THEY are not acting for big corporations or multi-national companies.
They are not doctors.
Yet, they have 'panels' of doctors to whom they refer patients.
And these doctors are not paid by them.
Instead, it has been whispered that some doctors may be paying them a commission for the patients that they recommend.
They are 'medical agents' and they are powerful people.
They even act as 'doctors' because they don't allow doctors to refer their clients to other specialists if there is a need for further care.
Instead, the agents do the referrals themselves.
Ten doctors in private hospitals interviewed by The New Paper say that they have known of the existence of medical agents for about 10 years.
Another five said they have not heard of them.
Of those who have, opinions are divided as to whether doctors should rely on these agents for patients.
Medical practices that accept these referrals do very well, but it comes at a cost to their 'referred' patients.
Speaking on condition of anonymity, one surgeon said that part of the deal is that the doctors recommended by the agent cannot refer the patients to other specialists.
Said the surgeon, who has been in private practice for six years: 'The agent will do the referral to other specialists if the patient needs further care.'
Doctors not consulted
Sometimes they do not even consult the doctor regarding which type of speciality the patient needs, he claimed.
That is why he is not comfortable accepting patients from these agents.
'The doctors they recommend may not be the best man for the job. Doctors will know who is the best specialist for the job, but the agent wants the patient to be seen by someone within his 'panel' of doctors,' he said.
He is not part of any panel of doctors used by these agents.
The New Paper spoke to two doctors who accept such patients but say they do not pay commissions to the agents.
They said they would try their best to ensure the agent-referred patient goes to the correct specialist for further care.
Said a general surgeon who declined to be named: 'I have been accepting such patients because usually the agent calls for an appointment, and you don't really know they are agents until they turn up with the patient.'
It becomes obvious that the patient is with an agent when the agent takes care of everything, including paying the bills, he said.
'Even if you are taking your friend to see a doctor, you won't pay his bills too, right?'
When such patients need follow-up care, he will make sure the agent knows which type of specialist the patient needs.
'I will tell my nurse to give them a list of appropriate names,' he said.
So far, he claimed, no patient of his has suffered under this system.
To the agents, they are simply providing a service for foreign patients who don't know how to navigate the private medical system here.
Among them is a middle-aged woman.
Five doctors told The New Paper that she has been in business for about 10 years.
She said she provides a valuable service for sick patients from Indonesia, but she did not want to divulge her name or how long she has been doing this.
She said she brings patients from different parts of Indonesia, including Medan and Jakarta, to Singapore and helps them seek medical treatment.
She recommends doctors, pays her clients' bills and even arranges housing for accompanying relatives. In return, her clients pay her a fee.
What is not clear is whether the doctors she recommends also pay her a commission. She declined to confirm this when asked and also did not want to say why the doctors cannot refer her patients to other specialists.
It is understood other agents also operated in the same hospital as this woman agent. They appear to have their own 'panel' of doctors.
Agents' billing 'rules'
A urologist related his own encounter with an agent. 'The strangest thing I found was that I was not allowed to bill the patient directly.'
The agent called on him after another doctor could not handle the case.
'I was called by the agent to treat this patient for a kidney stone. When it came time to collect my fee, I was told to invoice him, the agent,' said the urologist, who has been in private practice for four years.
'I was not charged any commission, but I'm not sure if the other doctors are paying commissions,' he said.
The urologist said he would usually ask the hospital to collect his fee for him rather than charge the patient directly.
'The hospital charges me a small administrative fee, which is okay because I am spared the hassle of collecting my fees via cheques or credit card. But in this instance, I could not ask the hospital to collect my fee,' he said.
He also spoke of an encounter with another agent.
'There was an obstetric and gynaecological emergency last year. A call went out for help and I was able to respond. After that, I did not have a chance to tell the patient what my fee was. I was told not to write down my fee in the charge form provided by the hospital.
'The gynaecologist asked me to invoice him. Later, I found out the patient had been referred to the gynaecologist by the agent,' he said.
Not all doctors are approached by agents to be part of their 'panel'.
Said the urologist: 'From what we can see, it appears that they form a panel of doctors consisting of all the specialities that they need.
'Once all these 'positions' are filled, they won't ask other doctors. For instance, if they already have a urologist, they won't ask me,' he said.
He said the agents also look out for new specialities and doctors in these areas coming out to private practice.
'A few new doctors have asked me what the deal is with these agents. Some of them are hungrier because they are new and have not built up their practice, so they see these agents as a way to help them get patients.
'Others have been quickly asked to join the agents' panel because they have a skill set the agents need,' he said.
But he said he won't, even if he is asked.
'I must be able to refer my patient to the best specialist for the job. I can't sit by and watch my patient go to a doctor who is not suited to look after him, knowing that there's someone better who can help him,' he said.
COMMENT: RESTRICTING MEDICAL OPTIONS A BAD IDEA
DOCTORS in private practice face a dilemma. They cannot just be doctors. They have to look after a business too.
And that business is their practice.
The more patients a practice has, the better it is doing. But not all doctors have busy practices.
Hence, some rely on people like medical agents to bring in patients.
In principle, there is nothing wrong with this. The agents provide a service to patients who may find it hard having to navigate a foreign medical system.
And the doctors get the patients they need for their practices to thrive.
But doctors should not be prevented from referring their patients to other specialists.
If the cost of the patient referral is that the doctor can only see him for a particular ailment and not be able to offer a more holistic care approach, then the doctor should say no.
If enough of them do, perhaps the agents will be forced to remove this condition from their referrals.
wanching@sph.com.sg
This article was first published in The New Paper on August 20, 2008.
