The current discussion about healthcare in Singapore dredges up memories of my NUS med school interview, where one panel member grilled me about my opinions regarding patients who contract diseases caused primarily by poor lifestyle choices - do they deserve government subsidies for their treatment?
It was a tough question, and I recall stammering something about Medisave and Medishield helping to offset ( hopefully ) such costs. And thankfully, the interviewer smiled and let me off the hook.
That was in 1994.
Over the past 15 years, I've pondered this scenario intermittently. And now that I have 10 years of clinical experience under my belt, I wonder if such a proposal should be considered?
My line of work involves treating acute cases, a significant number of whom admit to defaulting medications and follow-up, or persisting with habits known to worsen their conditions, despite doctors' clear instructions otherwise.
Real-life examples:
1) A middle-aged man who's had multiple heart attacks and balloon angioplasties, but who recurrently refuses to take his meds, never returns for clinic follow-up, and continues to chain-smoke.
I've seen him at least twice, and each time his family signs consent for angioplasty, because the patient is usually critical to the point of being put on a ventilator.
He is always admitted to a C class ward, which is heavily subsidized.
2) A male in his 60s who comes to us almost daily for chronic obstructive lung disease. He smokes heavily even though he's fully aware that this precipitates his attacks, recently contracted lobar pneumonia but refuses to take his antibiotics or COPD meds, never keeps his appointments with the specialist, and has begun to give us doctors hell when we refuse to prescribe cough mixtures - which we suspect he peddles on the street.
3) A 20+ year old fellow ( yes, it does seem the recalcitrant ones tend to have XY chromosomes ) who's been consuming large amounts of alcohol since his teens and was diagnosed with liver cirrhosis, comes in one day vomitting massive amounts of blood. Turns out he'd just returned from Thailand, where he'd gone on a drinking binge.
Is it fair to use taxpayers' money for cases where the patients' own irresponsible actions clearly contribute to their healthcare expenditure?
I suppose means testing is one option, but like President Obama's universal healthcare plan, should our government also enforce a policy where some form of personal health insurance ( other than Medishield ) is compulsory for all citizens?
My greatest concern is for the poor and unemployed, who probably can't afford these premiums and are likely to be relatively ignorant about their medical conditions ( which may result in them purchasing packages that don't offer adequate coverage, or insurance companies may challenge their claims citing some obscure clause that wasn't highlighted or explained fully upon signing the policy ).
A few weeks ago, I treated a diabetic with kidney and heart failure. He stopped his meds for 6 months because he lost his job and was in financial difficulty, and a referral to the medical social worker apparently did little good. This middle-aged gentleman began to sob as he told me his sad story, and I recalled another patient I attended to years earlier, who was retrenched soon after a hospital admission for a heart attack, thereby causing him to lose all his healthcare benefits. He didn't have a personal health insurance plan.
Granted, healthcare expenditure is a complicated issue, and I don't profess to be an expert dishing out advice to those who're far more experienced than I could ever hope to be.
But speaking from the perspective of someone who's "on the ground", as opposed to a policymaker ensconced in his/her comfy office staring at charts and graphs, this is a problem which will only escalate as our population ages further, and the younger generation displays an increasing disregard for their own well-being.
All these Wellness campaigns and health promotion events may look impressive, but it's equally vital to clamp down on those who irresponsibly drain our healthcare resources, and increase awareness about the importance of adequate insurance coverage.
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17 comments:
Your post actually touches on many things, including our society's values system, economics, our healthcare system, phiosophy, etc.
I hesitated in posting a comment in reply for the past few days, but then what's the point in having a blog if I were to just avoid writing controversial things?
The reason why we currently currently ration subsidised healthcare by means and not by need is (I suspect) simply because it is a non-judgemental way of rationing.
To have a system where someone has to make a judgement on whether someone's behaviour makes him less deserving of healthcare subsidy requires too much moral courage to enforce. A person's income on the other hand is something objective - he makes this much money every month; no judgement is required.
