Several local health care issues were raised at a prior blog post. The truth of the matter (I am refraining from using the much-abused "hard truth") is that it is better if health care is not brought up as an election plank, beyond cheap soundbites about sending the former Health Minister to JB. It is a complex issue that is well beyond the scope of a 10-day campaign period.
The cost of health care will only go up in the next several years, no matter whether PAP sweeps the House or several GRC's fall to the opposition. This is because of an aging population, the advance of medical technology and influx of new, expensive drugs for chronic diseases and cancer. Keeping health care expenditure at 4% of GDP (note that the government's share is only about a third of this) is well-nigh impossible in the medium term, as health care costs outstrips GDP growth.
Some, including fellow bloggers at SingaporeMD, have argued that it is necessary for individuals to take greater personal responsibility for their own health. This is certainly a persuasive line of thought, and the government has never held back from promoting this point of view, election or no. The whole business of cost-sharing and "health care subsidies" is an attempt at avoiding moral hazard and indirectly driving home the point of personal responsibility. Yet in all fairness, we recognize that personal responsibility can only go so far. Catastrophic illness can occur even if one lives a life of moderation. For lower- (and perhaps even middle-) income families, circumstances prevent many from leading healthy lifestyles. The health care system is also not structured in a way that promotes health, i.e. focusing on primary and preventive medicine, even though efforts are underway to do so.
Catastrophic illness, as the term suggests, can be devastating not just for the patient, but also for his/her family. If one depends on the 3M's, one cannot avoid paying far more than $8 for any major operation or hospitalization. Private insurance plans are available that can cover hospitalization and even outpatient treatment costs, but these are less well advertised and perhaps the majority are still unaware that anything other than the 3M's are required - until it is too late to apply. Or perhaps the cost of the premiums is too much of a burden in addition to the other costs of living.
What policies can we adopt or tweak that can reduce the burden of chronic and/or catastrophic illnesses on the lower- and middle-income households? Without becoming a welfare state or raiding the reserves, that is?
21 comments:
"For lower- (and perhaps even middle-) income families, circumstances prevent many from leading healthy lifestyles."
I don' think that is true. You can never to too poor to not smoke, too poor to not drink alcohol, or too poor to not eat so much.
I agree that catastrophic illness can be devastating, but let's look at the facts: about 65% of people will die of stroke, heart attack, or cancer. MOST people will die from a catastrophic illness. One in three Singaporeans will die of cancer, which means more than that percentage will HAVE cancer.
Regardless of how much control you have over getting cancer, heart disease or stroke, the sheer probability of you having it tells you you should EXPECT it, and to prepare for it. If you KNOW you are likely to get one of these diseases, shouldn't you set aside money to pay for the medical fees instead of expecting other tax payers to pay for your healthcare? Don't forget that these are fellow citizens who will also themselves suffer these catastrophic illnesses.
I don't think we disagree on the fact that healthcare is expensive, or that one cannot completely prevent onself from getting a catastrophic illness. But regardless of your degree of control, why does it become fair for other people to pay for your healthcare needs?
It is fair for other people to pay for your healthcare needs because as a country we work as a team. Unless you earn as much as the top earners in Singapore, most of us citizens are indirectly subsidized by the taxes paid by them. Then, most of us are already recipients of their tax monies for our healthcare, thus, it only makes sense that we should contribute what we can.
I think that one needs to realize that as a citizen (as opposed to foreign talent), we spend both the productive and non-productive periods of our lives in Singapore. Hence, there will always be a dependence on others paying for our medical bills (when we are children, or when we have retired). Perhaps the foreign talents would have medical treatment in their childhood or old age in their own country, which may reduce costs, and hence they can accept lower working wages than Singaporeans.
I believe that healthcare should be free to the patient. The patient should not have to decide between different forms of treatment based on their costs, but they should decide their treatment based on the merits of the treatments themselves. The payer (government or insurance company) together with the doctor should then be managing the cost aspect, as to maximize the benefit to the patient in accordance to the budget.
Healthcare is a necessity. The more people we can treat, the healthier they will be, and the less chronic diseases they will have. This leads to a happier and more productive working life, and reduces the non-productive duration of our lives. Ultimately, we have to structure policies so that the people are supported to be as productive as they can, for as long as they can, and stop worrying about the short-term costs.
Admirable sentiments, Downhere, but you ignore a few realities.
