"There is no abuse"

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?

A Lifetime to Master

A colleague recently remarked that being the (self opined “best”) expert that he was in his field, there was no one else he could discussed his cases with anymore. It is true that in this day and age you may end up as the only expert in your area (even internationally) especially if you sub (x n) specialize. However, whilst one might think one is the crème de la crème or the king of the hill, as a doctor, he must never assume that he can no longer learn from anyone. One can obviously turn to literature, research and international expert meetings but in truth, although background noise is aplenty, there are only that many substantial findings worth committing to memory, barring special breakthroughs. But when the science of medicine stagnates, it may be time for us to hone the art. Personally I find that I have learnt much from two groups of people.


It is an unfortunate (hard) truth that most doctors are narcissistic to begin with or will become one in the course of their training. It is already a daunting task to ask to experts to listen to one another much less to their undifferentiated juniors. However, this is silly as young bloods often have new ideas and have fresh eyes to some of the clinical problems we face. They are not burdened by the prejudices accumulated together with the years of experience and do not have preconceived notions. I often hear good ideas from MOs and Registrars and even if I may not agree with their ideas, it always good to listen to what opinions they have to offer when it comes to a difficult clinical scenario. Also, there are many junior Drs who may be extremely well liked by patients, receiving good comments (as well as cards and gifts) from them. I would observe (and learn from), albeit quietly, their mannerisms and attributes which endears them to their patients. The rapport that a doctor has with his patient often would make or break the management of the case and such soft skills had often been ignored by hardcore physicians and might not be the forte of many a senior Dr.

It may also come as a surprise that we often (consciously or unconsciously) learn from our patients. It does not matter how familiar you are with the literature, nothing beats having a firsthand account of the effects or side effects of a medication from a patient. We continue to learn about signs and symptoms presented in their many varied forms and often distorted in many ways by cultural overlays.

To illustrate, I had an elderly lady who came late for her appointment and complained of anxiety and itchiness in her womb. As she had been late and I was in a hurry to end my clinic, I was quick to dismiss her. My dismissive attitude continued for a few visits and I felt rather irritable with her persistent complaints of itchiness in the womb which I knew to be anatomically impossible. During one of her visits, my clinic was unusually empty and perhaps as I was less flustered that day, I chatted with her for an extended period of time. She told me that after her husband passed away, she had single handedly brought up her two children doing odd jobs. She had since retired as her children have all grown up and she was staying with her son, a successful engineer. Unfortunately, her daughter-in-law and her grandchildren found her uncouth and her son without putting in much thought was negotiating for her to move in her daughter. However, her daughter was not willing to take her in either due to space constraints. She was immensely disappointed and had worries that she would be abandoned. It became clear from her account was developing the anxiety due to the recent turmoil in her life particularly to the fear of being abandoned by her children. I felt ashamed of myself for having ignored this lady previously because she was late. Given her lack of education, she would have had difficulties maneuvering around our rather complicated hospital system to have made it to see me, thereby being late. More importantly, her accounts made me reflect on my own relationship with my parents.

It is important to sometimes slow down to look (at), listen (to) and feel (with) the people around our clinical practice. We may learn powerful lessons from the most unlikely person in the most unlikely place. For it may take ten years for one to become a fully accredited specialist but it will take a lifetime for us to master the art of medicine.

Dr BL Og

If healthcare in Singapore is unaffordable...

... then who have been 'affording' these pills?

"Why Physician Compensation Plans Fail"

Here's an interesting article from Medscape:

(abstract)

What is the number one reason why physicians leave their practice group?

Discontent over their compensation.

There are many ways to structure a compensation plan, and each has its pros and cons. A group may compensate its partners on the basis of productivity measured by relative value units generated, bonuses that are based on productivity and patient satisfaction, equal pay model in single-specialty groups, achievement quality and efficiency measures, or a number of other plans.

Unfortunately, many groups rush to create the compensation plan design before they bother to develop clear-cut strategies that would guide the building of the plan. They also neglect to reevaluate the plan on a periodic basis and to pay closer attention to critical signs of dissatisfaction with the plan.

For example, the compensation plan was a real sticking point for one 27-physician orthopaedic surgery group. They had a long-standing income- and expense-sharing plan in which expenses were shared on the basis of revenues. The 3 spinal surgeons produced more revenue, and so their expense allocation was greater than that of their partners.

