Earlier this month, in the comments section of one of our posts, a reader disagreed with me that abuse of the healthcare system exists. She asked:
I believe no one likes to fall ill. No one wants to be sick. Therefore,
tell me who is there to abuse system?
Well, in his first blog post as Health Minister, Mr Gan Kim Yong writes:
We will have to review our funding framework, as well as the various financial assistance schemes, and make the necessary adjustments to ensure they remain appropriate and effective in helping Singaporeans cope with healthcare costs and yet prevent wastage or abuse.
Bravo.
Now this does not mean that the Health Minister *knows* that abuse exists, but it does mean that the feedback he received from healthcare workers is that it does exist; so if you think that the existence of abuse is merely a figment of my imagination, well, now you know.
To simply say: "let's subsidise more" is the populist and easy solution in the short term, but it does seem that Mr Gan is not going down that route.
Longtime readers of the blog will know that I am against our current subsidised healthcare system because of the lack of moral courage in policing and stopping abuse, and that the way to stretch our healthcare money is not to simply put more into the budget, but to cut waste. Will a new minister and new policies make me change my attitude towards subsidised healthcare? Well, we'll just have to wait and see, won't we?
49 comments:
Won't a better approach be to actually ask whether any studies has been done to examine the effects of waste and abuse in the Singapore healthcare system?
If none has been done, shouldn't one be comissioned?
Waste certainly exists, and "quality improvement" projects are routinely done and publicised, so no issue there.
As for abuse, given that healthcare workers report that abuse exists and have been reporting it, the question really is why haven't studies been done.
Abuse?
What about doctors that abuse the system for their benefit? I am sure that happens too.
Of course. And what kind of abuse do you think we should tackle first?
Curious Healthcare Ignorant
I am interested to know more what type of wastages are there in our healthcare system?
Can anyone help to advise me here.
For one area that I feel might be seizing some of the healthcare budget pie is the expensive medical IT systems that is costly to maintain but also introduces redundancy due to the existing healthcare landscape that we have.
Yes, I agree there is much waste there in redundancy, and in systems that cannot "talk with each other" that result in other bridging system being required (I am not IT-trained, so I cannot give you specifics here).
Other wastes are in processes that have too many unnecessary movement of staff, too many levels of approval etc., which waste man-hours and lower efficiency.
Same as most big corporate organisations, I guess?
there are different kinds of redundancy. some are required, such as data redundancy for recovering from a catastrophe (eg hard disk failure / server dying)
redundancy that isn't useful are things like the division between singhealth and nhg and the different clinical management platforms that results in, as angry said, bridging systems.
the overall architecture is messy, and information flow is not ideal (odd considering what a small country we are.)
there are also a large, large number of IT staff employed, and I've heared rumours about the payscales of some of the consultants brought in to bring sense to the madness, which put our ministers pays to shame. of course these may just be rumours. shrug.
PainRack wrote:
"Won't a better approach be to actually ask whether any studies has been done to examine the effects of waste and abuse in the Singapore healthcare system?"
Sure, the MOH would probably be more than happy to commission yet another study, like the awesome patient satisfaction survey which is a total load of BS.
My dad was recently operated on at KTPH. I was far from satisfied with the way the surgeon managed him.
While one may argue a system of healthcare subsidies creates more opportunity for passive long-term "self-abuse", we should not lay full causal blame on the former. Any rules-based system will be subject to abuse by those who are able to either game or work the system. It's not peculiar to healthcare. It remains to be seen if any one such active abuser will be brought to account. But one thing looks certain - more rules are coming!
"Sure, the MOH would probably be more than happy to commission yet another study, like the awesome patient satisfaction survey..."
The thing about surveys is this: if you don't ask about something, you won't find out about it.
So if you don't ask about things that is up to you to change, then essentially your survey results will not tell you to change.
So if MOH wants to commission a survey or study on abuse, then it must, before it even begin to script the questions, ask itself whether it is prepared to do anything once the results are known.