Free healthcare leads to abuse and inefficient use of resources. You say on the one hand that "patient should not have to decide between different forms of treatment based on their costs", yet you acknowledge that "doctor should then be managing the cost aspect, as to maximize the benefit to the patient in accordance to the budget" - that means you understand that healthcare must be rationed. So how can there be a system where the patent can choose any form of treeatment he wants for free, yet the doctor can still exercise control over the cost and budget? You contradict yourself. Your system simply cannot exist.
"The more people we can treat, the healthier they will be, and the less chronic diseases they will have."
Wrong. By the time we have to treat someone, it is already too late. The key to good health is not good medicine, but good public health, and a healthy lifestyle. That means what the government and doctors can do is to educate the people; that also means that this is largely in the hands of the people themselves.
Secondly, people suffer from the complications of chronic diseases not because of a lack of treatment being offered by doctors, but from a lack of compliance. We do not lack knowledge or resources to treat diabetes, hypertension, hyperlipidaemia, ischaemic heart disease, stroke, asthma, and COPD.The reason why most people have poorly controlled conditions and complications is beacuse they refuse to adopt the advice of their doctors. You know this to be true: look at the number of patients you have who continue to smoke despite their disease, look at the number of patients who produce excuses but not results when you tell them they should eat healthier and lose weight.
The reality is that we have an accessible, affordable healthcare system out there, but the lack of accountability on the part of the patients and the lack of moral courage on the part of the provider to ration healthcare has resulted in a system with abuse and inefficiencies. Is it fair for the tax payers to bear the cost? The cost is not just borne by the top earners, but by every citizen who pay taxes, including the ones who do keep themselves healthy and do not abuse the system. It may just be a single-digit percentage point of the government expenditure, but it is still a large sum of money.
It's OK to 'have compassion', it is OK to want to be altruistic, but we need to remember that we should not be generous with other people's money.
My system exists in the form of the NHS. I agree with you that compliance is the main issue with chronic disease, and that we should do all we can to decrease barriers to compliance, and promote the adoption of healthy lifestyles. Making healthcare free is one way of decreasing barriers to compliance. Like you said, there will be increased utilization of healthcare resources, so you agree with me in principle on that.
Free healthcare leading to abuse and inefficiency is a implementation problem. Even within our Singapore healthcare system, we do have means testing, treatment guidelines and other options to reduce the abuse of healthcare resources. I don't see why these means of regulation will go away when healthcare is made free.
As for whether it's fair for the taxpayer to bear the cost, as I said, healthcare is a necessity. We've already agreed to this principle when we accept the free vaccination of our children to reduce the incidence of communicable diseases. I think you would not argue that childless taxpayers should not have to pay for the vaccination of other people's children?
When SARS hit Singapore, the costs of caring for each patient who came down with SARS was astronomical. That is as catastrophic an illness as you can get. Without taxpayer support, the toll of SARS on these patients, their families, their healthcare providers and the country would be even greater.
Already, the HIV epidemic has shown that failure to subsidize HIV medication leads to increased prevalence of drug resistant tuberculosis. This affects all of Singapore as well.
In cancer treatments, the cutting edge treatments fund cancer trials that support research into a cure for the various cancers.
We are all in the same boat when it comes to healthcare, and we derive benefits indirectly from the experiences of other patients, as well as directly from the treatment itself. How can we support only paying for our personal healthcare needs?
Plus, when the patient is no longer the payer, he is no longer buying a service, but receiving treatment. And the implications of the change in patient-doctor relationship will help to promote rational use of care, and minimize abuse.
"My system exists in the form of the NHS."
It does not. NHS is not really free at the point of delivery, nor does the patient have full freedom to choose the treatment he wants.
"Making healthcare free is one way of decreasing barriers to compliance."
It is not. It costs no money for the patient to stop drinking, stop smoking, and stop eating so much.
"Like you said, there will be increased utilization of healthcare resources, so you agree with me in principle on that."
I agree there will be more consumption, but the consumption will be waste because it does not result in better health outcomes.
"I don't see why these means of regulation will go away when healthcare is made free."
It will not - it just lowers the barrier for people to abuse healthcare.
"We've already agreed to this principle when we accept the free vaccination of our children to reduce the incidence of communicable diseases."
Communicable diseases form a special category because of the principle of harm to others. Not only do we provide it for free, we mandate it. We violate the civil liberties of patients, we ignore their autonomy, all to protect the rest of the population.
