16 November 2001
Fiscal morality! Or is it fiscal immorality? This phrase is often intimately associated with the medical profession. Why? Private health care does not come cheap. Everybody has come to expect that. Are these services really expensive in Malta? Are doctors paying all their dues to the Inland Revenue Department (IRD)?
If one should compare the cost of the private health care here with say the USA, UK or Germany, to name some countries at random, the highest fees chargeable here are nowhere near as expensive. But can the Maltese public afford such fees? It often all depends upon whether the patient is insured or not. The affordability, therefore, is a question for the non-insured or the inadequately insured such as those who have group policies. There is still a significant number of people who are not covered by any health insurance cover. These people may still be able to afford the fees charged by their GPs (simply because they are low) with perhaps the odd consultation at a specialist. But when it comes to major problems, many opt for free treatment provided at the state hospitals.
Many "doctors" are said not to issue any receipts, therefore are not declaring their true income and subsequently are not paying all the taxes that they should be paying, a situation which the government is not tolerating and has vowed to tackle seriously. Doctors are also reported to charge higher fees on finding out that patients are insured and/or when a receipt is requested.
What is the real situation?
The medical profession is virtually unique amongst most trades and professions in that it has the free NHS as a direct competitor. Despite all its shortcomings, the NHS is in great demand because it is free. The NHS in fact is provided at considerable cost to the tax-payer and is not free at all. No doctor can charge indiscriminately high fees for fear of losing clients to another doctor who charges less. To inflame matters, there are no established official tariffs to guide the profession. I correct myself: there is one, issued by the Medical Council of Malta (MCM): it quotes the fees in £ s p, a currency that has been obsolete since the early 70's! So any doctor is free to charge pittance without falling foul of the MCM's code of ethics which strictly forbids undercutting!
It follows that many doctors charge very low fees to build and keep their practice... and a flow of income, of sorts. The situation is different when the patient is covered by a health policy. Insured patients are hardly deterred by the higher fees as these are paid for by the insurance company. So why should a doctor hold back from his legitimate fee when he gets to know that an insurance company is going to fork it out? A lower charge is at the doctor's discretion - often as a kind, "social" gesture to patients not otherwise covered - a discounted fee for the poor souls who meet their own expenses and are regulars at the doctor's surgery. The myth that the doctor raises his fee when a receipt is requested or an insurance form is presented is just that - a myth - a misconception - a delusion.
The general rule is that GPs are the cheapest amongst members of their own profession; indeed amongst all professions, trades and services! A podiatrist may charge Lm5 (Euro 12) for toe-nail clipping; a doctor charges an average of Lm2 (Euro 5) at his surgery. A house visit to a regular local client may cost around Lm5 (Euro 12). Let us take the latter case further. The GP uses his own car to drive to the patient's house. It takes him at least half-an-hour to get there, do the consultation, write out a prescription, issue a certificate and return to base. For this he charges Lm5 (Euro 12); Lm1 (Euro 2.33) needs to be deducted to cover car expenses and at least another Lm1 (Euro 2.33) goes to the Inland Revenue for NI and tax, leaving the doctor with just Lm3 (Euro 7) for his professional services. Members of all other trades and professions earn far more than that. Some doctors may have several patients to attend to but many do not have the number that would make this a profitable, viable business. In fact, a large percentage of doctors do private work only on a part-time basis.
The government ought to consider two options to rectify an anomalous, pathetic, discriminatory and unjust situation doctors find themselves in. Rather than gearing the IRD to chase, investigate and penalize doctors who are providing a sterling service at great personal sacrifice, the authorities should either (1) dismantle the NHS* so that doctors are guaranteed a more decent practice which would improve their (taxable) income, even if tariffs have to be regulated in some way; or (2) exempt all health service providers from paying tax altogether so that low fees can be maintained in the face of competition with the NHS. After all, the "subsidy" is enjoyed by the same public which stands to gain from the taxes otherwise paid. I personally prefer the former not only for financial reasons but for the concomitent improvement, that would invariably follow, in the delivery of health care services to our patients*!
Food for much thought!
*In this context, I refer the reader to Health, Page 1.