The patient satisfaction survery places the focus of improvement on service and workflow, which is the purview of the healthcare institutions, and not MOH directly; a survey on abuse, however, will place the focus on policy, on policing and - more importantly - test the political will to stop the abuse, which lie with MOH and not the institutions.
If you are not prepared to do anything, why bother asking?
I find it funny that you suggest no subsidy at all. Tell me how many can really afford healthcare if it is not subsidised? If a huge segment of population is burdened with a financial debt because of healthcare do you think you still have a productive workforce?
The truth is we don't exist as solo singaporean each minding their own business and ultimately responsible for their own actions. We exist as a society. In a society, if it is a normal distribution we would have people who are responsible for their health and there are those who are not and the majority are the inbetweens. There will always be people who needs help and there are those who are in a position to help. You can trim abuses but you will never get rid of it.
I have no idea why you do not see the need for subsidy. Just because there is abuse in the system, doesn't mean that subsidy is not necessary.
If your parents is sick would you help them up financially to pay the bills? If your irresponsible brother is dying would you lend a helping hand? Or would you leave them to die because it is their responsiblity because they haven't taken care of their health.
In the same way we call ourselves singaporeans. Aren't we part of a bigger family. It would really be sad if you think that people don't deserved to have subsized healthcare because they did not take responsibilty for their health.
But I guess different people take different paths.
"Tell me how many can really afford healthcare if it is not subsidised?"
Tell me how many really cannot afford healthcare if it is not subsidised.
"Just because there is abuse in the system, doesn't mean that subsidy is not necessary."
Not completely; it's also the wider issue of justice which I wrote about in my other posts and comments.
"In the same way we call ourselves singaporeans. Aren't we part of a bigger family."
No. If you want to use the "family" argument, then we might as well go the way of the welfare state.
I am curious about the point of non-subsidised healthcare.
Can any good doctor please share the actual cost of say:
1) Cataract surgery;
2) Heart bypass;
3) Hysterectomy
in a restructured hospital?
Thank you.
eve+line,
http://www.moh.gov.sg/mohcorp/billsize.aspx?id=302
The amounts may appear huge, but bear in mind that this is before Medisave and Medishield, and mostly not recurrent expenditure - the average person has 2 eyes and half a uterus.
It may be hard for most of us to come up with tens of thousands of dollars at a moment's notice, but is saving up that amount of money over years or decades really "unaffordable" if we prioritise how we use our money?
How many percent of the people really cannot afford healthcare, and how many just don't want to pay even when they can?
Actually healthcare here is not unaffordable but the key is to get proper insurance coverage.
Looking at the private medishield plans for Class A restructured hospitals (source: http://www.moh.gov.sg/mohcorp/hcfinancing.aspx?id=11222), the annual premium is still less than $1000 right up to the age of 65, of course, the premiums increase significantly after age 65.
And besides coverage for hospitalisation bills, it is a good idea to also have insurance policy to cover critical illnesses. The premiums are still quite cheap when you are relatively young(that is less than 45 years old) and disease-free. When you get older, say about 65 years, you can stop the critical illness policy when the premiums get too high, and depend on your own savings (although it is still a good idea to have a Shield plan)
By the way, I am not an insurance agent, just a regular GP. I know of many working adults who don't get adequate insurance coverage when they are young, and I always advise them to do so because it is relatively cheap for them to do so, and they don't have much savings to fall back on if serious illness should strike.
Sorry for being dense but are the costs quoted for say Ward A the unsubsidised costs? i.e. no funding received from MOH?
I am interested in the costs of providing the procedures not the cost to the patients.
For Ward A it is the unsubsidised "price" to the patient, which is not what the patient has to pay out-of-pocket though, since there are Medisave and Medishield.
The "cost" of the procedure I do not know, but I assume the "price" for ward A includes "cost" and "profit".
Dear Angry Doc,
You are very lucky:
1. to be young and healthy and fearless
2. to be young and have a good job and savings
3. to avoid contact with people with none of points 1 and 2.
