As predicted, SDP's "National Healthcare Plan" involves increasing the government's healthcare expenditure from the $8 billion this year (up from the figure of $4 billion last year) to $10.5 billion, with the projectd increase being be paid for in part by "[i]ntroducing luxury tax" and "[i]ncreasing corporate tax". So now the rich will not only not be allowed to "buy immediate and better treatment [while] the poor have to wait months on end to receive medical care", they will be made to pay even more for healthcare they do not consume themselves than they already do now.
You can read the details of SDP's plan following the links on their site which I linked to above, but what it boils down to really is a $500-a-year consume-all-you-can healthcare buffet, even as SDP dismisses the existence of the "buffet syndrome" with what is effectively an "Oh, I'm sure it won't happen".
Now you only have to read the comments to the few posts before this one to know that it already is happening, and that it is naive to expect that the situation will in fact improve when such a plan is implemented.
Granted, we don't all spend $500 a year on healthcare now, but eventually more than half of us will die of cancers, heart diseases and strokes, and in getting there consume many times more than $500 during each of those final year; when the "silver tsunami" hits, this great "Plan" will fall apart.
I'll end with the words by a fellow doctor-blogger, a comment he posted on my blog when I looked at the subject of free healthcare many years ago:
I am absolutely certain that having medical care free at the point of entry leads to complacency and abuse. I have watched it with increasing horror in the NHS for 20 years.
People attend for medical consultations for the most unmitigated trivia; they demand inappropriate tests and, in particular, inappropriate medication.
I am committed to good health care for all, and I never thought I would ever want to change the "free" principle but common sense has triumphed.
As I have argued many times (and people seem to thing it is a trivial debating point - it is not) why is food not "free at the point of entry to the supermarket"?
Food is even more important than health care.
21 comments:
"People attend for medical consultations for the most unmitigated trivia; they demand inappropriate tests and, in particular, inappropriate medication."
Patients can demand for inappropriate test/ medications, but it cant lead to abuse unless the doctor orders or prescribes them.
Free healthcare can still be viable if the doctors serve as the gatekeepers to the system to prevent the abuse. After all, patients need the orders of doctors for access to test, medications, referrals etc.
To prevent doctors from caving in to unreasonable/ inappropriate request from patients, the system should back doctors on their clinical decisions and not side with patients unrealistic expectations.
There are too many instances of doctors ordering unnecessary test/ medications/referrals just to make patients happy and not because they think it is clinically indicated. However, patient satisfaction does not equate better clinical outcome.
Abuse of the system results if patient satisfaction is placed above the doctor's clinical judgement.
Just my thoughts
" Patients can demand for inappropriate test/ medications, but it cant lead to abuse unless the doctor orders or prescribes them. "
Sounds good but sadly it can never be like this as our system is all about "Service".
Person wavinig CSC card : " I want XXX test and YYY medicine. Why can't i? I AM ENTITLED. Call your head now. I demand this. You call yourself a doctor? Can you guarentee the test will be normal if it's not done?? I may/will/definitely sue you if..."
The above is already happening NOW and EVERYDAY in our primary care services. No matter how you look at it, this is abuse. No euphemisms needed. All together now...A..B...U...SSSS....EEEEEE.
Utopia is sometimes but a dream.
Have you missed the co-payment part before criticising the plan as "all you can eat"?
This is not a free healthcare plan. There is an annual premium element and a co-payment element involved.
Abuse applies on both demand and supply side. Just as some patients see doctors for non medical reasons (e.g. to buy MC) some doctors being paid under a FFS scheme over prescribe to get more payment. Such abuses are bound to happen despite checks and balances due to the creativity of the human brain.
Actually, the $500 I used in the post refers to the co-payment component, which is capped at $500 per year; the annual contribution is a fixed sum which is deducted from one's CPF and which *replaces* the Medisave contribution of the CPF, essentially making it "invisible".
Maybe it's just me being stubborn but I don't see how the $500 per year is any different from let's say a CSC card.
In fact, i think it may make people want to "make full use" of it since they are already "paying for healthcare".
SingaporeMD is already being optimistic with the view that people will consume more than $500 dollars only during the later years.
I feel many people will start rejecting generic drugs since they have paid for the "better medicines" already and many people will start to reject tests since they have "paid" as well.
