Just to re-iterate a point I made earlier...
Why health care is like water
DEPUTY Prime Minister Tharman Shanmugaratnam's proposed review of improved financing, regulation frameworks and clinical programmes to better integrate private and public health-care services bodes well for both health professionals and users ("Private sector to ease health care load?"; July 10).
While the mainstay of health care remains within the public sector, the private sector has reservoirs of reserves locked within, awaiting deployment once the Government can integrate the two with policies to overcome the major obstacles of cost containment and efficiencies.
Health care is a commodity that should be treated the way the Government treats water: essential and affordable, but with a price commensurate with its worth.
Like water, it starts with conservation of health through a conducive lifestyle.
Primary health care that is priced too cheaply and used as a political tool to garner popularity will be abused and fraught with wastage. Tertiary health care in hospitals will also be saddled with unnecessary and frivolous referrals.
However, the removal of the fee schedule for doctors, because it was deemed anti-competitive, has moved the cost of private health care sometimes to stratospheric levels.
A middle ground is sorely needed where general practitioners can practise good medicine without the price pressures generated by insensibly subsidised polyclinics; where private specialists can act as a valuable release valve from heavily utilised public hospitals, if only patients are assured that charges are capped at a fixed premium.
Dr Yik Keng Yeong
Well, I don't think that healthcare is like water - for one thing, healthcare doesn't fall from the sky like water, and I don't agree that the government automatically has rights over all the healthcare that falls onto Singapore...
But I certainly agree with Dr Yik's observation that:
Primary health care that is priced too cheaply and used as a political tool to garner popularity will be abused and fraught with wastage. Tertiary health care in hospitals will also be saddled with unnecessary and frivolous referrals.
Dr Yik recognises that abuse is a problem, and he diagnoses correctly (in my opinion) the reason why abuse is not tackled. However, by proposing that we solve this problem by re-siting patients to the private sector and making it attractive for the patients to want to be re-sited by capping how much doctors there can charge is merely punishing them for the lack of moral courage on the part of the politicians.
The problem, as Dr Yik has pointed out, is the "anti-competitive" "price pressures generated by insensibly subsidised polyclinics"; so if you cap GPs' charges at equal to or below that, then how will they make any profit? Or, if you cap the charges at higher than the polyclinics', then why would patients then choose to see a GP and pay more?
The way I see it, the real reason why abuse occurs is because we have a system where people are not required to pay for what they consume. As long as you are not willing to change that, you will have abuse; until you are willing to change that, or until you are willing to police for and stop abuse if you find it, the problem will remain with you.
23 comments:
Abuse?
I think the problem with the healthcare system in Singapore is that there is a tremendous amount of waste.
Polyclinic doctors are seeing patients who are just asking for the referral letter to get subsidized specialist treatment. Polyclinic and GP doctors are seeing simple self limiting cases just because each worker needs an MC to take the day off. They don't need medical treatment per se.
So what are we paying all these doctors to do? Write letters and sign certificates?
Put most workers on hourly rates. No work (regardless MC or not) equals no pay. That solves the MC problem to a certain extent.
As for referral letter writing, restructure the subsidy work flow. Instead of having doctors determine the subsidy by writing referral letters at the polyclinic get social workers involved. Let patients have their referral and appointment but with NO GUARANTEE of subsidy (means test them later). So they can get referred by GPs and Polyclinic without any difference. Then doctors will see patients who need referrals for medical reasons proper.
Seriously, go to the Polyclinic and do a review of the type of cases they deal with. How many MCs are issued for example for self limiting conditions. How many referral letters are written for example.
Another thing to do is to expand the role of pharmacists and over the counter drugs. In North America most people self medicate for URTI and GE since it is self limiting. In Singapore, patients go to the doctor for every little thing.
Pay doctors good salaries for what they are needed for.
Right now we pay doctors a lot less because they are doing work that is largely trivial.
I totally agree.
We should right site doctors to hospitals and have nurse practitioners see patients in primary care.
This will help to reduce cost of primary care in Singapore.
With more doctors in hospitals, the hospitals can then manage patients holistically and resulting in better care.
Win Win for all.
But if nurse practitioners do the same work as GPs and do it as well as the GPs do, then why should they be paid less and why then will the cost of primary care be reduced?
That is a valid point but I doubt any nurse practitioners will price themselves like doctors.
It is like broker assisted trade vs online trading.
Even if online trading is as effective as broker-assisted trading, it is cheaper.
Since I work in the A&E, I keep asking why people insist on coming to us for minor conditions - e.g. flu, headache, aches and sprains - even on weekdays during office hours, when OPS and GP clinic services are widely available.
Because it really won't matter how qualified nurse practitioners and pharmacists are, if patients (1) only want to see the doctor and no-one else, (2) think only doctors at hospitals are able to treat whatever they have, (3) pay what they consider a small fee for 'specialist' consults at the A&E, (4) aren't turned away, no matter how trivial the symptom.
So unless something is done to improve patients' opinions of primary care physicians and deter them from indiscriminate (ab)use of the A&E, things will stay exactly the same.
Yes, I agree with Spacefan completely. It boils down to the fact that patients have poor perception of their illness. To them everything is serious and needs to be attended to immediately, better still to be attended to by a specialist!
A poster above commented that in North America, patients usually self medicate for minor ailments.