However, because those 3 surgeons saw fewer patients in the office than the other partners, they used the staff (the major expense item) much less than their colleagues did. In addition, because those 3 surgeons' fees were higher than any of their fellow orthopaedists, the billing staff devoted much less time to billing and collecting those revenues.

The 3 spine surgeons wanted to change the expense-sharing arrangements and were ready to quit the group if the changes weren't made. The other surgeons didn't want to make the change.

The outcome? We recommended a minor variation in the expense-sharing formula that resulted in modest decreases in the incomes of 24 partners but in measurable increases in the spine surgeons' take-home pay.

The article refers to a private group practice in US, but I think it's just an example of human nature at work and that the experience is universal and applies not only to medical practices, but any other profession where contribution and renumeration are not consciously and regularly managed, and of course society at large.

Subsidy - the cure for all woes?

The problem with the 'subsidy mentality' is that after a while, it becomes so ingrained that people begin to look at 'subsidy' as the solution to what we perceive to be a social problem. Now, it seems that a doctor (dentist?) is calling for doctors and dentists to be subsidised too!

GPs and the elderly bear brunt of foreign doctor influx

HEALTH Minister Khaw Boon Wan believes that his ministry's current 3M (Medisave, MediShield and Medifund) health-cost strategy facilitates even expensive procedures such as a heart bypass with minimum cash outlay ('Opposition has strange ideas on health care: Khaw'; last Wednesday).

Regarding doctors, Mr Khaw's present strategy seems to be to leave market forces to equilibrate. This means that doctors are left to fight for their survival, causing many general practitioners (GPs) to practise aesthetic medicine to supplement their income.

The influx of foreign doctors to fill places in government hospitals and polyclinics has resulted in a communication breakdown between elderly patients and their doctors. Our health-care system is in a lose-lose situation in which doctors and patients suffer.

Such a fire-fighting strategy could be avoided with proper planning. Our health-care system is well-developed, so why have health-care needs for the next 10 or 20 years not been forecast?
The full social impact of the influx of foreign doctors will be felt in a few years but local GPs and elderly patients are already feeling the pain.

As GPs cope with rising costs, the cost of medical care will rise with inflation. Lowering medical fees artificially will only result in poorer quality of care.

To help GPs contain operating costs, the Government should consider offering subsidised rentals in Housing Board neighbourhoods.

GPs and dentists must now compete with the likes of cellphone traders and bubble tea sellers for the same shop space. Which is a greater public service? Is return on investments more important than health-care affordability?

Dr Ng Yong Kheng


Now the thing is, if you fail to identify a problem correctly, you are not likely to come up with the correct treatment for it. Or even worse - if you begin by deciding on a treatment and then go back and try to frame the problem so it fits your treatment...

The first misconception here is that GPs do aesthetics to make ends meet. While GPs may initially go into or dabble in aesthetics to "supplement their income", my experience is that they soon find it so lucrative it becomes the main source of their income. I have had colleagues who started doing aesthetics "out of interest" or to "supplement income" or whatnot, and for a while even as they expanded their aesthetics practice they continued to keep a foot in primary care "as a form of social responsibility" or "to stay in touch with the basics" - but now they are in full-time aesthetics, operating out of full-fledged aesthetics clinics. Ask yourselves this: You have seen 'normal' GP clinics turn into 'aesthetic clinics' or the 'aesthetic branch' of a clinic chain - has the reverse occurred? Has a clinic ever turned from being an aesthetic clinic to a 'chronic disease clinic'? Have you ever had a doctor refuse to take on another botox case because he has made enough for his rent this month, and would rather spend that time slot looking after a patient's diabetes?

GPs may start aesthetics to supplement their income, but they do not stop once the overheads are all covered. The resources, in terms of training and equipment, once invested, just makes it economically more sensible to convert one's entire practice into aesthetics.

So will lowering rental for clinic spaces make GPs turn from aesthetics to primary care? Well, as I asked in the comments section of a previous post: if you are selling tea for $2 a cup when HDB halved your rent, and people are still willing to pay for your tea at that price, will you lower the price to $1?

And that brings us to the next point Dr Ng brought up when he asked: Which is a greater public service - GPs, or cellphone traders and bubble tea sellers?