I used to champion rationing by need rather than by means, but of course as you have illustrated above even within those who need healthcare, there are those who from the point of view of healthcare providers behave in such a manner that tells us they 'deserve' the subsidy, and those who behave in such a manner that convinces us they are abusing the system. Certainly two patients with equally severe COPD both 'need' healthcare - but does the one who continues to smoke 'need' it less?
At the end of the day human beings are creatures of incentive. We are economic creatures and we deal with each other by exchanging things of value.
Healthcare has a value. Those who provide healthcare (in this case the ministry in the form of subsidy) demand something of value in return, specifically co-payment of a portion of the cost, and political mandate. Requiring a certain set of behaviour as a further part of the exchange on the part of the patient adds a new variable to the equation. To me the most difficult part of this is to ascertain adherence to a set of behaviour: how do you determine if someone really watched his diet? Exercised regularly? You cannot with any degree of certainty.
Increasingly I am beginning to see the justice in rationing by means and not need: if people valued healthcare, then it is only just that we require from them in return something of value, being money and a healthy lifestyle. Since we cannot determine or enforce a healthy lifestyle, then the only variable we can control is money. Healthcare must be expensive enough that people would rather adopt a healthy lifestyle rather than to pay for it.
People like to criticise the healthcare system by repeating the mantra: In Singapore one can afford to die but not to fall sick. To that I ask in return: why shouldn't that be the case? Why shouldn't receiving healthcare cost you something of value if you value health? Let us no longer admonish the fat man or the smoker for saying that, but let them realise that it is simply a case of economics working. If they will not pay in behavioural changes, let them pay in cold hard cash.
At the end of the day, rationing by need does not take into account the patient's willingness to offer something of value in return for healthcare. Rationing by means does.
W.r.t the comment "If they will not pay in behavioural changes, let them pay in cold hard cash.", this may not be possible if those who abuse the system are simply unable to pay - and this is the case for many of the so-called "bad" examples I've encountered.
As a result, hospitals have to "write off" ( i.e. absorb ) their expenses.
The COPD guy who comes to the A&E almost daily, for example, is often observed overnight under a protocol that costs about $150, which he of course doesn't pay.
Multiply this by, say, approximately 20x per month, x12 months.
Although, even with personal health insurance plans, once you start submitting claims, the premiums will escalate, right?
So another option: getting the pt's family to help foot the bill, which already applies to Medisave, but how long can that last if both parents are ill and there's only 1 son/daughter?
What do we do to people who owe money but won't or can't pay? Why should it be any different for people who won't or can't pay for healthcare?
Why should people like you and I, who probably pay more taxes in one year than people like your patient does in a lifetime, subsidise their behaviour?
Healthcare only becomes an entitlement because the government makes it a promise to provide 'affordable healthcare', and stories like your patient's happens because people like you and I continue to work for such a system - if enough healthcare workers leave the system, it will collapse. We are part of the problem.
We may stay in the 'public sector' for reasons other than supporting such abuse of subsidy - altruism, training, research, etc. - but by staying as part of the system, we allow it to continue.
What do I propose to do about it? Well, I am going to see if the changes I heard are coming do come to pass and if they do change things, getting overpaid doing my job in the meantime, and if it doesn't work out I will move to a job where what value I have to offer is exchanged for what I value. Honestly: Is seeing a drunk driver walk out of the hospital alive *really* worth more than money and time to go on an extra whale-patting vacaction a year?
And until I quit, I intend to make more of my juniors convert to my way of thinking: subsidised healthcare distorts the value of healthcare, and since the government will not stop subsidising healthcare, the solution is to degrade subsidised healthcare such that it is little better than no healthcare at all by not contributing towards it. When the only viable alternative is a 'private' healthcare system where healthcare is priced at its true value, people will have to give what they truly value in return for it, in the form of healthy behaviour or cash. Is it fair? Probably fairer than one where people with nothing of value to offer consume things of value at the expense of those do do contribute, don't you think?
