Trick, Entreat

It had to come. Sooner or later. Like head lice or scabies when you live in the tropics and you don’t bathe for three months. “Making it harder for errant doctors to cheat” (The Straits Times, Opinion Page A28, 25 October) looks like another Salma Khalik hit job. It is also timed to be the journalistic equivalent of a Halloween trick or treat; designed to scare doctors and dentists by entreating the authorities to witch-hunt. She wants someone to clean up the houses of the medical and dental professions by writing this long opinion piece when all that is needed is for someone to pass Ms Salma a broom. This Hobbit happens to think she will look decidedly befitting with a broom. Preferably an anti-gravity one placed between the adductors.

Let’s first go back a little to 15 October 2018; in the article “Penalties are lower if doctors own up”, she wrote, “There is a big difference between tax avoidance and tax evasion. In avoidance, the person fully declares his income, but tries to pay lower taxes by using possible loopholes, such as setting up a company simply for tax breaks, or claiming personal expenses as legitimate business expense. The penalty for an “omission” is two times the taxable amount”

She moves seamlessly from tax evasion, tax avoidance to “omission”, giving the impression that the omission refers to avoidance. But actually, are they the same? Tax avoidance is NOT a crime or an offence. The person deemed to have committed tax avoidance by IRAS will be asked to pay up the difference between what he would have paid and what he actually paid and not “two times” the taxable amount.  The reasonable student of the English language on reading this, would probably infer that tax avoidance (like “omission”) is a crime and that it may be punished with a penalty of two times the taxable amount. No one really knows what is this omission she is talking about. Does omission equate to avoidance, or is she referring to evasion? Only she knows.

As for tax avoidance, the principle is simple – no one wants to pay more taxes if he can avoid doing so legally, just like you wouldn’t want to pay more for a pair of shoes if another shop offers the same pair at a lower price. IRAS is merely asking for information from some doctors and asking a few others to pay up for tax avoidance. If you agree to pay up, it stops there. There is no criminal record if you pay up. Has IRAS charged a doctor for a tax crime yet this year? Not that this hobbit knows of. And certainly, no doctor or dentist has been convicted of tax crimes this year yet.

In any case, with the obfuscating word “omission” in place, she launches her major offensive 10 days later with the aforesaid long opinion piece. Highly predictable; almost boring already.

Her strategy is to use the highly evocative and bewitching word “cheat”. She suggests many doctors and dentists are cheating, and gives a litany of examples: cheating Medisave money, cheating CHAS, cheating taxes, cheating insurance etc.

At last count, there are some 15,000 doctors and dentists in Singapore. Is there a cheating epidemic?  In the same article of 15 October, it was mentioned the last time a doctor was jailed for tax evasion was 2011 and he was subsequently suspended by SMC for four months. One case in 7 to 8 years doesn’t sound like an epidemic to me.

Then what is the whole point of her latest tirade against the medical and dental professions? Is she asking for

• Stricter or better laws or ethical codes?
• Better enforcement?
• More punishment?

She seems to be saying that doctors and dentists should be held to higher standards when they commit tax offences because they are “not ignorant” and doing so out of greed. The first principle of law is that the law shows no preference to any group of persons. All men are equal under the law. The same standards and burden of proof applies to everyone. A doctor should not be more easily convicted of tax offences just because he has a MBBS degree. Likewise, a doctor or dentist should not be punished more for tax crimes versus say a banker, journalist, accountant, lawyer, hawker or taxi driver.

As for ethical codes, the latest SMC Ethical Code and Ethical Guidelines (ECEG) as well as the accompanying Handbook of Medical Ethics (HME) are two of the lengthiest and most detailed publications of this sort in the world. And SMC is already empowered to strike-off a doctor. What else is there? Lengthen the SMC ECEG and HME some more? Empower the SMC to give 10 strokes of the rotan?

The doctor or dentist already suffers from “double jeopardy” of being punished by the professional board for bringing the profession into disrepute after he has been also punished by the other authorities. If a journalist is found cheating on taxes, he pays the fine, and he maybe goes to jail as well. He doesn’t have a Journalist Board or Council to suspend or strike him off the Journalist Register because there isn’t such a thing.

As for cheating CHAS, well, last I looked, I signed a CHAS contract with a public sector Polyclinic Group. It is what it is – a contract. If I am found to have filed claims wrongly, they can claw-back the monies as per contractual terms. There is no specific legislation for CHAS (unlike Medisave, which is covered under the CPF Act), so enforcement of a contract between contracting parties is quite different from enforcement of a law.

Then she complains about doctors who do not give adequate MC to foreign workers. Well, they should be punished. But do notice that she is completely uncritical of the other elephant in the room – the employers and supervisors. Is this just purely a doctor problem?