I think the question to ask instead is this: Does the average Singaporean spend more on primary care each year, or more on handphones and bubble tea? What about cigarettes and alcohol? Hairdo, nails, spas? Now the fact that all these service providers can compete for the same shop spaces as the GP tells you something - they can turn a profit at the same rental. And the reason why they can do it is because Singaporeans are willing to spend money on what they have to offer. Granted the people whom we normally associate with spending on such things may not be your typical picture of a patient with chronic diseases, but you cannot deny that many will become such, and that the money not spent on those discretionary expenditures now can be saved to pay for one's healthcare needs later in life. If Singaporeans are willing to spend as much on primary care as they do now on all these things and on aesthetics, will GPs have any incentive to go into aesthetics or to let their spouse run a bubble-tea stall out of the same shop space? The players in this equation are not just the landlords and the tenants, but also the consumers. The consumers' choices determine to a large extent whether a business model is successful or not - just ask any Luohan fish seller.

I believe that this 'problem' of GPs doing aesthetics rather than primary care cannot be 'solved' if we continue to deny the economic realities, which is that patients help create that market by the choices they make, and they make those choices because of the perceived value of primary care to them, and because our subsidised healthcare system allows them to abdicate responsibility for their own healthcare.

Doctors & Nurses (and other healthcare staff)

This article - "Physician, heel thyself" - was published in the New York Times on polling day. Written by an oncology nurse, it decried the fact that even today, a significant number of doctors do not respect nurses and the work they perform, dressing them down or treating them with condescension.

Such things also happen in Singapore. During my service in public hospitals, I have seen doctors yell at nurses, jeer at them with sarcastic remarks, and make fun of them behind their backs. Thankfully, only a minority of doctors do this, although more may feel that they are at the top of the pecking order in clinical care. The situation is not helped by the fact that more and more nurses (and doctors) are foreign-born, and adjustment to work in Singaporean hospitals is not the easiest thing in the world.

Nonetheless, good teamwork makes for more effective clinical care. Currently, nurses are doing more and more of the jobs previously performed by physicians - an advanced practice nurse is the virtual equivalent of a medical officer (except for prescribing rights), and may have more knowledge in their area of specialty. Conversely, this frees up more time for doctors to further their skills and knowledge.

GE 2011: The Aftermath

The ruling party may have retained an overwhelming majority in Parliament, but the overall results for the PAP are less than stellar, as their national vote share dropped to 60.14%, "the lowest in all post-independence elections".

At Singapore MD, readership hit an all-time high of 1,532 on 6 May, as varied opinions from our contributors generated spirited debates. Prof. Tambyah's SDP rally speech was especially contentious, resulting in a steady stream of comments and rebuttals.

A number of S'pore MD's writers have met Prof. T in person, and have great respect for him as a physician and tutor. I sat at the same table with him at a wedding dinner a few years ago, and still can't quite believe that this mild-mannered gentleman could stand up in front of thousands at an opposition party rally, to lambast the MOH. Bravo!

As for rumours that he was asked to resign, these remain unfounded. However, a source indicates he may have been called up by certain powers-that-be for, ahem, "a chat".

So as the new government prepares to tackle the next 5 years, I hope the PAP will indeed "reflect" on what it's done wrong, and endeavour to rectify its mistakes. And since S'pore MD is featured in daily reports churned out at the MOH, I trust Minister Khaw will pay more attention to the issues being raised by our bloggers and readers, who comprise healthcare workers and laypeople.

From what I've read in recent weeks, the hottest topics appear to be:

1) manpower imbalance between the public and private sectors - how to plug the leak?

2) foreign doctors - boon or bane?

3) improving subsidized medical care for S'poreans - increase Medisave usage? increase GDP expenditure?

4) the plight of GPs - what can be done to channel them back into primary healthcare and away from aesthetic medicine?

5) assistance for singles caring for elderly parents with chronic illnesses - they should not be left out of the equation

Any additional suggestions are welcome in the comments section.

As for the "horror stories" about high-profile patients who punish innocent doctors, I suggest these doctors report the incidents to the Worker's Party. More ammo for the next GE.