Limiting the types of medicines/tests/treatments and adding a co-payment if patient opts for something not in the list can be possible but then we may we going in one big circle and landing back at the same place we are right now.
As the human mind is creative, i just feel this plan has more potential for abuse though it has many many merits in it as well.
Beardoc,
I think you and I have both been in the business long enough to know what will happen when we read SDP's proposed plan.
When there is no political will to ration healthcare by need, healthcare will be rationed by limitation of choice - modes of treatment will be withdraw because they are no longer "cost-effective"; not because they are truly not effective, but because we will no longer be able to afford the cost. Instead of some people not being able to afford the more expensive treatment, it will now be unavailable to all, except in the private sector.
The lessons are there for us to learn in NHS and the Canadian healthcare system - all we have to do is to imagine how those lessons will apply in the local context given what we know about our patient profile and political scene.
If you put the Canadian healthcare system in the hands of Singaporeans, it will bankrupt the system.
In Canada there is no MC. People do not like going to see their doctor for trivial things despite free consultation.
All drugs prescribed by the doctor in outpatient setting is paid for by the patient or his/her insurance plan.
Only inpatient costs are borne by the system.
In Singapore because of the MC system, you get millions of dollars flowing to doctors pockets. You want to save healthcare costs? Abolish the need for MC. You want less patients seeing their doctor for trivial things? Abolish the MC system.
This MC system is silly and immature. For the SDP plan to even have a chance of working, you have to abolish the MC system first.
If workers are taking too much sick leave, the HR department should deal with them. Nothing to do with doctors.
I am not in the system so am not privy to the insider knowledge.
Greed is in human nature so a heavily subsidized healthcare system will bound to invite abuse.
Our healthcare system should be among the best in the world but I am just wondering what can be improved in your opinion?
The point is that abuse can be stopped if doctors just say "NO".
It means saying " This test serves no purpose in managing your current condition. If you insist on having this test, I can order it for you but you will need to pay from your own pocket for it" to those CSC card holders etc....
Of course, doctors cave in to unreasonable requests as the administrative system is indeed geared towards patient service/ satisfaction and patient complains are a big deal to them.
Doctors end up with more trouble/ hassle to deal with when they say "NO" versus those that say "YES" to every patient request and make them so happy. Some of these doctors even get compliment letters, commendations or awards for it. Like i said before: sometimes patient satisfaction does not equate to better clinical outcome.
To do what the patient wants is the easier approach rather than to do what the doctor thinks the patient needs. This leads to abuse.
There are some problems with the analogy of the food in the supermarket with healthcare.
People generally like to have a variety in what they eat everyday. There is no "gold standard" food which people would generally accept as being "right" or "good" for them. Whereas when it comes to medical treatment, there are things you should and should not "consume". Which is why you get a doctor to help you make decisions whereas by and large what you want to eat is free for you to choose.
Food can be expensive or cheap depending on what you choose to eat. By and large food is kept affordable enough for most people so that they won't starve to death. After all, if you price food so expensive such that most die of hunger then you have no more customers and no business. Of course there's that other aspect about social upheavals in the name of survival.
Medical treatment on the other hand is usually a lot more costly and without subsidy or a pooled sort of payment system eg insurance, it is out of reach for most people. Also not everyone has to consume healthcare on a daily basis, which further complicates the comparison with food.
All analogies are imperfect, but they offer a perspective on the issue being discussed.
There are more copayment elements in the plan than this. It is not free at the point of entry.
Yes, the MC system in Singapore is silly. Unfortunately, companies will still want employees to get the MC as a slight deterrant. If not, there will be many workers who will take the maximum 14 days of sick leave (or whatever the number may be). The higher management/supervisory employees probably will not abuse the MC-less system but there are much more rank and file workers who will.
Using MC as a deterrant for workers to take maximum 14 days sick leave?
There are far better ways to manage employees and discourage taking unnecessary days off.
I am appalled that HR professionals cannot manage this issue better and have to resort to MCs!
"I am appalled that HR professionals cannot manage this issue better and have to resort to MCs!"
Erm, have you been living in Lala land where everything is bright and shiny and perfect?
Angrydoc, Obviously there are may medicos with years on experience in this forum. It will do poor ordinary Singaporeans a lot of good if you and your friends can suggest a better system. Singapore needs solution and not cynicism.
Better for whom, anon?