"We are all in the same boat when it comes to healthcare, and we derive benefits indirectly from the experiences of other patients, as well as directly from the treatment itself."
We do, but people do not fall sick so doctors can benefit from the experience of treating them so I can benefit when I become similarly ill. Does the smoker deserve free healthcare because his COPD exacerbation allows you to learn about the disease? Does the robber deserve a break for letting policemen learn how to solve crimes? Do you ask for free food from the hawker because you allow him to practise his cooking?
"How can we support only paying for our personal healthcare needs?"
How can you demand that others pay for your personal healthcare needs?
"Plus, when the patient is no longer the payer, he is no longer buying a service, but receiving treatment. And the implications of the change in patient-doctor relationship will help to promote rational use of care, and minimize abuse."
You are either naive, or inexperienced. Patients who do not pay for their own healthcare (be they on Public Assistance, Blood Donors, CSC holders) are not the sterling exaples of rational users of healthcare as you imagine them to be.
Do yourself a favour: run your ideas by a few of your older colleagues and see what kind of feedback you get. Really.
I may not be experienced. But I try not to make factual errors. This is straight from the NHS website, and I support their 3 principles.
http://www.nhs.uk/NHSEngland/thenhs/about/Pages/nhscoreprinciples.aspx
I quote:
"The NHS was created out of the ideal that good healthcare should be available to all, regardless of wealth. When it was launched by the then minister of health, Aneurin Bevan, on July 5 1948, it was based on three core principles:
that it meet the needs of everyone
that it be free at the point of delivery
that it be based on clinical need, not ability to pay
These three principles have guided the development of the NHS over more than 60 years and remain at its core."
Those are the principles, not the realities.
http://en.wikipedia.org/wiki/Criticism_of_the_National_Health_Service
Perhaps there is something to be said about having fixed principles in mind - however distant they may be in reality - as compared to having... remote controlled goalposts? :)
1. If one were not to expect others to pay for their health cost, would it also be equitable that others not mandate or expect one to give up time, opportunities and possibly their life/lives to protect these Others’ wealth or life/health (in the spirit of “not to be generous with other people’s time, opportunities and life”?)
2. Although people do not fall sick just to let doctor “practise” but the doctor’s knowledge and skill do get better each time and perhaps could lead to new remedy. And if one finds any hawker (more so a food manufacturer) is trying to “practise” on you, it should be free, otherwise walk away. (On the other hand, try walking away from being sick!)
3. In the analogy of the robber and police, if the robber is the disease, policeman the doctor, and the victim and society at large - the patient instead, then we do “pay” a flat fee and expect a good job done. If each crime, big or small is pursued only with a fee, would there be an incentive for holistic prevention approach or total eradication of the problem, which otherwise would simply conveniently sustain an “industry”?
I'm a Singaporean working as a doctor in Australia, where we have a Medicare system somewhat similar to the NHS, although it is not in as bad a state. I would just like to point out certain areas that I disagree with.
"For lower- (and perhaps even middle-) income families, circumstances prevent many from leading healthy lifestyles"
https://www.mja.com.au/public/issues/feb16/mathers/mathers.html
There have been studies linking poor health to lower socio-economic groups. On the ground level, working as a doctor in Australia, this is because eating healthy, fresh food is actually more expensive than eating cheap, unhealthy food.
Angrydoc is right in the sense that certain diseases are brought on by lifestyle issues. I cannot tell you the amount of frustration we get on seeing patients being treated with exacerbation of COAD only to be seen smoking within metres of the hospital once they feel better. He might also argue why are we wasting resources on ppl like these?
If we do that, it means we are putting a value on people's lives and health, judging whether someone should be saved based on how much value we think they would bring or contribute to society. We are doctors, not God.
I have also attended clinics in Singapore. I still remember seeing a 70 yo lady with a fungating breast tumour come in. When asked why she did not come in earlier, it was not because she was ignorant, but that she knew or suspected it was something bad, but was afraid of the cost of treatment.
I have seen the abuses of the welfare system in Australia, as healthcare in public hospitals is essentially free if you are a Citizen or PR. So we get patients coming in jamming up the A&E dept on hot summer days to enjoy the air-conditioning. But, I would rather think that we would be able to have been able to treat the old lady before she reached that stage if we had a system that would provide free healthcare,at least for the elderly or disabled and currently, the Singapore system does not cut it.