Good idea, no? :)

Doctors And Politics VII

The furious debates over healthcare issues affects me in 2 ways: first, as a physician in a public hospital, and second, as the only - and single - child of elderly parents with chronic illnesses.

As a healthcare worker, I am disappointed and appalled by how the MOH has managed the manpower issue.

17 years ago, it clamped down on the number of overseas medical schools with degrees which are recognized here, effectively preventing many foreign graduates from returning to Singapore to practise. Fortunately, I was one of the lucky ones, and was accepted at NUS after clearing the interview.

As time passed and the shortage of doctors became obvious, this restriction was gradually lifted. NUS began increasing its annual intake of medical students. Then Duke GMS materialized. Now a third medical school. Plus a huge influx of recruits from non-traditional sources ( e.g. the Philippines, India, Pakistan ) as the floodgates opened.

Prof. Tambyah echoes my sentiments that 'maldistribution' is the root of this problem. It has never been an absolute shortage, and I'm certain the MOH realizes this. But its strategy remains the same: plug the leak with more new graduates and foreign recruits, and everything will be fine.

Does the MOH wonder why there's a leak in the first place? Often, it is due to poor welfare for overworked and underappreciated doctors. Ridiculous patient loads in the wards, clinics and emergency departments. Minimal protected time for teaching and research ( unless you hold a fancy position like 'physician faculty' or 'clinician-scientist' ).

With 2 spanking new hospitals being constructed, the thinning medical workforce will only be stretched further, and more non-local HCWs roped in to fill the gaps.

KTPH opened without sufficient preparation, in an apparent attempt to pacify Singaporeans. Shortstaffed departments resort to pilfering specialists from other public hospitals to run their clinics, do ward rounds and supervise A&E medical officers. It may have come out tops in the recent patient satisfaction survey, but feedback from the ground is far from favourable.


Which leads to the next bane of my existence: those blasted surveys. I would like to get my hands on the forms used, and have a detailed explanation of the methodology utilized. How are respondents selected? Tell us every single KPI that was assessed. Do the patients' answers match objective data?

The last question deserves scrutiny, because my HOD informed us during a recent meeting that despite patients seen at our department complaining that waiting times are long, these do not reflect statistics collected from computerized records. In fact, our waiting times rank among the best of the lot, but patients' PERCEPTION is opposite to actual performance.

Instead, the Health Minister praises KTPH for maintaining its excellent service record ( transferred from AH ), and tells the rest to buck up.

Obviously, I don't work at KTPH. I belong to a department that has taken numerous measures to improve waiting times and patient care, and which is one of 3 important divisions that is regularly assessed in these hospital surveys. Do you know what such results do for our morale? It is gut-wrenching, especially when patients' ignorance is printed as fact, and facts are left out of the picture altogether.

We are indeed very fortunate to have a CEO who values clinical quality above such nonsense. Other institutions may not have such an understanding leader ( *cou-KTPH-gh* ).


Next, my role as an only child whose elderly parents have an assortment of chronic illnesses requiring long-term medication and assisted care. I do not have a maid, and thankfully, they are both still independent in most activities of daily living, though an unforeseen event ( e.g. an accidental fall, perhaps even a simple viral infection which develops into something much more serious ) could alter the situation drastically.

While they do have CPF reserves and personal insurance plans, in addition to my own Medisave funds as backup, benefits for singles are scarce. As a blog reader pointed out in a personal email to me, singles are not entitled to foreign maid levy relief, and eldercare leave is non-existent. The former is reserved for married couples, for the main purpose of allowing mothers to continue contributing to the workforce.

I contribute to the workforce on a full-time basis, compared to many colleagues who part-time for family reasons. Why do I not qualify?

Eldercare leave is also worth looking into, especially for those of us with less familial support ( no siblings, siblings who have migrated, etc ), parents who are home- / wheelchair- / bedbound, and/or require frequent medical follow-up for multiple co-morbidities or complicated diseases. I routinely use my off days to accompany my parents, but not everyone enjoys the luxury of a flexible schedule and 5-day work week. Caring for children may be challenging, but managing frail parents is no easy task either.

Last but not least, the use of Medisave for the treatment of chronic illnesses approved by the MOH. An annual withdrawal limit of $300 is allowed per account, and up to 10 accounts belonging to immediate family members ( spouse, child, parent, grandchild ) may be used. So again, since I am single and an only child, our options are markedly reduced.

