Charging Ahead

It is finally over. The titanic struggle between two parties that made Jaegar vs Kaiju battles in the movie, Pacific Rim look like two pygmies wrestling in a plastic infant bathtub, is over. We are of course talking about the Susan Lim overcharging saga that has finally come to an end.

And certainly it must. This Hobbit has actually gone through the SMC judgment (83 pages) and the Grounds of Judgment for the appeal to the Court of Three Judges (153 pages). This Hobbit encourages all of you to do so. Going through these two documents entails certain health benefits:

·     The hair on my feet has grown by an inch in thesame period.

·     It cures all forms of diarrhea.

·     It gives you inner peace as you better understand why you are still poor and languishing in your HDB clinic.

·     Your mind can “drift” just like the Jaegar pilots without any co-pilot. In fact, you can drift right into stupor after about 5 pages.

These are quite a few lessons one can learn from the whole saga and from reading these two documents.

Firstly, its OK to charge poor patients less or to even waive charges completely. But it’s not OK to charge richer patients more just because they are rich. So no “Robin Hood”. In other words, please raise your “standard” charges for everyone else (other than the poor) just to take into account the possibility that you do not want to always subsidise the poor out of your own pocket. Of course, the middle-class will suffer the most from this, since they neither deserve charity as the poor nor are they as wealthy as the rich. Take home message – the wealthy cannot be disadvantaged because they are wealthy. To borrow and adapt from tax terminology, there can be no “progressive professional fee charging” even though there is progressive taxation. Too bad if you do not buy this logic, but this what the powers have pronounced. Next take-home message – if you are middle class and not poor, you have to pay as much as the rich for doctors’ fees.

Secondly, it is generally a bad idea to charge a third party payer a lot if your chief lobbyist, i.e. the patient, is dead. If possible, try and charge more when the patient is alive so as to avoid complications like in this case.

Thirdly, charging an average of $15,000 a day appears to be OK, but $200,000 is out. But how about an average of $20,000 a day? (BTW, that’s about what an anaesthetist appears to have charged in the Susan Lim case, over a period of about 110 days). That appears to be OK too.

Long ago, it was opined by an oncologist that taking away the Guideline of Fees was like taking away the speed limit on our highways: the driver used to driving at 60km/h when the speed limit was 90km/h would still continue to do so, with or without the speed limit. But the person who had been driving at the 90km/h speed limit would be uninhibited and have no qualms driving as fast as he could. Now we are told there is an ethical limit to charging. To borrow the same metaphor, that means we now have an ethical speed limit. Only problem is we do not know what is this ethical limit in definite numerical terms. How does ethical limit translates into numbers? Charging is about numbers as much as it is about ethics. Imagine telling motorists on the German autobahn that there is an ethical speed limit when there is no numerical speed limit. Now you know why “angst” was originally a German word.

More importantly and encouragingly, the Courts and SMC have decided that ethics should trump contracts (or market forces) for the individual doctor. The Hobbit agrees with this 100%. But it appears the converse is true for a professional organisation: the CCS said that fee guidelines issued by a professional association like the SMA is anti-competitive. In other words, market trumps ethics for SMA but ethics trump market and contracts for the individual doctor. So it appears that that are different philosophies, principles, standards for the individual doctor versus the professional association/body. Can the Courts, SMC and the CCS rationalise this? Because this Hobbit certainly can’t.

Here is the crux of the matter. No one argues that pure water can exist as a liquid and as a solid. Ice is 100% water. So is liquid water. Likewise, there are also two dimensions to charging by doctors – an ethical dimension as well as a numerical dimension. By imposing an ethical limit but denying the medical profession any definite numerical guidelines on the matter of charging is to try to have your cake and eat it too and denying this duality exists. But this is exactly what the regulatory authorities (SMC and CCS) are collectively doing. The medical profession has been inadvertently put into a most unpleasant position by these two bodies. This is not only grossly illogical, it disadvantages the patient and places the medical professional in an untenable position in the long run.

Contrast this with what’s is being discussed now in the legal profession: champerty: which is allowing lawyers to take on cases for a cut of whatever the client may recover in a legal action, otherwise known as “contingent fee arrangement”. Straits Times journalist Andy Ho said on 2 August 2013 “Let David take on Goliath in court” said that a contingency fees system is consistent with the market ethos of our culture” and that such an arrangement was first started in capitalist USA.

Legal aid already exists in Singapore for the poor but it appears that this may not be good enough and there are some folks who think that champerty should be allowed for the poorer segments of society as well so that they have improved access to lawyers. The first point to be made is how do we define who is poor and entitled to champerty?

If in the future, if champerty is allowed for the legal profession in Singapore, then seriously folks, we should really allow doctors to take a cut of the patient’s wealth for keeping the patient alive and healthy? After all, one’s wealth is meaningless to oneself if dear oneself is feeding daffodils seven feet underground or gathering dust in an urn somewhere in Kranji.

And to make champerty more “progressive” in nature along the lines of improving distributive justice, perhaps we can put in requirements that doctors who get a share of the patient’s wealth be required to donate apart of these champerty earnings (say 25%) to a healthcare charity or to Medifund to help the poor have better access to healthcare.

Finally, it was reported in the Business Time recently that the starting pay for lawyers is now 6000 bucks a month. Also, one can safely say that some of the people who benefited most from this Susan Lim saga are the lawyers who have collected probably lots of fees for their work. So, if champerty is allowed in Singapore, one can expect a lot more work for litigators, and that includes cases that involve malpractice suits against doctors and hospitals, both in in the public and private sectors. Medical malpractice and hospital insurance premiums are likely to go up in such a climate and if so,will be passed on to patients eventually unless you really believe doctors live only on fresh air and Newater and hospitals are here to make losses. But if a British actor can play Superman and promote the values of truth, justice and the American way, then anything can happen in this crazy world now.

As another (green) short guy remarked long, long ago in agalaxy far, far away, “I sense a grave disturbance in the Force”.

Meanwhile, sources working in the private hospitals tell this Hobbit that the referral agents are now working with greater ferocity –they are now asking for up to 25% kickback of professional fees as “referral charges”for the patients they refer to agreeable specialists. Agents and participating specialists both stand to gain from the ever upward spiral of fees on these unsuspecting patients who think that the agents only charge a small administrative fee for these referrals. Fee-splitting is not allowed by the SMC but everyone knows this is going on. These agents are the real weapons of mass overcharging that pervade more and more of our private specialist care delivery system. They remain in the shadows. And these agents and the participating specialists are also smart enough to leave no paper trail and all transactions are done in cold, hard cash. Perhaps only a forensic audit will uncover the truth. But no one wants to deal with the problem for now.

So, perhaps the last and only useful take-home lesson from this Susan Lim saga is – be a lawyer. As for the medical profession, we are certainly going boldly to where no man has gone before – we are charging (over,under or otherwise,) ahead into darkness….

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