"If we do that, it means we are putting a value on people's lives and health, judging whether someone should be saved based on how much value we think they would bring or contribute to society. We are doctors, not God."
You are right: we are doctors, not God - God doesn't have to struggle with limited resources when it comes to managing patients, does he?
But I am not arguing my position solely from the point of view of a doctor, but also as a citizen who is privileged (or unfortunate) enough to know what the abuses on the ground is like. We may not want to put a value on life, but someone has to pay the drug companies, doctors, nurses, and janitors.
The fact is, if you agree that healthcare has to be rationed, then you will have to make the decision on how to ration it. We have to put a value on life and health. Somehow.
But currently, abuses in our system occur not because we don't put a value, but because we don't have the moral courage to enforce our decision to ration. Patients who don't require a referral get referred, patients who don't require admission get admitted, patients who don't require investigations get investigated, patients who can be discharged don't get discharged - all because subsidised healthcare is a political tool.
As a doctor and a citizen, I say this must stop. A subsidised healthcare system that does not hold its patients accountable will fail. It must fail.
"As a doctor and a citizen, I say this must stop. A subsidised healthcare system that does not hold its patients accountable will fail. It must fail."
I agree somewhat with this point but it assumes that patients are able to be accountable for their health all the time.
What about the intellectually disabled? The paediatric population? The demented population? The psychiatric popluation? How are they meant to be compliant with their own health if they can't understand what is going on? Not all will have family members to help them, and this is where either we as a community, or the government should step in.
Your statement also assumes that ,nonwithstanding the above population, a person is able to have full control of their health issues.
"It costs no money for the patient to stop drinking, stop smoking, and stop eating so much."
Health is often not an isolated issue, as I have mentioned before above. Sure, it does not cost money to stop smoking, drinking and eating so much. But what are the factors leading to them smoking, drinking and eating badly in the first place? Sometimes, these factors are beyond their control. It is often multifactorial, but involves social-economic issues as well which as the government of a country, should be their responsibility to solve some of those issues.
"Patients who don't require a referral get referred, patients who don't require admission get admitted, patients who don't require investigations get investigated, patients who can be discharged don't get discharged"
I think the above also happens because of the culture of "defensive medicine", esp with the high rates of litigation in the Western countries. Everything is now "just in case", so we might not trust on our clinical judgement as much, "just in case" we miss the 0.01% chance the headache is due to Klippel-Trenaunay Syndrome, or something obscure.
"The fact is, if you agree that healthcare has to be rationed, then you will have to make the decision on how to ration it. We have to put a value on life and health. Somehow."
I do agree that healthcare has to be rationed in some respect due to our limited resources( unlike God). However, I disagree that we need to put a value on each person's life to be able to do that. Nonwithstanding a mass casualty situaion where time spent on someone who is close to death means time that could have been spent on saving someone more "salvagable" was wasted, that value of someone's life should not be the first things on our minds when we meet and treat a patient. We already do a form of valuation or triage by using our most important resource, time, such that we would maybe spend 15 min seeing someone with a cold and spending more time on someone with more complicated health issues. But this valuation is based on the health condition(s) of the individual rather than the value of what their life may bring, as that can never be measured.
For example, will we spend only 15 mins on diagnosing and treating an 87 yo with multiple health conditions as he is a hopeless case and will therefore be not worth saving and wasting resources? (I am not talking about CPR as that would be another issue)
End of the day, I agree that Public Health and ultimately good health policies, (as unsexy a specialty in medicine it may be), is the most useful tool for better health on the whole for the masses. Unfortunately, research is usually spent on cures as that's where the money is. Prevention is key, as you have said.
I suspect the solution will be probably a happy medium between some subsidies on the government's part with possibly health incentives to the individual so that they have a certain reward for staying healthy, aside from good health of course.
Don't be mistaken that I think a welfare health system is best. I believe, like yourself, that an individual must take responsibility for their own health, however, the government must also play a part in the country's health, and I think the current goverment/ruling party, could have done more and should be doing more.
"Your statement also assumes that ,nonwithstanding the above population, a person is able to have full control of their health issues."
No, my position, as I stated here
(http://singaporemd.blogspot.com/2011/05/healthcare-issues-responsibility.html)
is "a person's healthcare is his individual responsibility regardless of whether or not his illness is his fault."
"this is where either we as a community, or the government should step in."