Must be nice to practice medicine without having to worry about whether your patient can afford the treatment. Unfortunately, as a GP in the heartlands, I often have to consider my patients financial means and am personally scared to death (haha!) of the costs of any catastrophic or chronic illness befalling me.
C. Chin
Fear doesn't pay your medical bills, Dr Chin. Why don't you do something constructive about it instead?
You could do everything in healthy lifestyle 101, but some catastrophic illness are just plain bad luck.
Sure. That's why you should put aside money to pay for the healthcare you need, and/or buy health insurance.
Just because some things are beyond your control, or because you are "scared" doesn't mean other people should pay for your needs.
angrydoc,
so what should some of these "other people" do with their money?
You're clearly not a socialist. You also probably are against any form of taxation.
While you subscribe to this notion that other people should never pay for others needs, there are people out there who will feel otherwise.
Well I guess it would be interesting to see how a country will work if it relied on "donations" from willing parties and had ZERO taxes.
Lastly, is health care expenditure an investment or an expense? Versus say spending on defence, education, trade, foreign relations etc?
"so what should some of these "other people" do with their money?"
Beats me. It's not my money, so I don't think I have any business telling them what to do with it. Don't you think they have a right to decide how they want to spend the money they earned themselves?
"You're clearly not a socialist."
Correct.
"You also probably are against any form of taxation."
No. I think taxes are necessary - I just don't think the current way we are collecting and spending is fair.
"Lastly, is health care expenditure an investment or an expense? Versus say spending on defence, education, trade, foreign relations etc?"
Can't say about the rest, but I think there is no doubt that investing in one's own health and healthcare is, well, an investment. The question here is not whether we should spend on health, but one *who* should be the one paying for that expenditure.
The government has set up or otherwise allowed a healthcare infrastructure in this country. To use your term, the investment has already been made. Moving ahead, does that mean that the government should continue to tax people unequally to fund needs which are ultimately individual?
A minimum expenditure in maintaining a surveillance and regulatory framework must exist, to protect the interests and legal rights of the healthcare providers and users, but to continue to subsidise healthcare indiscriminately the way we have been doing? Why do you think means testing has been introduced?
On some of the issues in the healthcare debate in the US, see http://www.newyorker.com/online/blogs/newsdesk/2011/05/atul-gawande-harvard-medical-school-commencement-address.html?printable=true¤tPage=all
actually, what does angry doc mean by the abuse or waste?
Abuse towards doctors? or abuse by patients who sees a doctor for no reason whatever so?
there's always imperfection in any system. And with imperfection, u will always find people who have issues with these imperfection.
"actually, what does angry doc mean by the abuse or waste?
Abuse towards doctors? or abuse by patients who sees a doctor for no reason whatever so?"
Which one do you think is acceptable?
"Beats me. It's not my money, so I don't think I have any business telling them what to do with it. Don't you think they have a right to decide how they want to spend the money they earned themselves?"
Well said.
"No. I think taxes are necessary - I just don't think the current way we are collecting and spending is fair."
Err didn't you just say that I have a right to decide how I want to spend the money I earned myself? And now you say taxes are necessary? So what is a way of collecting an spending that IS FAIR? Again, didn't you say I have a right to decide how I want to spend the money I earned myself? What taxes?
"Can't say about the rest, but I think there is no doubt that investing in one's own health and healthcare is, well, an investment. The question here is not whether we should spend on health, but one *who* should be the one paying for that expenditure."
Of course it should be myself lah. No one should get a cent of my money to spend on anyone else but myself.
"The government has set up or otherwise allowed a healthcare infrastructure in this country. To use your term, the investment has already been made. Moving ahead, does that mean that the government should continue to tax people unequally to fund needs which are ultimately individual?"
What sort of needs are ultimate not individual and justifiable that the government tax people unequally to fund?
Valid points.
In the ideal world all the things currently funded by taxation should be a form of collective purchase with the consent of all those who are taxed; in reality, that is impractical.
