introduction of bundles will address the recurring problem of doctors ordering too many tests too frequently, or over-relying on test results than their clinical acumen to treat patients. Sometimes, patients have already been treated before the test results return, meaning that the test results did not influence any clinical decision, Dr. Jeyaindran said.

Using existing evidence from other countries, he said that when care bundles are applied correctly, they can improve the quality, consistency and efficiency of healthcare.

"Bundles achieve better outcomes with lower costs. The Harvard Business Review recently talked about trimming tests and setting a single price for treating a patient’s particular medical condition, as the way forward in cost containment.

“This cost and treatment ‘bundling’ is what we’re doing,” he explained.

He also stressed that tests should only be used to confirm a diagnosis or provide an estimate of the degree of severity. The practice of medicine must be both evidence- and value-based to keep medical costs affordable, he added.

Fewer tests will not compromise patient safety

The possibility that fewer tests would lead to misdiagnosis was brought up, and in response, Dr. Jeyaindran said that doctors could order additional investigations if really necessary.

He also drew comparisons between managed care organisations and hospitals, stating that bundling was done by medical professionals in hospitals, not by businesses such as insurance companies and employers, therefore keeping costs down would not compromise on patient safety.

“Bundles will only limit unnecessary or inappropriate investigations being ordered – not the doctor’s freedom to order additional tests.

“Doctors can still order tests outside of those listed in the bundle but these must be justified to a senior doctor who will then decide based on the patient’s condition.”

The move is expected to save the ministry between 10% to 15% annually.

The government has also called for private hospitals to implement the same move.

Private hospitals have implemented bundling system in some disciplines

Commenting on the MOH's call, Private Hospital Association Malaysia president Datuk Dr Jacob Thomas said that bundling was already implemented in certain disciplines such as cardiac surgery, bone marrow transplant and spinal surgery.

However, unlike in Australia and New Zealand, where bundles or diagnosis-related groups are set by both insurance companies and the government, bundles in Malaysia are more like treatment packages.

“In Australia, whether it’s Hospital A or B or a public hospital, prices are the same. But when a patient sees the doctor about a procedure here, the overall cost – barring complications, is made clear as part of the financial planning consultation. The sum varies between hospitals,” he explains.

He stressed that knowing the actual costs is crucial and should be accurately assessed first, regardless of whether a private or public hospital is implementing the bundling system.

Public and private hospitals have to account for different factors

“From the time a patient is admitted to the point of discharge, everything including the room, medical supplies, nurses, doctors, and food charges, must be clearly identified so that we know the hospital’s exact cost. And, there must be different bundles that take into account the medical technology used in treatments.

“Charges for the use of a 0.5-Tesla MRI or 3-Tesla MRI, for example, can’t be in the same bundle. Nor can a laparoscopy be lumped with an open surgery where the patient is warded for one week," Thomas explained.

He also compared the public and private hospitals, emphasising that private hospitals have to factor in land price, building construction and taxes unlike public hospitals that are heavily subsidised. He added that Malaysia cannot "copy and paste" the bundling system in Australia and New Zealand, but instead should be tailored to the country's needs, with constant reviews by a specially set up panel.

"The MOH must engage with private hospitals to understand what are our costs and expenses," he added. MIMS

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