Private healthcare is the just form of healthcare because it demands value in exchange for provision of something of value. Any other system in which value is given without something given in exchange is morally bankrupt, and will become fiscally bankrupt in the long run.
Dr Toh Chin Chye believes that healthcare shoud be free. Do you know of anyone who actually likes to be sick? Michael Moore's "Sicko" may be a bit of an exaggeration, but at least he shows that there are countries who provide free healthcare. On your issue of deserving and undeserving patients, I only have one word - "charity".
I think it is a good idea to make those responsible pay for the costs of the healthcare they incur through their activities.
Begin with the tobacco companies who advertised "More doctors smoke Camels", move on to the people who planned all the carcinogen spouting factories in one part of the island and finally finish off with our grandparents who gave us the wrong genes for familial hyperlipidemia so we need angioplasties while the guy next to us who smokes like a chimmney and does not bother with exercise has clean coronaries.
Great idea! Would save those of us who chose our parents wisely a ton of money!
"Do you know of anyone who actually likes to be sick?"
I do know of patients who use their illnesses as excuse to not work when they have the ability to - do they count?
No one wants to be sick, Chloe, just like no one wants to be poor, homeless, unemployed, hungry. That's a given. But the question is: what are they doing to reduce their chances of being sick/poor/homeless/unemployed/hungry?
If I neglect my health, do not see to my own education and training, and then come to ask you for 'charity' because I "don't actually like to be sick, unemployed, poor, homeless and hungry", what will you think of me?
'Charity' is a fine word, Chloe, but charity doesn't cure cancer or treat COPD. What cures cancers and treat chronic illnesses are medicines, diagnostic equipment, and the skills and labours of healthcare workers. These are things of value and people who produce them rightly expect to be given things of value in return, and they are going to get it either from the patients themselves, or from you in the form of taxes and then subsidy, or they are not going to produce them at all - countries that cannot give their healthcare workers something of value for their contribution see them leaving for other countries. I don't know if you pay taxes or how much you pay, but unless you are a healthcare worker you do not see how some patients spend your tax dollars as if it were their right just because they are sick (because after all, they don't like to be sick, do they?). And if you are not a healthcare worker, then please don't tell me how to dispense my charity - it is mine to give and withold as I see fit.
What spacefan is saying in her post (I believe) is this: she doesn't mind staying in the 'public' sector now, but she feels that the system does not demand the same things from patients that she thinks it should, namely a willingness and an effort on the part of the patients to attend to their own health.
Now in a few years she will be able to make much more money at less effort (if that is not already the case). When that happens, the choice between staying in a system that does not share her values and one where she can gain something of value to her will become easier to make. I hope she makes that choice.
We are presenting the extremes of scenarios, Prof, when the reality is something in between: the spectrum of human diseases span those over which we have no chance of preventing, to those that are amenable to primary and secondary prevention.
The result is that we can see the system as half-empty or half-full: one that subsidises all so those who are not responsible for their illnesses are not left out, or one that subsidises all so that those who are responsible for their illnesses parasite off the rest.
You may argue that it is a more moral system, but as you can see the realities on the ground is that it has eroded my idealism over the years and it has begun to wear at spacefan's.
Let me just add a quote from "Atlas Shrugged":
"I quit when medicine was placed under State control, some years ago," said Dr. Hendricks. "Do you know what it takes to perform a brain operation? Do you know the kind of skill it demands, and the years of passionate, merciless, excruciating devotion that go to acquire that skill? That was what I would not place at the disposal of men whose sole qualification to rule me was their capacity to spout the fraudulent generalities that got them elected to the privilege of enforcing their wishes at the point of a gun. I would not let them dictate the purpose for which my years of study had been spent, or the conditions of my work, or my choice of patients, or the amount of my reward.