I don't imagine that we can have a situation where there is no govenment and no taxation, but then the dichotomy here is not between anarchy and socialism - there are in fact a range of possibilities here.
I think we should strive to be fairer in the way we tax, trying to avoid taxing some more than others even if they are not consuming more resources.
angrydoc,
answer the questions. don't fudge around.
example
What sort of needs are ultimate not individual and justifiable that the government tax people unequally to fund?
"What sort of needs are ultimate not individual..."
Nothing, I guess. All needs are ultimately personal, but provision for that need may not be. For example, treatment of water at the plant may not be for your personal need, but the consumption of that water is - which is why we charge you for it.
"... justifiable that the government tax people unequally to fund?"
My position is that as far as possible we shouldn't tax people unequally.
Tell me how many really cannot afford healthcare if it is not subsidised.
I don't know but judging from the fact that some people need to sell their houses to fund their medical bills when it is already subsidised, I believe many would need to sell their houses to pay their bills. The median house hold income is around $5000. Tell me if an operation comes up to $100,000 how many years does it take to save $100,000?
Not completely; it's also the wider issue of justice which I wrote about in my other posts and comments.
It has nothing to do with justice. If only the deserving gets to benefit from tax dollars then you will make everything subsidized so complex it takes more tax dollars to administer the benefits.
Once you pay your taxes the right to the use of money no longer belongs to you. It belongs to the government that manages it. You can choose the parties in government but not the way the government spends it. Unless you are in the policy department, you do not have much of a choice. Maybe voting them out.
No. If you want to use the "family" argument, then we might as well go the way of the welfare state.
What is a welfare state? Is having subsidy considered welfare state? There are different degrees of subsidy. Does it mean that if you are in a family you don't have to be responsible? Can you keep gambling and your parents will bail you out every time the loan sharks come knocking on the door? The question to me is what is a good level of subsidy.
angrydoc,
you said
"Beats me. It's not my money, so I don't think I have any business telling them what to do with it. Don't you think they have a right to decide how they want to spend the money they earned themselves?"
Then you said
"No. I think taxes are necessary - I just don't think the current way we are collecting and spending is fair."
So from somewhat implying that people should keep all the money they earned and governments have no basis to take that money to spend on other things you went towards collecting and spending issues.
And then you also said
"Moving ahead, does that mean that the government should continue to tax people unequally to fund needs which are ultimately individual?"
Somewhat gave the impression that you did not like TWO points.
1) Taxing people unequally
2) Using taxes to fund needs that are ultimately individual
Then you said
"My position is that as far as possible we shouldn't tax people unequally."
So does that mean you are now saying
1) It is inevitable to have taxes. Or it is necessary to have taxes
and
2) Tax everyone equally.
Sorry angrydoc, but you seem to change your positions far too often especially whenever you are asked for possible solutions.
So I ask again.
Should there be taxes?
And if yes, would it be agreeable to you as long as everyone was taxed equally?
I actually thought you would be suggesting something like a shopping list type of tax system.
Eg
Parents with children pay taxes that fund school educations programs while singles without children pay no such taxes
People who take public transport pay taxes that subsidize the costs of providing the services while those that drive pay taxes that fund the costs of maintaining roads and traffic lights.
People who use the library pay taxes to fund the cost of running libraries. While those who never go to libraries pay nothing.
To be frank if that were the case then we might as well have NO TAXES, but have a totally pay as you use system. In other words totally privatise every single civil service.
For example there will be no more police. Just private detectives and security guards.
No more army. Just mercenaries for hire as and when required by individuals.
All hospitals are private. If you can't afford it, die on the street.
What say you?
" I believe many would need to sell their houses to pay their bills."
How many?
"The median house hold income is around $5000. Tell me if an operation comes up to $100,000 how many years does it take to save $100,000?"
And what is the median annual healthcare expenditure for a househould?
"1) It is inevitable to have taxes."
Yes.
"2) Tax everyone equally."
Yes.
"Parents with children pay taxes that fund school educations programs while singles without children pay no such taxes"
That would be nice.