My father has diabetes, hypertension, hyperlipidemia, renal impairment and severe DM retinopathy. He is fully compliant with medications and lifestyle restrictions, but still requires a fistful of drugs to ensure tight control. Despite all these measures, his vision continues to deteriorate. ( In case our doctor-readers are wondering, the retinopathy was already present upon diagnosis - not a result of poor compliance - so subsequent therapy was aimed at slowing progression, since prevention was no longer possible. )

A blanket sum limit of $300 is not enough for those with multiple co-morbidities, especially if disease control is a challenge. In such cases, more medications, or more powerful drugs - which are often also more expensive - are required, not to mention more frequent consultations involving multiple specialists. A one-size-fits-all approach clearly doesn't work.

Last but not least, as the mortals ponder their fate and suffer sleepless nights, I wonder if our well-paid politicians are subjected to the same policies they draw up and publicly support? Do they see polyclinic doctors? Do they consult specialists as subsidized patients? Do they stay in subsidized-class wards when they're admitted? Do they dig into their own pockets to pay for their medical expenses? Or do they choose only the best physicians and surgeons, skip the long queues for appointments and at crowded clinics, stay in A-class rooms, get treated like royalty and make the taxpayers foot the bills?

We can argue that government officials deserve medical benefits of a completely different scale. But how many government officials are paid such high salaries?

A few things the opposition should bring up in Parliament in the near future...

Doctors and Politics VI - Fisking Prof Tambyah's speech

Well, as I promised, here is my rebuttal to Prof Tambyah's speech at the SDP rally.

The first few paragraphs are populist rants and jibes which I have come to expect for rally speeches, so let's get straight to the meat.

1. Medisave

Prof Tambyah asks how many Singaporeans "can afford to pay $250 a day or $7500 a month for medications for three to six months on top of the needs of their own families". Well, $7500 over six months translate to $45,000. Now if you lived in a private condo, and needed $45,000 to fund something in your life, what would you do? Do you expect other Singaporeans to help you pay for your need?

What if someone who lived in a private condo who needed $45,000 took some money from you without your consent to fund his need? Do you think that is fair? Wouldn't you ask him to explore other options of raising that money before he took it from you? Cut back on some discretionary expenditure? Sell some assets? Borrow from friends and families? Or even downgrade to a less costly home, perhaps? Charity? Why should "get someone else to pay" be the "solution" of choice?

Now ask yourself why things should be different when it came to healthcare?

It is easy to say "ask the government to fund", "ask the medical social worker to help", but we need to recognise that at the end of the day, that money come from all tax payers. By demanding that others pay for our healthcare, we are making our own health other people's burden.

2. Primary Care Proposals

It is perhaps impossible to get precise statistics on this (so feel free to ignore this section if you disagree with my basic premise), but our outcomes in the management of chronic diseases at the primary care level does not fail at the level of access or provision, but at patient compliance. Our polyclinics are already staffed with nurse managers, nurse practitioners, dieticians, physiotherapists, podiatrists, psychologists... all charging nominal sums for their advice and treatment. But ask your friend who works in a polyclinic what the take-up rate for these services is like.

Patients can afford these services which will help them understand and manage their health better, but they choose not to. Their health is not a priority to them when their diseases are still in the primary stage and they choose to invest their resources elsewhere; but when complications set in as a result of their decisions, it suddenly becomes everyone's problem?

3. GPs

It is often said that GPs go into aesthesics to make ends meet - I prefer to think that they do so because aesthetics is more lucrative. And that aesthetics is lucrative tells us two things: 1. Singaporeans are not too poor to afford healthcare that they want, and 2. Singaporeans choose to spend on aesthetics.

Can the government make GPs stop doing aesthetics by lowering HDB rents? Well, ask yourself this: if you are running a tea stall selling tea at $2 a cup and people are willing to pay for it, will you lower your price to $1 just because your landlord lowered your rent?

The reason why GPs can do aesthetics is simple: people can afford aesthetics, and they are willing to afford it. If patients are willing to show that they are willing to afford good primary care, then GPs will return to providing good primary care.

+++

My take on the speech overall?

It is true that healthcare can be expensive - if your health is valuable, then why shouldn't healthcare be expensive?