I observed that in all the discussions that preceded the enslavement of medicine, men discussed everything—except the desires of the doctors. Men considered only the 'welfare' of the patients, with no thought for those who were to provide it. That a doctor should have any right, desire or choice in the matter, was regarded as irrelevant selfishness; his is not to choose, they said, only 'to serve.' That a man who's willing to work under compulsion is too dangerous a brute to entrust with a job in the stockyards—never occurred to those who proposed to help the sick by making life impossible for the healthy. I have often wondered at the smugness with which people assert their right to enslave me, to control my work, to force my will, to violate my conscience, to stifle my mind—yet what is it that they expect to depend on, when they lie on an operating table under my hands?
Their moral code has taught them to believe that it is safe to rely on the virtue of their victims. Well, that is the virtue I have withdrawn. Let them discover the kind of doctors that their system will now produce. Let them discover, in their operating rooms and hospital wards, that it is not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of man who resents it—and still less safe, if he is the sort who doesn't."
Making doctors work in an environment where the practices are in conflict with their sense of justice will erode morale, and eventually cause them to quit.
I hope.
As a society, we need to decide which of the following we can live with:
equal expenditure per capita: variation in demographics, illness, cost of care
equal resources per capita:
equal resources for equal need:
equal assess for equal need: will have opportunity to use
equal use for equal need: will use
equal marginal unmet need:
equal health: goes too far, unacceptable and unattainable
It turns out that if you give healthy people (as representatives of society) the facts about cost and benefits of different health care interventions, they can make fairly rational choices. Asking funders, doctors, patients or any other stakeholders to make decision will tend to be bias.
Thank you for visiting and commenting, Prof. Let me first say I admire the work you have done to promote the understanding and use of evidence-based medicine in the medical community, and hope you can join us as a contributor and use this blog as a platform to reach out to doctors and laymen.
With regards to your last paragraph: I used to believe in John Rawls concept of justice, but I have come to realise that in reality if you ask people to imagine themselves being in a system where they cannot know their place, the vast majority of them will design a system to benefit those with little to contribute, because that is the position they see themselves most likely to be in.
Subsidised healthcare is a moral hazard, and subsidised healthcare which does not demand accountability for one's own health is downright immoral.
As a thought experiment imagine you are the head of a surgical department who has just asked your surgeons to vote on whether or not to scrap individual surgeon's fees and instead pool all the fees together, to be divided equally per surgeon on the team. What will you think of those who vote for the idea? Will not those who pull the most weight vote against it?
Everyone - government, doctors, patients, healthy people - wants more for less, and a system designed by any person will be biased. That is natural.
My stand is that those who bring more value to the system should have more say in how the system is designed and runned, and the thing of greatest value (and indeed that which defines the healthcare system) is medical knowledge and expertise.
We all demand value for value. Our employers demand competence from us for the salary they pay us. We demand from our patients the desire to get well and compliance. What do subsidised patients who refuse to give either bring to the table? The answer is a vote on election day. Are we to be held hostage to that? Are we to not take pride in our knowledge, and mistake an unfair exchange as humilty of wisdom?
The system needs to change. The system needs less choice and more accountability. Letting patients have a say is like letting airplane passengers tell the pilots how much fuel to carry. Let them stick to requesting for peanut-free meals.
Please call me TC. The most urgent problem Singapore faces now is the problem of ownership of complex patients who are unable to pay.
Here are some possible solutions we can consider:
1. Promote exercise and healthy lifestyle to prevent illness, especially in older people, promote social interaction to avoid social isolation and depression. We need innovative approach to improve acceptance and adherence.
2. Cost effective and targeted intervention strategy to prevent frailty in older people, to be targeted means we need accurate diagnosis that is comprehensive (comprehensive geriatric assessment may be one approach)
3. Funding that is based on outcome rather than site of service provision. Whoever can do a good job of preventing adverse outcomes should be funded to do the good job. Then there will be incentive to manage complex patients to prevent adverse outcomes. This will encourage ownership of complex patient.