"People who take public transport pay taxes that subsidize the costs of providing the services while those that drive pay taxes that fund the costs of maintaining roads and traffic lights."
Well, "public" buses also use roads and traffic lights...
"People who use the library pay taxes to fund the cost of running libraries. While those who never go to libraries pay nothing."
Makes sense.
"To be frank if that were the case then we might as well have NO TAXES, but have a totally pay as you use system. In other words totally privatise every single civil service."
Nice idea, but like I said not practical.
"For example there will be no more police. Just private detectives and security guards."
CISCO? Aetos?
"No more army. Just mercenaries for hire as and when required by individuals."
National defence is a bit more difficult to privatise; I don't think this is the place to discuss that at length.
"All hospitals are private. If you can't afford it, die on the street."
You assume that if *all* hospitals are private then it will automatically mean healthcare will be unaffordable and that people will die on the streets. I don't think so. But I guess we won't know until we get there. In the meantime, I am glad we are moving towards that direction with means testing.
Actually, when you think about it, we have generally been moving towards less government funding in services that can be provided by a "private" provider: telephone services, TV (no more TV license fees!), security (CISCO, Aetos), education ("Independent" schools), healthcare (means testing), "public" transport...
Then the next question to wonder is where the government is spending our tax money then ?
Indeed. I don't think my taxes have come down that much over the past few years...
The less we ask them to do, the fewer reasons they have to tax us, don't you think? Well, in theory anyway...
As we can see, "Reductio ad absurdum". Angrydoc is within his rights to rant about subsidized healthcare and how he doesn't want taxation to be "unequal", whatever that means. All others are free to agree or disagree. It doesn't make any position "right". Live with the current system, or try to change it. That's all, as Meryl Streep's character might say.
Dogmatism rules.
" I believe many would need to sell their houses to pay their bills."
How many?
"The median house hold income is around $5000. Tell me if an operation comes up to $100,000 how many years does it take to save $100,000?"
And what is the median annual healthcare expenditure for a househould?
I don't know the answer. But anedotal evidence suggest that it is so. Why is there a need to allow people to use their medisave in a Malaysian hospital? To help malaysia medical tourism? You are an intelligent person. You also work in the hospital. I am sure you've heard enough stories to know the financial burden on some of the less well off. If there is any data you know about mean household medical please share. I doubt this will be done because it is not in the interest of the ministry. If they do publish data that shows healthcare is unaffordable they are effective getting themselves voted out. And perhaps only the ministry will have the data and they cannot be selling the three ms and publish data that healthcare is unaffordable.
So is anecdotal evidence sufficient justification to continue indiscriminate subsidised healthcare?
For every patient who cannot afford healthcare, how many who can are subsidised?
For every patient who cannot afford healthcare whom *we* subsidise, how many who can are *we* subsidising?
So is anecdotal evidence sufficient justification to continue indiscriminate subsidised healthcare?
For every patient who cannot afford healthcare, how many who can are subsidised?
For every patient who cannot afford healthcare whom *we* subsidise, how many who can are *we*
The anedoctal evidence tells us something. If you cannot infer from it, I cannot help you. You are of course free to hypotheses any way you like. As a mere mortal I would not have the resources to test the hypothesis.
So are you telling me people who pay more taxes should have less subsidy?
You ask me for facts and figures. Why don't you provide some facts and figures to prove your point. Eg abuse in the hospital. What is the percentage. Rampant or negligible. What parameter do you use. What is your definition of abuse?
Anedoctal accounts tell us that there are those who cannot afford healthcare, and anedoctal accounts tell us that there are people who abuse healthcare - the two are not mutually exclusive, and you can in fact be unable to afford the healthcare resources you are abusing.
There are, as far as I know, no studies on abuse of healthcare - you can read comment #10 on this thread for my theory on why - but as I wrote in the main post it is prevelant enough for the point to be made to the new Health Minister. Whether anything comes out of that we will both have to wait and see.