Having dealt with patients here and also some from North America, I will have to say that the latter generally have a much better understanding of health and disease. It is not uncommon that patients here do not know the diagnosis of their past medical history or the names of medication that they are on. Thus having more resources in terms of nurse practitioners and pharmacists is not going to be very useful if public perception of health and illness in general does not change. Unfotunately educating the general populace is going to take a very long time.
Isn't there a triage set up in every hospital's A&E to assess each patient that comes into the A&E? Isn't their role to refer out those patients who do not meet the criteria of conditions requiring A&E attendance? I believe if they diligently perform this role, this is one of the best direct ways of educating the public on the use or abuse of A&E services.
With personal health records in future, patients will be more well informed of their medical conditions.
There will be less abuse of A and E and Everybody will live happily ever after.
"I believe if they diligently perform this role, this is one of the best direct ways of educating the public on the use or abuse of A&E services."
And why don't they perfrom their role diligently?
I quote from Dr Yik's letter:
"... health care that is... used as a political tool to garner popularity will be abused and fraught with wastage."
"Isn't there a triage set up in every hospital's A&E to assess each patient that comes into the A&E? Isn't their role to refer out those patients who do not meet the criteria of conditions requiring A&E attendance? I believe if they diligently perform this role, this is one of the best direct ways of educating the public on the use or abuse of A&E services."
Having worked in an A&E before (thankfully no longer!), the triage is just there to pick up patients who are seriously ill so that they can be seen first or uptriaged to resus area. All those trivial cases will still get seen in the normal rooms outside according to queue. And you can't turn away patients or refer them anywhere else, they still must be seen (otherwise they will complain like mad!)
So, while the patients are the problem, the real problem seems to lie with the authorities in the hospital system for failing to exercise their moral authority, for political reasons. I hope the new Minister of Health will do something about this if he really wants to see improvements in his ministry.
It will be interesting if the MOH will publicly reveal its statistics on the emergency vs non-emergency cases seen at each hospital A&E to know the extent of wastage of these critical resources.
"...they still must be seen (otherwise they will complain like mad!)" - I'm not sure if we should be so fearful of their complaints since they should be embarrassed for insisting on A&E attendance for a non-emergency. Sometimes, I think health care authorities/staff are overly paranoid of complaints that they end up acceding to every whim and fancy of the patients.
"I'm not sure if we should be so fearful of their complaints since they should be embarrassed..."
I'm guessing that you have never worked in subsidised healthcare?
we are lay people. How do we know whether our problems emergency or not?
We already pay to see doctors in A and E so why should we not get to see? Hospitals should just hire more people instead of wasting money on healthcare administrators.
Yes Anon, you are obviously a lay person who only trust the doctor at the A&E. Just to let you know, some of the A&E doctors do work in polyclinics or GP clinics as well.
Just speaking as a layperson who had the misfortune to require A&E service and subsequent admission. What I can recall and was impressed while at the A&E is that the triage do inform patients of non-emergencies of the hefty A&E charges and advising them to use nearby clinics (with a list given to them).
I don't remember patients needing to pay until they finished seeing the A&E doctor as the case had to be assessed if it was a true emergency or not so that the correct amounts (subsidized charge if it was an emergency case) are charged. Thus, patients are free to decide not to continue to be seen by an A&E doctor in a case assessed as a non-emergency.
improving the perception of primary care physicians AND upfront payments by NS-men - wouldn't that cut the waiting time and reserve A&E for real emergencies.
A&E MO doing an otherwise OK shift.
But the A&E generates most profit from P3 cases. Without the large number of P3 cases, A&E departments would be deep in the red and the administrators will certainly NOT want that. Furthermore, implementing all those measures will not be popular with the public.
So as a politician and administrator why would you choose to do something that is hugely unpopular and loses money?
Having worked in Primary Care and A&E before I understand the arguments for improving the A&E from a clinical perspective but unfortunately, it's not all about that.
Once again:
"... health care that is... used as a political tool to garner popularity will be abused and fraught with wastage."
Triaging P3 cases away will only make the A&E lose money if you continue with the current pricing structure; if you are open to re-pricing your services, there is no reason why seeing high priority cases alone will automatically mean loss.
Yes re-pricing UPWARDS can mean seeing high priority cases alone still makes a profit but it is also not all about the profits. Public sentiment is a huge factor as well.
Right now we have a system where A&E is affordable for everyone for minor ailments to major medical emergencies.
Government hospital A&Es have also promised short waiting times with excellent customer service (they even do surveys to monitor this) at these affordable prices. Any change away from these without the cheaper, better, faster, safer paradigm is not going to go down well.
Think of it as a really really spoilt child who is given the best of everything, and then you want to instill some sense and discipline in him and yet want to be loved by him all the time.
Somethings you have to do even if it makes you less loved because there are higher benefits.
Then again, what are the KPIs for the hospital bigwigs?
KPIs. It's all about KPIs.
It's really a surprise to me to find out from the above posts that the A&E is a profit centre and the more non-emergency cases the merrier! Then why bother and spend taxpayers' $$$$ to educate the public not to use it for non-emergencies?
I think MOH must have come down on the blog authors here. <<<<<>>>>>
Think some of us are just too busy with other things right now. Stay tuned...
Haha, at least there is an indication this blog is still alive. Thanks goodness. For awhile I thought the MOHH trolls won the day.
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