But is primary healthcare really out of reach to the average or low-income Singaporean? No. I reiterate my point that the key barrier to good control of chronic diseases at the primary care level is compliance and not access or cost.

Look at what Singaporeans spend on instead of investing into primary care, or setting aside for catastrophic illnesses: cigarettes, alcohol, hairdo (yes, I actually wrote that word), iPhones (what, you think iPhone users don't get diabetes?), that year-end trip to Perth - show me a polyclinic doctor who hasn't had a patient who can afford to go on a year-end holiday in Australia ask him or her for subsidised travel medication.

Cases like that related by Prof Tambyah are not unique, but it is disingenious to conclude from that one anecdote that Singaporeans are dying at a massive scale for want of healthcare, and that our healthcare system is heartless or has failed. Prof Tambyah wants you to think about the patient with a stroke and his son who lives in a private condo, I ask you to think of all the Singaporeans who by paying tax have a little less of the money they have earned themselves to spend as they wish to, to invest in their own health and their own future. If they wish to help, they can always donate to a charity - but to say that they must help? Is that fair?

What I do agree with Prof Tambyah though is this: Dr Vivian Balakrishna is an excellent ophthalmologist. I too think Singapore will be better if he returned to clinical practice.

Doctors and Politics V (Local)

Election fever seems to have hit SingaporeMD as well - we have more posts (and more page views) in the recent two weeks than anytime since inception, robust discussion in the commentary (mainly our colleague angry doc defending his point of view against all comers), and no "groupthink" despite the similar careers of the bloggers.

In the real world, it seems that that the doctors actively involved in politics and civil society are divided as well. The initial prominence of doctors in the ruling party has given way to the surprising revelation that some doctors have also given their time and energy towards alternative policies. This is a welcome change as doctors worldwide tend to have a conservative outlook (no surprise as most doctors earn quite a bit of money and lead comfortable lives despite all the moaning) - most doctors in the US tend to vote for Republicans, for example.

Among newcomers in the PAP, we have Dr Janil Puthucheary, a bright and dedicated pediatrician and a great teacher who unfortunately chose to conflate his profession (saving children's lives) with national service, and Mr Chia Shi Lu, who literally "parachuted" into parliament without having been introduced to the nation. Now, I have only heard good things about the SGH orthopedic surgeon, and he is likely to do a good job as an MP. We should also not begrudge those who grasp opportunities firmly as they arise - if he had (and this is speculation) negotiated the Tanjong Pagar slot while his popular colleague Mr Baey was sent to buttress the former MND minister's team in Tampines, then kudos to him. It is good election strategy for both him and his party.

Among newcomers in the opposition, we have Dr Ang Yong Guan, a psychiatrist with very impressive credentials and experience. His rally speeches sound a bit strange to me, but perhaps that's the hazard of his profession. During my medical school days, I thought virtually all the psychiatry tutors and professors sounded a bit odd. Then there is the "outed" medical team that provided expert input for the SDP's shadow healthcare plan, many of whom are not actually SDP members. Prof Paul Tambyah, in particular, also spoke at the SDP's final rallies as a "guest speaker" along with Mr Tan Kin Lian. Prof Tambyah is well known in the medical and biomedical research community, and possibly more famous internationally than he is in his own country. He is an infectious disease physician by training, a prominent debater, and a member of the local human rights group Maruah. He was put up for the nominated MP position by the Singapore medical community recently, but was rejected by the governmental selection committee.

Many doctors (well-educated as we are) continue to express the fear that the votes are not secret, and that there might be future repercussions in terms of their career prospects (public sector-wise) if they voted "wrongly" or assisted the opposition parties. In this light, it will be interesting to follow the careers of Prof Tambyah and Mr Chia Shi Lu from now and see if such fears are in fact groundless.

Doctors And Politics IV

As Polling Day looms and election campaigns heat up, I'm sure many voters have already more or less decided on their choices. I know I have.

Debates about the local healthcare system rage on, as they have for decades. Cliched as this sounds, no system is perfect. But as someone from the Workers' Party recently commented during a rally: What makes sense isn't necessarily right.

If the opposition wins more seats in Parliament and calls for change, only time will tell if new policies will prove superior to what we have now.