On the other hand, the data for average bill sizes for hospitalisation are available at the MOH site, and clearly your $100,000 bill is not a realistic one. Have a look at the data, learn about Medisave and the withdrawal limits, then judge for yourself how "unaffordable" healthcare in Singapore is.
"So are you telling me people who pay more taxes should have less subsidy?"
I don't think you understand my position very well... But just so you know, people who pay more taxes do enjoy less subsidy when warded at the hospitals or when staying at nursing homes.
Anedoctal accounts tell us that there are those who cannot afford healthcare, and anedoctal accounts tell us that there are people who abuse healthcare - the two are not mutually exclusive, and you can in fact be unable to afford the healthcare resources you are abusing.
I am not excluding the fact that they are mutually exclusive.
My point is if your anecdotal evidence is good enough for proving your point, I don't see why mine is any less credible.
On the other hand, the data for average bill sizes for hospitalisation are available at the MOH site, and clearly your $100,000 bill is not a realistic one. Have a look at the data, learn about Medisave and the withdrawal limits, then judge for yourself how "unaffordable" healthcare in Singapore is.
You are a doctor. Tell me how much does the average chemotherapy cocktail cost a month? How many cycles do they need? The fact is cancer bill varies in size depending on the stage. Do you have the data on cancer treatment in the MOH website? Do point it out to me if it is available. If it is available is it the full bill or only part of the bill?
"So are you telling me people who pay more taxes should have less subsidy?"
I don't think you understand my position very well... But just so you know, people who pay more taxes do enjoy less subsidy when warded at the hospitals or when staying at nursing homes.
what is your position then? Why tell me there is means testing. I know there is mean testing but your statement seems to suggest that people who pay more tax should not get any subsidy. It would be more helpful for communication if you can explain your position.
"The fact is cancer bill varies in size depending on the stage."
As you obviously know, there is no such thing as "average" when it comes to cancer, which is not a single disease entity. Yes, the latest chemotherapy drugs can cost hundred of dollars a day, but even then, why *should* the cancer patient's medical bills be subsidised?
"It would be more helpful for communication if you can explain your position."
I think my position is clear. What is *your* position then?
P.S. - Do use a nickname, your comments are being shunted to the Spam folder by Blogger.
as an aside, what makes anyone think doctors know the charges of chemotherapy any better than the lay public? Doctors aren't a "generic" entity - angrydoc could be an orthopedic surgeon for all we know. Orthopedic surgeons don't know diddly squat, uh except how to get into parliament. :D In truth the pricing for individual treatments / operations can be pretty bewildering, with all the different deduction rates for different types of subsidee, and often a single quote isn't available.
As you obviously know, there is no such thing as "average" when it comes to cancer, which is not a single disease entity. Yes, the latest chemotherapy drugs can cost hundred of dollars a day, but even then, why *should* the cancer patient's medical bills be subsidised?
There are 2 issues here, don't mix them up. 1 is affordability and 2 is whether subsidy should be given. You mention to me that my estimate of chemotherapy is unrealistic and healthcare in singapore is pretty affordable. Let answer this first before we go into answering the part about subsidy.
"It would be more helpful for communication if you can explain your position."
I think my position is clear. What is *your* position then?
You say your position is clear but you also say I don't understand your position very well. You might know your position very well but definitely not very clear to some people. You make statements that contradict each other and expect others to understand you without having to explain.
My position is written in previous post which is "what is a good level of subsidy." Subsidy is a funny thing. If you subsidize too much it actually pushes up the price of medicine. If there is too little subsidy then people who otherwise can live would have to choose death or being burden with financial debts that are really unnecessary. To me a great society is one that provides the best environment for their citizen to nurture them and help them flourish.
Dear Reminisce
The fact that doctor have friends who work in different specialization makes the information readily available to them. Whether they want to ask their friend is another thing. As you can see Angry Dr knows the cost.
"To me a great society is one that provides the best environment for their citizen to nurture them and help them flourish."
It's not your ends I have an argument with, but how you think we should achieve them.
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