A healthcare system can be evaluated by
1. cost
2. quality
3. access
Japan may be low cost and quality but access is a problem
In Japan, services are provided either through regional/national public hospitals or through private hospitals/clinics, and patients have universal access to any facility, though hospitals tend to charge higher for those without a referral. As above, cost in Japan tends to be quite low compared to other developed countries, but utilization is much higher. Japanese patients favor medical technology such as CT scan and MRI, and they receive MRI at a per captia rate 8 times higher than the British and twice the amount of Americans.[6] Japan has about three times as many hospitals per capita as the US[14] and, on average, people visit the hospital more than four times as often as the average American.[14] Due to large numbers of people visiting hospitals for relativity minor problems, shortage of medical resources can be an issue in some regions. The problem has become a wide concern in Japan, particularly in Tokyo. A report that more than 14,000 emergency patients were rejected at least three times by hospitals in Japan before getting treatment in 2007, according to the government survey for that year, got a lot of attention when it was released in 2009, and around this time there were several incidents reported in the Tokyo area, such as an elderly man who was turned away by 14 hospitals before dying 90 minutes after being finally admitted,[15] and a case of a pregnant woman complaining of a severe headache being refused admission to seven Tokyo hospitals and later dying of an undiagnosed brain hemorrhage after giving birth.[16]
Taiwan
Even with all their success in their health care system, Taiwan has suffered some misfortunes. The government is not taking in enough money to cover the services it provides, so it is borrowing money from banks.[15] The revenue base is capped so it does not keep pace with the increase in national income. Premiums are regulated by politicians[16] and they are afraid to raise premiums because of voters. The country is slow at adopting technology except for drugs. There is a low doctor-to-population ratio resulting in too many patients depending on too few doctors. Patients visit the doctor more frequently causing doctors to keep visits short to about 2 to 5 minutes per patient.[17] There is no system to regulate systematic reporting of clinical performance, patient outcomes and adverse events.
Singapore system
is costly but that costly, access is good if you can pay for it and quality is top notch.
To improve further, we need to train more doctors to increase access but this may add cost (% of GDP will increase) and quality may suffer (shorter time to become specialists due to the residency system)
SDP suggestion will simply make an overworked public healthcare system even more overworked.
The silliest thing to do is for a restaurant that is fully packed is to lower prices to attract more customers.
As I have suggested, abolish the need for MCs. The civil service can take the lead.
Supervisors should monitor the absentee rate of their employees and take appropriate counseling or action if it is excessive.
That's one suggestion.
I don't live in a perfect lala land but I don't live in Singapore!
I think the realistic picture is, if we abolish the MC system, companies will start evaluating employees based on the number of sick leave they take (which is already obscurely high, at least for the 6 companies I've worked with). The MC system deters a certain percentage of people (long queue, specific company doctors etc) to visit the doctor for non serious issues.
In Singapore, there are people who visit the doctor for the slightest issues, doctors should know what I am talking about. I agree that having such a system will expose it to abuse and in the long run be a problem than a benefit for the nation.
Just my 2 cent worth.
No country in the world has healthcare 'right'.
Right being : Timely access, good quality and low cost.
What the public does not realize is there is no 'right treatment' or wrong treatment', they are shades of grey which is individualized So I take isse with "anonymous' about Whereas when it comes to medical treatment, 'there are things you should and should not "consume" in healthcare, that would be far too simplistic a view.
A simple survey will already inform us how SDP's co-payment scheme will pan out. We currently have people who pay full private rates for everything, those who have co-payment for CSC and Co-payment in the subsidized scheme and fully free medical treatment in 100% CSC covered schemes. The answer is that when patients do not have to pay, they ask for everything (just in case), whether it is appropriate or not (simple example being CSC patients asking for stocks of paracetamol -just in case, 'it's free what'. People who have to pay for everything weigh their decisions about value. They are usually well to do but are prudent in spending where they feel that the outcome is worthwhile.
People who are asking for subsidies are also liberally buying cigarettes to kill themselves slowly. People are willing to spend on wants (car, condo, holiday and good food) but are not willing to spend on needs. They would prefer, that they spend their hard earned money on wants, whilst spending tax-payers money n their needs.
And by the way, I notice that the majority of the expert panel for SDP's proposal are in private practice. Do they truly understand or believe in public healthcare, or is it something other doctors should do, but not them. Just like how they believe 'others' should pay for their healthcare and not themselves.
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