1) Intrathecal/Epidural (Item 648)

This code should be used for all epidurals performed in a non-operative setting, including patients in labour and there should be no linkage between this charge and what the obstetrician charges nor what happens to the patient at a later stage (e.g. if the patient requires a Caesarean section later).

2) Central Venous Catheterisation (Item 536)

Although already charged at a rather low rate of RM31.50 (Unit Price) in the current CDM, this had been further reduced to RM26.99. I suggest a Unit Price of RM50 be more in keeping with the rates charged in other hospitals. Note that Items 606 and 607 are priced at RM71.82.

1) Endotracheal Intubation

I could not find the codes for endotracheal intubation. We should either reinstate the codes in the current CDM (567, 569, 571, 573, and 575) or introduce new ones based on either difficulty of intubation (one for normal intubation and one for difficult intubation) or based on the route or method of intubation (e.g. oral, nasal, transtracheal, fibreoptic, awake, etc.). The Unit Price should vary from RM30 for the simplest to RM80 for the most difficult and challenging cases.

2) Cardio-Pulmonary Resuscitation (CPR)

There does not seem to be any codes for CPR. Even the one we had for Resuscitation of the Newborn (245) has been discarded. Suggested Unit Price is RM60.

3) Patient Controlled Analgesia (PCA)

A new code should be introduced for Patient Controlled Analgesia. Suggested Unit Price is RM30 to RM40.

4) Anaesthesia and Sedation for Radiological Procedures

Many procedures, especially the radiological procedures, do not have a corresponding procedure code. There is a clear need for a code for the anaesthetist to charge appropriately in these cases. I would suggest that 2 codes be introduced.

a) One code is for preoperative assessment, induction, reversal and recovery with a Unit Price of RM30, and

b) Another code is a time-based code that is calculated based on the duration of the anaesthetic. The Unit Price should be RM50 per hour calculated to the nearest minute.

5) Minimum Anaesthetic Fee

As we have stated before, many of the surgical procedures are very simple ones with minimal surgical risks. However, the anaesthetic risks of induction, reversal and recovery are no less here than in more complex procedures. Further, many of these procedures are performed on paediatric cases where the anaesthetic risks are clearly far higher.

It is well recognised that in many minor surgical procedures, the anaesthetic risks far exceed those of the surgery itself and our fee should reflect this.

Many private Malaysian hospitals have such a minimum anaesthetic fee and it is also recommended in the Malaysian Medical Association Schedule of Fees 1997. Please note that the MMA fee schedule recommendations for anaesthetic charges are all above 35 %, varying from 35.4 % to 62.6 %. Hence, the anaesthetic fees in SJMC are already generally lower than the MMA recommendations (calculated as a percentage of the surgical fees).

I am therefore strongly of the opinion that a more equitable anaesthetic charge is required and the introduction of a minimum anaesthetic charge will go a long way towards achieving this goal. A Unit Price of RM40 seems reasonable and would be in keeping with the rates charged in other hospitals, for a C Code. Alternatively, a flat rate of RM200 could be used with no distinction between A, B, C, D, E or F. The lowest rate recommended by MMA is RM210.

6) Other Codes Left Out From the Current CDM

The following codes, normally used by the anaesthetists have all been left out from the proposed CDM. They are 895, 897, 907, 927, 929, 932, 934, 954, and 956 in the current CDM. The problem is particularly acute for codes 927, 954 and 956 which are often used although the others are probably rarely used. These codes should be reinstated.

There are other areas in which the new CDM fails to meet the needs and expectations of the medical staff.

1) Adjustment for Inflation

The last review was in July 1992 and yet the current review only aims to achieve parity in our fees. It is obvious that the cost of living and the hospital costs have gone up considerably over the intervening years. Yet, no attempt was made to correct this imbalance. I therefore suggest that,

a) The rate of inflation as published by the government be used as a basis for the adjustment of our fees to be in keeping with the general rise in the cost of living. The exact increase can be adjusted if so desired by the medical staff.

b) As the quantum of the increase to compensate for the inflation from July 1992 till now will be considerable, this increase should be spread out over the next 2 to 3 years.

c) Subsequent to this, there should be an automatic increase of the fees. This, in the absence of a specific review of the fees, will be equal to half of the previous year's rate of inflation every six months. There should not be any need to have a review. Implementation should be automatic.

2) Parity of Earnings Within Each Specialty

While the aim to maintain parity in the overall earnings of all the doctors in the hospital would seem to be a laudable one, it has instead given rise to much dissatisfaction and enmity among the doctors, as the earnings in some specialties would rise at the expense of the those in other specialties. I would therefore suggest that a different scheme be implemented.

a) Each specialty should discuss and decide among themselves, the appropriate charges for each procedure. These charges would then be "normalised" to maintain parity with the old charges for that specialty. A further correction should then be applied to account for inflation since the last review as suggested above.

b) Alternatively, if the Australian CDM is to be used, instead of attempting to achieve parity for all doctors in the hospital, we should aim for parity within each specialty. In this way, no specialty would feel "cheated" and no one would feel that they are subsidising the increase in income in another specialty. Again, the effect of inflation should be accounted for.

All in all, I am rather disappointed that in spite of the fact that the anaesthetic consultants had taken the trouble to hold meetings and come up with our proposals for incorporation into the proposed CDM as requested by the CDM Review Committee, our proposals were largely ignored. Furthermore, none of us were called up for discussion nor informed why our proposals were disregarded.

I include a copy of the suggestions made by the Anaesthetists dated 13 January 1999 for your perusal.

The opinions expressed above are my personal ones and not necessarily representative of the anaesthetists in general.

Dr. Ngun Kok Wah.
Anaesthesiology.
20 February 2001.