Storing Up Problems

The government budget for 2016 has just been announced by the new Finance Minister. The first thing you notice is that the new Finance Minister has a lot more hair than the last one. And I mean a lot. In fact, the old and new Finance Ministers lie at the two extremes of the Cabinet in the trichology spectrum. This is the most important and exciting thing about this year’s budget, the new Finance Minister’s super-thick, jet-black hair. Post-politics, he has a great future as a model in the hair industry.

The second most exciting thing in the budget is the MOH budget. The budget for MOH got bigger (as usual). In the space of three financial years, the MOH budget has grown from slightly more than $7B (FY 2014) to almost $11B (FY2016). And that’s on top of the Pioneer Generation Package which is mainly used for health needs too. The MOH budget is growing faster than the hair on this Hobbit’s feet. This is a good thing for us doctors. But one must wonder – is this sustainable? What happened to cheap and good? This hobbit thinks we are getting less cheap and hopefully still good. But more money is always better than less money. So this Hobbit shouldn’t be complaining. Problems will surface in the future. But for now, let’s enjoy the gold rush.

Growing even faster than MOH’s budget is the appetite of managed care and third party administrator (TPA) companies. Apparently the “administrative charge” levied by some of these companies now reach 15% of the total bill. And apparently, the effective rate can be as high as 20% once the managed care companies “moderate” your claims. (I always wonder what they are moderating when the savings are not passed to the patient or their clients but kept by them).

Problems with managed care and TPA companies are not new. After all, managed care companies have been in existence since at least the late eighties and early nineties. TPAs are just a new and more virulent incarnation of managed care, like electronic cigarettes vs good old 555 State Express (OK, now you know I am ancient. For those younglings out there, 555 State Express was THE cigarette brand in Singapore before the Marlboro Man had armpit hair). The point is, they all kill, even though some tobacco is more expensive than others. (As a responsible doctor, this Hobbit has to put out a public health warning whenever tobacco and cigarette brands are mentioned).

But I digress. Let’s return to managed care and its problems. Doctors have many issues with managed care and TPA. I hope the survey conducted by SMA and CFPS recently will shed more light on this. But before the results are published, this Hobbit will give you an overview. Broadly speaking, problems can be divided into two main categories: They either pay. Or they don’t. (Gee, I am a genius, aren’t I?). If they don’t pay after you have done work, you have several choices. You can consult your lawyers or maybe you can write to SMA or CFPS to alert them. If enough of you write to SMA or CFPS, maybe these professional associations can help.

And if they do pay, problems are also subdivided into two categories. They either pay enough or they don’t pay enough. If they pay enough, you can stop reading this stupid column and go back to watching/puking over Descendants of the Sun as you wonder why on earth are women fussing over Song Joong-ki while you drool over Song Hye-kyo. Or vice versa. I mean, if there was a female surgeon as drop-dead gorgeous as the female lead, there will be lots of blood splashed on the OT ceiling, what with all the bleeding from the ethmoid and palatine arteries. And we are not talking about the patient here.

But if they do not pay enough, you can, like all Singaporeans do – complain. You can whine and complain all you like about the 15 or 20% that they are skinning off you. At these rates they are probably taking more than the skin, especially if you are a GP and working on thin margins. You can even approach SMA or CFPS or whatever to complain. But really, you can do better. You can quit the managed care or TPA company as soon as possible.

You see, no one is putting a gun to a doctor’s head to join any managed care or TPA company. You have a choice. But while you remain in a scheme that is manifestly unfair and grovel at the referrals that are thrown your way, or that you hope will be thrown in your way, nothing will change. They offer, you accept. This is the basis for contract law in this country. They only change if enough of you call it quits.

I heard there is a TPA scheme that is offering a $3 consultation rate. Actually I haven’t heard. I have seen a copy of the letter addressed to doctors in the scheme. If you can live with a $3 consultation, go on – take it. And don’t complain. Or you can drop out. Or perhaps you can complain to MOH. The professional bodies like SMA cannot do anything about a $3 consultation because the Competition Commission of Singapore (CCS) may consider this as price fixing. Actually maybe all CCS staff should go under this $3 scheme too to understand what they get for $3 when all they care about is getting the lowest price for the consumer and letting market forces reign. We store up serious problems when dogma reigns without reality checks.

Prices aside, one has to also consider the ethical perspective. Is giving a 15 to 20% cut even ethical? Is this not an inducement to the managed care and TPA companies to refer patient to certain doctors and not others? Is this in the best interests of the patient?

Maybe MOH can do something about a $3 consultation rate and 15% administration charges. But even if they can, it’s obvious they haven’t. Maybe they will just continue to ignore the problems that managed care and TPAs are creating and are left to fester. One day all this will probably blow up in MOH’s faces. But hopefully not on somebody’s watch. Meanwhile, don’t hold your breath for this. Managed care and TPAs remain unregulated as healthcare entities while they retain great powers to influence and direct healthcare provision in this country.

Next we move on to our residents. Residency has been in place for a number of years and its products are now finally leaving the system as qualified specialists in big numbers. Anecdotal evidence suggests that many newly-minted specialists may have problems securing long-term jobs in the restructured hospitals.

The problem is something akin to the Ministry of Transport/LTA and SMRT/SBS Transit problem that we have. LTA funds and builds the MRT lines. Then SMRT (and SBS Transit) operates and maintains the MRT system. The two sets of organisations have different resources, priorities and needs. This disjunction in roles, deliverables and funding had led to many of the problems we now experience.

Similarly in our specialist training system, MOH funds the training of residents, so the hospitals can put up many residency positions and recruit them to be filled. But once training is finished, funding for the employment of new specialists falls on the operating budget of the restructured hospitals. Restructured hospitals have different priorities, less resources and have to look at the bottom line. So they tend to want to hire far less than they train.

But these new specialists have to go somewhere. If they cannot get a job in the restructured hospitals, they either go overseas or they go into private practice. And if you consider the shortened training period that residency provides versus the old system, you really have to think, are they ready for private practice? But they already are fully qualified and registered specialists in every legal sense of the word. It only takes four years to produce a general surgeon post-housemanship now, versus seven in the old speciality traineeship system (one year MO, three years BST, three years AST). In truth, these newly qualified specialists trained under the residency system need more experience and some supervision by heads of departments and professors before they can truly work independently as specialists.

Again, when we rush headlong into something without thinking deeply, we are creating massive problems for ourselves in the future. In the case of the residency, the future is almost here. The chickens are coming home to roost. The day of reckoning is almost here. And the people responsible for this mess have left the room.






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