The recent call by the government to convert private healthcare facilities into Covid-19 treating centres, whether wholly or as hybrids, has met differing comments from private healthcare givers and the public. The Association of Private Healthcare Malaysia, the Malaysian Medical Association and the Association of Specialists in Private Medical Practice, etc, including individuals such as former directors-general of health have given their comments.
The prior strategy was to decant non-Covid cases first from government hospitals to military hospitals, then to university hospitals and then to private hospitals. But due to near maximal bed and staff utilisation in government hospitals as mentioned by the director-general of health in a directive on Jan 19, private hospitals were instructed to make preparations and to start treating Covid-19 cases, especially those that land in their premises including the probability of receiving referrals from government hospitals.
This letter has been misunderstood by some authorities both in private and public to mean that private hospitals have to start treating Covid-19 cases straight away without preparation. That is not the proper context of the directive when read in totality including the annexes. To adjust to the new function, private hospitals need to prepare and modify a few functions, structures and facilities and that need prior assessment and certification by the relevant authorities. Some of the jobs are in fact not easy or straightforward.
Here are some of the bottlenecks in the implementation of the above directive:
1. Payment coverage by insurance companies and managed care organisations (MCOs), financial institutions and companies
Most insurance companies, MCOs, companies and financial institutions do not pay for admissions due to Covid-19 as it is considered a pandemic. This depends on the existing agreements and policies between the insurers and the policy holders. Furthermore, stage 1 and 2 Covid-19 patients do not usually need admission but rather home quarantine for those selected by the Centre of Assessment for Covid-19 (CAC).
Thus, for stages 1 and 2, maybe only those with comorbidities such as uncontrolled diabetes and hypertension will need admission. The availability of ICU beds will dictate the appropriateness of admitting patients at stages 4 to 5 anticipating possible disease progression. There is a limited range of patients that can suitably and safely be admitted to private hospitals.
The government therefore has to create enough funds to pay for the bills or play a major role in negotiating with the creditors. This is mainly outside the jurisdiction of private healthcare authorities.
Additional funding will hopefully come from the government to pay private hospital bills.
The consideration of manpower should be across the board. There is generally usually just optimal manpower in private hospitals from the cleaners and care aides to nurses, administrative personnel, medical officers (MOs) and consultants. There are no house officers (HOs), whereas in government hospitals there are tiers of HOs, MOs and medical consultants.
Private consultants generally manage their patients without MOs. The duty might be overtaxing especially considering that the age of medical consultants is predominantly older in private hospitals and they might need to be excluded from treating Covid-19 patients. Generally, over 60% of consultants in private hospitals are above the age of 50. Breaching of infection to this group of people might bring grave medical consequences especially to those with comorbidities.
3. Building structure
The type of existing building structure is a very important consideration. A hospital may convert a section or a whole wing or floor to treat Covid-19 patients, taking into consideration patient safety and the prevention of the spread of the disease as Covid-19 is highly contagious.
There are situations where it is not possible to convert just a section, and the whole ward (ie. more than the 10% of beds requested) has to be converted. Routes of patients from the isolation room in the emergency department to their beds, through which doors and lifts, have to be planned and decided. The ventilation system and air conditioning need to be improvised for patient safety.
4. ICU beds and structure
Generally, private hospitals have relatively few ICU beds and a limited number of anaesthetists, what more intensivists. However the ICU ratio to bed number should meet ministry requirements. ICUs are shared by a wide range of disciplines such as cardiology, surgery, medical and obstetric and gynaecology. ICU beds are what the ministry really needs. But this not achieved just by creating logistics without having the proper trained manpower.
However, it is impossible to bring Covid-19 patients to ICUs without jeopardising the safety of other patients in terms of infection. ICU beds are as well needed to treat patients from other disciplines including emergency cases. Thus it is impossible to convert ICUs to Covid-19 wards without collapsing the services of the other disciplines. It also means that the facility most badly needed by the ministry cannot be offered by private hospitals of small or moderate size unless it is turned into one that is fully for the treatment of Covid-19 patients.
5. Medicolegal implications
Medicolegal implications with regard to patient management during the Covid-19 pandemic may be abundant. Hospitals that breach standard SOPs that lead to hospital transmissions may be sued. Who should treat Covid-19 patients in a specialist hospital? Infectious disease specialists or any consultant, given that there are only a few infectious disease specialists in private hospitals at the moment? Structural modifications that are inadequate might be also liable for litigation. This emphasises the fact that the Cawangan Kawalan Amalan Perubatan Swasta (CKAPS) needs to conduct a thorough inspection before certification. These medicolegal issues are uncharted waters, although the atmosphere may be a bit different in government hospitals.
Services in private hospitals come attached with costs. The expected average cost
of a 10-day stay is RM10,000 while the cost of an ICU stay of the same length might reach RM100,000 to RM150,000 or more. This does not mean that private hospital services are expensive. Do not forget that the total cost of service may be as high as that in government hospitals but the latter is subsidised or absorbed by the government.
7. Characteristic genre eg. business structure, governance and functions of private hospitals
Each private hospital has operated within its own genre for so long in contrast to public hospitals, each contributing to society and the nation in its own way. Not all private hospitals are owned only by rich tycoons. Some are shared with state agencies in quite big proportions, thus giving big dividends year after year. Some have been good cash cows for the state government. Maybe the public view on this has not been apparent or has been misleading. Disturbing this ecosystem might lead to a business collapse. Proper business forecasts should be made.
In conclusion, the decision of whether each private hospital should treat Covid-19 patients or not, whether fully or as hybrids, depends on the objective and total assessment of all of the above factors, taking into account real national needs in the fight against Covid-19, the safety and comfort of the patients and the sustainability of each hospital in the long run.
Sufficient time and room for negotiation should be given to the hospital authorities to present their views and suggestions. At the end of the day, the suggestion might be to let private hospitals treat non-Covid-19 cases only, and that might be in the best interest of the nation. This might even occur soon when the number of Covid-19 cases regresses and the government medical facilities in each state are able to cope well.
Dr Mohamad Hamzah is medical director at Hospital KPJ Perdana, Kota Bharu.
The views expressed in this article are those of the author(s) and do not necessarily reflect the position of MalaysiaNow.