The main question we have to ask is whether the PAP is willing to implement these changes based on the feedback they've received - even if on a trial basis - or do we need members of the opposition to push them through?

However, I find it increasingly difficult to pledge allegiance to a government that, in my opinion, swept the hospital overcrowding problem under the rug, until the Health Minister got badly flamed on a prominent blog, after which measures were hurriedly taken to minimize ( public relations ) damage control.

Or to a government which employs an MP who was fully aware of the overcrowding problem, but when directly asked to highlight the crisis to the Health Minister, let personal grudges take precedence over patient care, and replied, "Of course I can, but why should I?" [ direct quote, by the way ]

I have also heard enough horror stories from medical colleagues - it's a very small community after all - about the consequences of treating certain high-profile patients, even when the patients' stubborn refusal to obey instructions resulted in complications.

And I honestly hope the practice of having A&E doctors and nurses drop everything during a busy shift to make house calls will not be revived. VVIP ambulances exist. Use them!

Choose wisely, my friends.

Shadowy Health Plan

Blogger's impression of the James Gomez Wing of Chee Soon Juan Memorial Hospital

Since his fellow bloggers have touched on the topic of healthcare in politics, angry doc thinks he might as well join them... not that anyone can accuse Singapore MD of groupthink though...

Healthcare for those who need regardless of ability to pay it is an attractive concept, so much so that some doctors believe in it, and of course political parties promise it.

You can have a look at SDP's "Health Plan" here.

My visual gag aside, I find parts of the "Health Plan" worrisome...

I wonder, for example, how SDP plans to "encourage" "healthcare workers, general practitioners and senior consultants in private practice... to perform sessional work in public hospitals". You see, it is always easy for those who do not provide the funding or possess the skills to "volunteer" that of those who do. Somehow I am not "encouraged" by this part of the "Health Plan". Are my fellow healthcare workers?

SDP also proposes an insurance where "healthcare coverage is jointly managed by the Government and appointed national insurers". So the question here is of course: what's in it for the national insurer? Can they or can they not make a profit?

Well, the proposed insurance scheme "will not be a catastrophic policy with myriad exclusions like Medishield, it will be a truly comprehensive national health insurance policy that benefits from economies of scale and covers preventive healthcare rather than simply the expensive treatments at the end of life".

There are two problems with that.

First of all, if it is universal, and does not have a "myriad" of exclusion clauses and is "truly comprehensive", then most if not all Singaporeans will utilise it. For Singaporeans to benefit from it, they must be paying a premium that is less than what their claims amount to. That being the case, how can the insurers make a profit? It will be as though it were a lottery scheme where everyone wins more in prize money than they spend on the lottery ticket. When the insurance is "universal" and "comprehensive" and the insurer is not allowed to cherry-pick, then the only options for them are to make a loss or to charge a premium that ensures they don't make a loss, in which case the premium per capita will by definition have to be more than the pay-out per capita. There will be, at the end of the day, no free lunch.

Unless SDP decides to likewise "encourage" the insurers to... co-operate?

Secondly, the insurance does not cover (I may be reading it wrong, but the wording is vague here) "the expensive treatments at the end of life". Now this tells me that SDP actually realises and acknowledges the fact that the bulk of healthcare expenditure a person incurs actually occurs in the last year or the final months of his or her life. Add that to the fact that almost 100% of Singaporeans (yes, you never say always in medicine, especially since Mr Lee and Mr Chiam still seem to be out and about...) will eventually die regardless of how well they take care of their health, then you end up with either a) a healthcare insurance that covers you for what you can afford, but not what you cannot afford if SDP does not cover end-of-life treatment or abolishes the current 3M scheme, or b) a healthcare insurance that covers every Singaporean from cradle to grave, at either a premium too high to fund, or a loss too great to sustain.

And I haven't even touched on the issue of abuse yet.

So will it work?

SDP has given us the answer themselves when they write: If you do get struck by a serious illness, you will not have to sell your home if the SDP is in Parliament, we will make sure that all the money you have paid in GST, ERP and all the other taxes and levies go towards giving you the best medical care in the most appropriate manner.

It will work in the short and perhaps medium term (until the reserves run out) if the tax payers are willing to pay for it. It may not be a lot more than what you already pay now, but with "free" healthcare come moral hazard and abuse, and once the reserves run out, then whichever way they skew the income tax curve, someone's going to have to bear more of the burden. Are you that someone, or are you the person who thinks it's OK for that someone to bear more of the burden?