4. A national electronic health record will help to track outcome versus cost of intervention, therefore facilitating funding for outcome. Therefore the EHR must be comprehensive.
5. Stratify care and funding for care based on complexity, less complex patients can be co-manage by nurse practitioner/ pharmacist prescriber.
I sincerely believe that if each of us put our hands to the plough and impact positively in our areas of influence, there is still hope. The flywheel may reach tipping point someday.
TC,
I think a lot of what you wrote make sense, but is too idealistic.
1. and 2.
The people who will be comprising the 'silver tsunami' come 2040 or 2050 are not the frail old patients we see in our practice today, who frankly are a 'lost cause'.
They will be the people who are our age today. With the level of education today and the amount if 'health information' in the mass media, do you think they don't know *how* to keep themselves healthy? Do they not know that exercise is good for them? That obesity is bad for them, and the way to reduce one's weight is to reduce food intake? Do they not know that high blood pressure and high cholesterol are bad for them, and that they should take their medicines?
We have no problem making the diagnosis, we know what are the current best treatment to give, but they don't want to take our advice.
No. They whine about how much of their money the government takes away from them in the form of CPF, they refuse to pay for treatment they require if they can't use their CPF, they complain that in Singapore you can afford to die but not fall sick. They come to the subsidised clinic and ask for travel medicine 'by the way' for their trip to Korea next month. They smoke and drink.
They do anything but to stay healthy, or save to pay for their future healthcare.
These are the people who will become the problem, yet are not taking it upon themselves to solve it. To use your expression, they are not putting *their* hands to the plough.
They do not take preventive health seriously, and when their bodies suffer as a result, expect cheap and good healthcare, provided by us and funded by the taxes we pay.
They expect us to plough the fields, and they plan to eat off the harvest we bring in.
I choose to take responsibility for my own health and healthcare. I will make and save enough money so that I can afford good healthcare in my old age. Why shouldn't they? And if they don't, why shouldn't they not receive good healthcare?
I repeat myself: the system needs more accountability. To imagine that we can give a higher level of care for more people at the same level of subsidy is wishful thinking. (Call me a pessimist, but I prefer to think of myself as a realist, as all people do.)
3.
We both know what will happen if we implement your suggestion. Institutions will cherry-pick their patients if they can, and if they cannot suddenly all their patients will become 'complex'.
All patients will get discharged with at least 9 diagnosis codes, and all procedures performed will be "complex".
Remember why MOH implemented 'block budget'?
4. and 5.
A more 'mobile' patient whose EMR follows him will not foster a greater sense of 'team' between institutions, but will make it easier to shifty the blame. You implement treatment that makes his diabetes control better, but his next HbA1c is done at another institution - who gets the credit? A patient whose doctor did not bother to give him lipid-lowering drug comes to your clinic to have his annual blood test done - who gets the blame?
Add to that multiple tiers of care and patients no longer have a 'primary physician'. No one will exercise true ownership. What they call 'team-based care' I call 'fragmentation of healthcare'.
This so-called 'healthcare crisis' is no accident, but merely a demonstration of human nature - those with value to offer (healthcare professionals, pharmaceutical companies, manufacturers of medical equipment) want value for their work, and of course the people will want the best and cheapest healthcare they can get, and in this they are abetted by a government without the moral courage to demand accountability from them.
I too am waiting for the tipping point when I will exit the system.
Angrydoc:
I think the best we can hope for is a compromise. From an economic point of view this is arises from the conflict between achieving productive efficiency (producing good health at the lowest possible cost) and achieving an equitable distribution of income and giving help to the genuinely underprivileged dealt a poor hand by fate.
While you strongly emphasise the existence of patients who are not accountable for their health, you have completely failed to mention that there are those (I know a few friends in this situation) who are born with costly medical conditions they will live with for the rest of their lives, and who do their best to earn a living and contribute to society. Perhaps it is you that is being idealistic, because you suggest that all patients fall neatly into the category of leechers of the healthcare system and we can deal with them collectively with the single policy of making them pay for their healthcare and forcing them to internalise the cost of good health.