I have no problems with "community" stepping in to help - volunteers, charity, NFK, Renci... whatever. I take issue with people who insist the government should be "step in". The government does not "step in", the government compels people to "step in", be it through forced labour (ever been "volunteered" during NS?) or through taxation.
"Sometimes, these factors are beyond their control. It is often multifactorial, but involves social-economic issues as well which as the government of a country, should be their responsibility to solve some of those issues."
Sure. Their decisions to not take care of their health is beyond their control, just as my decision to look after my health and my ability to earn enough money to be taxed are not my own doing.
Go ahead, take my money - what am I saying? it's not even MY money! Society gave me that money and now society can take it away. Blessed be the name of Society!
"I think the current goverment/ruling party, could have done more and should be doing more."
Tell me what you think. I am genuinely interested to know.
I'll state this because I know I had not done so sufficiently:
I believe that a person's need, no matter how dire, no matter how little control he has over it, does not justify the state compelling another person to give up what is his by right.
To give an extreme example, a group of men trapped in a mineshaft and starving does not have the "right" to kill and eat one of their group to prevent starvation.
To give a more realistic example, the state does not have the right to force you to donate your bone marrow to a kid with leukaemia.
To give an actual example, the state does not have the right to take your kidney from you to give to a patient with kidney failure, unless you did not choose to... er, unless you choose to not choose... er, whatever, that opt-out thing.
We don't even rob a condemned man, a man's whose "right to live" the state has chosen to violate, of his organs unless he consented.
Sure, we're just talking about money now - but if you are going to violate my right to my possessions, how long before you claim a right to my time, my labour (wait, you already have! Damn you, society!), my freedom, body-parts, my life?
The irony here is that most of common people, still have to give up (compelled) their time, their freedom, their opportunity, their "right to live", their right to labour and heaven forbid their body-parts or their life / lives just to protect someone like the Angry Doctor, his family, his wealth, his property, in time of crisis so that he may and could do the same ranting all over again ….and kenna “damned” at the same time some more …
"I believe that a person's need, no matter how dire, no matter how little control he has over it, does not justify the state compelling another person to give up what is his by right."
Just to check, do u believe in the system of taxation? Or do you just don't believe that health care is a good use of taxes? Because from what you are saying, you believe that you have a right to own possessions, which is true(See Universal Declaration of Human Rights, Article 17,) and it seems that you are stating that the government does not have sufficient justification to take away any possessions(be it money/time etc) to help with another person's health, which is what part of our taxes are going to. Just trying to understand where you are coming from with your reasoning.
The examples that you gave as you rightly said, is different as it involves the human body and life, rather than money or material possessions. And with your last statement, I assume you are referring to a slippery slope argument, which might not hold true, and I can give you some examples.
I will await your stand on taxation before I try and reply to the ways that I think the Government can improve as it would give me a better understanding of your social ideologies. If your basic ideology is different from mine, we can comment til the cows come home on different methods but will never agree.
Thanks for taking the time to have a healthy discussion by the way, I hope you feel the same way.
"Just to check, do u believe in the system of taxation? Or do you just don't believe that health care is a good use of taxes?"
Ah, you get me. :)
My arguments in the previous comment tries to establish that the right to property is, well, a right.
Now taxation is necessary because it allows collective purchse of goods and services which individuals may otherwise not be able to afford.
I agree we should tax for collective good, for mutual defence, for law enforcement.
I disagree that we should tax unequally (e.g. with progressive income tax).
I disagree that a man's need entitles him to demand more tax moneys for his use through the government.
If you argue that subsidised healthcare and progressive tax are for common good, then at least we can have a discussion.
If you think I should give just because you need, then we have no common ground to start on.
Personally I think, whats wrong with giving others what they need,especially its whats gonna keep them alive? Whats wrong with sharing responsibility in ensuring all of us have equal entitlements to healthcare? You are just selfish posting comments judging the system based on all the faults. Why can't you look at the benefits? Are you saying that because of the minority that abuses it a little, you refuse to help the majority who actually needs it? Compliance is a issue, but its not the system's fault is it? It all starts out with education and responsibility and our moral development as a country.
Think about this, if only we can all give because you need, really seriously need, why not? In the end it will be possible for that to happen, if everyone thinks this way, where everyone helps on another regardless of anything. You need medical assistance, I give it to you. You don't agree with that?
You might argue that even if we feel that way, its impossible to have everyone feel that way. But if we do not take the first step to accept this possibility, this dream that we can achieve, everyone probably will think the same and nothing happens in the end.
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