Healthcare issues: Responsibility

Is it fair for other people to pay for your healthcare needs, especially if you fail to take responsibility for your own health? This is an emotionally-charged question that our colleague angry doc has raised several times, and it is quite clear what his answer is.

Where to draw the boundaries of that responsibility is less clear. Most people will agree that if you catch a flu because you are in a crowded MRT or workplace with people coughing and sneezing away, it is not your fault (yet why didn't you wear a face mask like some of the Japanese?). What about a child running onto a cycle track after a ball who then gets knocked down by a cyclist? That's probably not quite his fault too (after all, he's just a small kid - his parents could have taught him better, but there are limits there). A student who comes down with leukemia and then needs a bone marrow transplant? That's probably close to the ultimate in bad luck - and therefore thankfully extremely rare unless it happens to you. On the other hand, if you happen to be the sort who loves your weekly char kway teow with the fried crispy pork lard and cockles, and who dreads the weekly jog around the block that constitutes your exercise, perhaps you didn't do enough to prevent that AMI. If you are a diabetic with one foot lopped off for gangrene and you continue to smoke, most people and not just doctors will agree that you deserve the stroke or AMI that follows (although there is already a higher chance that it could have happened anyway). Just like if you started smoking today and came down with lung cancer 10 years later (but what if you were smoking in the 50's and 60's and no one warned you of these risks at that time?). God forbid if you have a hedonistic lifestyle and come down with HIV - but what if you are just the faithful spouse of such a louse and get HIV anyway?

Alright, personal responsibility for health is a tough one in most cases. How about personal responsibility for being able to pay for one's healthcare so that others (beyond your family) will not have to contribute part of their taxes towards taking care of you? We can ignore the flu example - it doesn't cost very much even if the doctor decides to tack on some antibiotics to cover his insecurity or increase his profits. The leukemia example is extreme. It can cost beyond $50k for the initial treatment and transplant - enough to wipe out the family's Medisave accounts and very few parents are wise or "kiasu" enough or have enough spare change to buy catastrophic health insurance for their kids from birth. In fact, many local patients end up depending on charity to pay for their treatment. But as said before, this is an extremely rare example. As for the rest, well, perhaps it's the fault of most people that they are unaware of the limits of Medisave (you probably only need to be hospitalized once for a major illness for this to be drained) and Medishield, or how hard it is to qualify for Medifund. We are not saying that the 3M's are bad - quite the contrary - but they are inadequate in ways that most "average" people don't realize until they are pushed against the boundaries. They will cover the majority of Singaporean's health needs, but it is a continually shrinking majority because of advances in health care and changing distribution of chronic diseases (for example, cancer). But private health insurance to cover the gaps in the 3M's is comparatively not cheap for the lower income groups, especially if you have other costs that you deem more important, such as money for your children's tuition.

So in essence, it may be better that access to health remains a public good in many ways (as it is in Singapore) and accept that there will inevitably be freeriders, while working on addressing the social factors (education, socioeconomic status, physical stress, etc) that contribute to health outcomes.

How about a priority system then? Rationing health care for those who are unable to pay on their own. It is illusive to pin down the exact amount of personal responsibility so let's have experts (like doctors and policy makers) decide for the healthcare system as a whole. No subsidization for cosmetic breast augmentation locally, for example, although you can perhaps still get it done for free in the NHS. Why not a case-by-case basis? Because it would be a bureaucratic nightmare (and also a political nightmare) and doctors tend to disagree on what is the best approach for an individual case (although there are guidelines), especially if their pockets are directly affected. The UK has NICE (National Institute for Health and Clinical Excellence) which is a fantastic idea as far as objective rationing goes, although unfortunately it can be politically overruled.

So all healthcare systems hold their patients accountable in some ways, and Singapore more than many developed countries except some like the US. The degree that patients are held responsible for their own health varies depending on culture and the social contract. Just as it is impossible to think of US developing an NHS-like system or UK dismantling the NHS even in the long term, the Singapore healthcare system will not morph into either "free" patient care or the predominantly private and capitalist system in the US. But it can change, for better or worse.