As for insurance, yes, she claims insurance patients with full first-dollar coverage may be over-serviced or over-charged and that compulsory co-payment will be introduced to address this. Well, evidence and experience around the world have shown that insurance claims are always higher when there is full first-dollar coverage. This is bad insurance design leading to bad doctor and patient behaviour. These outcomes have been replicated time and again all over the world. What does Ms Salma Khalik expect? Are Singapore and its doctors expected to be so different from the rest of the world?

Over-servicing is not just a doctor thing. Over-servicing can also originate from the patient. The patient, with full and first-dollar insurance coverage, often requests for more expensive services from the doctor. The doctor, being a patient-advocate, will happily oblige. For example, why should a doctor not use the best implant for his full-cover insurance patient and choose something inferior (but adequate)? After all, if my patient has paid for it through his insurance premiums, I will use the best. In fact, if I don’t use the best implant (which is often also the most expensive), the patient may be unhappy with me afterwards. He may tell me “Doc, what didn’t you use the best Brand Z pacemaker for me and instead used the cheaper, inferior Brand Y one when my insurance covers everything?”. Is that dishonesty on the part of the doctor? In fact, in the era of the Modified Montgomery test, I better use the best, lest I be accused of not considering a relevant consideration from the patient’s perspective that should lead me to offer the best pacemaker later on. You never know. Better safe than sorry.

Bad insurance product design probably drives patient and doctor behavior more than human greed, so to speak. Fear of the new medical legal climate also plays a part too.

As for her example about the probability of getting a procedure for unspecified gastritis, it really depends. There are more foreign patients in the private sector. They come here wanting to get a definitive diagnosis and treatment as quickly as possible and then go home, hence the bigger demand for “a procedure” (probably a gastroscope). Also, many patients seek treatment in the public sector first for gastritis, and when the problem recurs, they often wrongly lose faith in our public hospitals, and seek care in the private sector, where again the pressure on the doctor to come to a diagnosis quickly results in more scopes. Yes, money does matter and some doctors do more procedures to earn the dough. But one must realise that in the private sector, there are also other factors that favour doing a scope which are not pecuniary. When you are the first doctor dealing with the problem, the patient is more patient (pun intended). When you are the second, third or fourth doctor dealing with the same problem, the patient has often run out of patience and is already very emotionally distressed. In addition, private hospital bed charges are a lot more than public ones and observing a patient for a few more days in the private hospital may cost as much as doing a scope. And even after observing the patient for a few more days, you may still not get a definitive diagnosis.

Shouldn’t a senior health correspondence with decades of experience in healthcare reporting give much more balanced analyses than this shallow sweep of “cheating” doctors and dentists?

Actually, she seems like a sulking kid who refuses to admit a mistake. “Salmatologists” (This hobbit is one) will recall that she wrote another long opinion piece on 26 March 2018 (Sunday Times) where she made the claim, “Drilling down, the MOH concluded that much of the higher claims was the result of overcharging and overtreatment by doctors in the private sector”. (“Diagnosing the cause of rising costs”).

This was clearly refuted by MOH and guess what, The Straits Times itself! On 30 March, the newspaper clarified that “This is incorrect, the Ministry of Health did not draw such a conclusion”. It was a mistake by her, pure and simple.

And now, once again, she is again asserting essentially the same erroneous claim, only albeit in a more convoluted way, and wisely not attributing this to MOH but to the insurance industry instead, presumably to “one insurer” and the COO of AIA, Ms Melita Teo.

So what’s the message here – that like Ms Salma Khalik, the “one insurer” and AIA’s Ms Melita Teo disagrees with MOH – overcharging and over-servicing by private sector doctors are the main reasons for rising insurance claims?

There is a pattern to all this of course. Her usual and favourite trick is to drive a wedge between MOH and the medical profession; then she entreats the government to come down hard on the medical profession. This can be seen on at least three occasions:

• FIn 2005, she made the assertion that the then DMS will remove dispensing rights from medical clinics, which the then DMS refuted.
• Then in March this year, she made the claim that MOH is of the position that higher insurance claims was the result of overcharging and over-treatment by doctors in the private sector, a position that the Straits Times has since said MOH didn’t arrive at.
• Now, she is asking MOH and other authorities to go tough on cheating and unethical doctors and dentists. And she has also apparently roped in the insurance folks to beef up her claims (pun unintended).

You have to give it to her. As an object of antiquity, she has enormous energy. Apparently, she’s 63 years old (give or take a year or two), and this hobbit can only wonder how long more can she keep going like this. But seriously folks, other than Salmatologists, no one really reads these long opinion pieces anymore in the age of Instagram and Twitter.

In the meantime, will someone give her a broom? This hobbit is thinking of giving her a hat as a year-end gift. The two gifts will go nicely together. Hopefully they will come in handy when she finally retires.

Happy Halloween