I Just Smiled Back

In April, doctor-bashing has reached new heights with the United Airlines episode, even though the aircraft hasn’t even taken off. This hobbit has made a mental note that the next time they ask for any doctor onboard in any American flight, keep very quiet. And definitely no United Airlines. I will rather fly the unfriendly skies with Smaug than UA. Meanwhile, a new word has entered the lexicon – “re-accommodate”. It means bashing the brains out of you so that you will move your butt somewhere else. These guys are so mean, they make ogres look like smurfs. And remember the Korean Air princess that demanded the plane be made to dock again because the peanuts weren’t warmed? That’s literally peanuts and the Korean Air princess looks like Minnie Mouse compared to those “security agents” from the Chicago Airport Mob.

Enough on the subject of doctor-bashing, we now move on to Ms Salma Khalik, who does not ever indulge in doctor-bashing and is the acme of objective, responsible and quality journalism.

Recently, an opinion piece by her in the Straits Times (Two Quick Fixes to Rein in Healthcare Costs; 13 April 2017) on how to rein in private sector healthcare costs came to the conclusion that we need to re-introduce some Guideline of Fees (GOF) for private sector doctors and insurance companies need to do away with riders so that there will be no first-dollar coverage.

This drew out some varied responses in the medical profession (What else is new?). Most are in agreement that some sort of GOF would be helpful and after 10 years of GOFless-ness, it is clear and evident that GOF was helpful in reining in healthcare costs previously, although those geniuses in Competition Commission Singapore are still thinking otherwise apparently. Also, many doctors opined that doctors’ fees are not to be entirely blamed for the rapid rise in bill sizes. Hospital and implant bills have also contributed to the hospital bills that patients or insurance companies have to pay. The growth rate of doctors’ bill is comparable to the growth in implant and hospital bills. While we can rein in doctors’ bills with a GOF, we also need to tackle how hospitals charge, especially in terms of consumables, medicines and implants.

Some folks think that riders are not to be blamed for rising bill charges. And that without riders, patients with catastrophic diseases may not even be able to afford private care even if they had bought private medical insurance. The large amounts of money that go to deductibles and co-payments would be prohibitive. A cancer patient who needs radical surgery or repeated chemotherapy or radiotherapy would be bankrupted by the deductibles and co-payments alone.

Also, there is little risk of abuse arising from first-dollar coverage because no one would want to go for unnecessary and painful treatment options arising from catastrophic diseases such as cancer, stroke etc.

There is some if not much truth in all this. Yet, it would also be intellectually dishonest to suggest that abuse of first-dollar coverage does not occur. For example, do we really believe, hand to heart that doctors do not ever offer the more expensive diagnostic or treatment option to patients just because they bought riders and insurance, when there are cheaper and just as or almost as effective options?

The answer must lie somewhere in between. And it depends on whose perspective. For the unfortunate cancer or stroke or AMI patient who has to undergo long and expensive periods of therapy, he would be glad he had bought private insurance with the rider. There is no point arguing over this. The benefits of having done so in hindsight are evident and incontrovertible.

But from a systems perspective and building a sustainable model, something also needs to be done. Perhaps a rider that offers only first-dollar coverage for catastrophic diseases would be better that the current system where first dollar coverage is offered for everything. Riders should not include first dollar coverage for elective procedures like sleep apnoea surgery, total knee replacement etc and even elective PTCAs (I have heard of elective PTCAs involving 8 stents….but that’s another story for another time).

Personally speaking, I think Ms Salma Khalik has made some good points in her article. But the picture is bigger. Beyond GOF and riders, the government has a big role to play. For starters, it’s how the government looks at private healthcare. A case in point is that of private hospital land. The novena hospital site was auctioned off for ~$1.26B to the highest bidder. The amount went into our reserves but it re-rated the entire private hospital sector and costs have gone up tremendously since then. Contrast this to Hong Kong, they did not give their latest private hospital land in Aberdeen, Hong Kong simply to the highest bidder. The private land sale came with many operational conditions that the hospital owner has to be committed to before the tender was awarded. In other words, Hong Kong government was interested in seeing the private hospital sector develop in a sustainable and healthy way to meet locals’ needs. Singapore was initially just interested in pocketing the money arising from the land sale from the highest bidder. Sure, our reserves grew by $1.26B, but guess who’s paying for it now? Can the government now have the moral authority to ask the private hospitals and doctors to rein in their charges when they had pocketed $1.28B for a piece of land that is best described as “modest”? It’s a tough sell. I think the novena site is still the most expensive hospital site on this planet on a per square foot basis.

Finally, as we seek to control private sector healthcare costs, we should not neglect what is happening in the public sector. It is wishful thinking to believe that the private and public sector are distinct and separated by some great wall, but in actual fact, they are inter-linked, especially in terms of the charges for private patients (Class A or B1) in the restructured hospitals and private sector. Both compete with each other to a very significant extent.

Just last week, I came across an outpatient bill for the simplest and most basic of blood tests –  the urea/electrolyte/creatinine panel from a restructured hospital. The restructured hospital charged $59 + GST = $63.13 for this panel! The lab that my clinic usually uses has the same panel with a list price of $28. As you know, private clinical labs usually offer discounts of 30% to 40% which means the private laboratory only takes about $17 to $20 (+ GST) for performing the test while the clinic keeps the difference to cover administrative costs (syringes, needles, alcohol swabs, procedural effort, disposal of biohazard waste etc, etc) and review of test results etc.

The panel test was ordered by the specialist attending to her at the private SOC clinic and certainly it was warranted. Nonetheless, the patient complained bitterly that investigations were so expensive at this restructured hospital.

I just smiled back. I told myself there were some things she was better off not knowing.





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