While I sense that it is not at all the case that you do not see that there are patients who fall into both categories and some who are inbetweeners too, your comments seem to fail to reflect this.
The best solution I can see is for the government to do its best to ensure people can pay for the healthcare they need so that the government does not have to subsidise it so much. CPF is a good scheme for this. If you want to earn money to buy things that destroy your body, you jolly well make sure you have some left in your pocket to pay for your medical bills! While ensuring that patients are as far as possible able to pay their own bills instead of using their disposable income to pay for their wants and using tax money to pay for their needs, it also retains an incentive for the patients to keep healthy and reduce healthcare costs. So we do our best to make sure people can pay, and then for whoever falls through the gaps we give them the benefit of the doubt that they have tried their best.
In contrast, I think to simply stop subsidising healthcare in order to force inconsiderate citizens to reduce their burden on society at the expense of the truly deserving is to attempt to raise welfare in a zero-sum game.
I humbly await your response, forgive me if I have misunderstood anything because this is quite a complex discussion and I am only a simpleton.
Angrydoc, I would like to make one last point. (I get this is a very old post, but I'm hoping you *might* respond anyway.)
I have seen from the comments on some of your other posts that many people are accusing doctors of earning too much money and such.
I would like to suggest that you make clear that if healthcare subsidies were to be removed your salary will not rise.
I may be confused but if I understand correctly none of your propositions have anything to do with doctors being paid more. Why do you invite idiots to yell and scream on your blog when you could easily convince them that this is a matter of national interest and not just a personal one?
All of this has made me wonder if I have seriously misunderstood the entire problem. If I have misunderstood I hope you can clarify what the entire problem is about in the first place...
Angrydoc, I would like to make one last point. (I get this is a very old post, but I'm hoping you *might* respond anyway.)
I have seen from the comments on some of your other posts that many people are accusing doctors of earning too much money and such.
I would like to suggest that you make clear that if healthcare subsidies were to be removed your salary will not rise.
I may be confused but if I understand correctly none of your propositions have anything to do with doctors being paid more. Why do you invite idiots to yell and scream on your blog when you could easily convince them that this is a matter of national interest and not just a personal one?
All of this has made me wonder if I have seriously misunderstood the entire problem. If I have misunderstood I hope you can clarify what the entire problem is about in the first place...
"... to simply stop subsidising healthcare in order to force inconsiderate citizens to reduce their burden on society at the expense of the truly deserving..."
That assumes that people deserve subsidised healthcare.
I am not yet convinced that a person's healthcare needs entitles him or her to "deserve" the bills being paid for by others.
"I would like to suggest that you make clear that if healthcare subsidies were to be removed your salary will not rise."
I don't know if that is in fact true.
"Why do you invite idiots to yell and scream on your blog when you could easily convince them that this is a matter of national interest and not just a personal one?"
Everything I do is for my personal interest. I care about the whole healthcare system insofar as it affects my personal interests. I care about politics insofar as it affects my personal interest.
"If I have misunderstood I hope you can clarify what the entire problem is about in the first place..."
The problem is people trying to advance their own interests by hurting other people but disguising it as moral issues or matters of national interest.
You see, I've been looking at all the topics I've been blogging about over the years (both here and on my personal blog) and I realised that the one common thing is them is a disgust for those who would hurt other people to advance their own interests.
People who support continued criminalisation of homosexuality to make themselves feel superior.
People who make money selling unproven therapy to those who seek help.
People who try to gain power with promises of "redistributing wealth".
We all try to advance our own interests - even if you are advancing a cause bigger than yourself, it is still "personal interest" because it is something that you have identified as being in your interest to advance. The difference to me is not so much what we champion, but whether you are willing to trample over other people's rights to their liberty and right to their own bodies and possessions while doing so.
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