Random November Pickings

Heng ah.

The one key issue that has troubled if not bedeviled the whole nation in recent years has finally been resolved. Yes, I am talking about the fee benchmarks released by MOH Fee Benchmarks Advisory Committee.

“Kee Chiu” if you do NOT agree.

This hobbit will not talk again about how the SMA GOF either was killed by CCS or died after neglect by MOH. That’s all been discussed in previous columns. For the avoidance of doubt, CCS stands for Competition Commission of Singapore, not Chan Chun Sing.

A quick glance at the benchmarks gave the impression they were modestly generous. Some of the figures were better than what some TPAs and insurance companies were willing to pay previously. Of course, the figures were also substantially less that what some “star” surgeons and proceduralists were charging.

I met up with a few old classmates recently: an ENT surgeon and an interventional cardiologist. They lamented that their actual charges were even lower than the lower end of the benchmarks. This experience reinforced my belief that all my life I have been hanging around too many Cheap Charlies. I gotta stop mixing with such dubious company. But not before I get this ENT classmate to dig my ears first. He sucks our more ear wax from me than the cyber-attackers had exfiltrated data from the IHIS EMR.

Having the doctors’ fee benchmarks is a good thing. But it is not enough. There are two aspects to runaway healthcare costs: over-charging and over-servicing. Fee Benchmarks only deal with over-charging by doctors. How about healthcare facilities like hospitals and day surgeries? There should be fee benchmarks or guidelines too for healthcare facilities. And then there is over-servicing, which is often subtle and therefore harder to prove. Poor insurance design is often the problem behind over-servicing. All these have to be dealt with before healthcare inflation in the private sector can be brought down to manageable levels again.

Speaking of the cyberattack on Singhealth, the Committee of Inquiry (COI) hearings have more or less ended. We now await the Report by the COI. But the hearings were quite a shocker to say the least. It was literally such a jaw-dropping experience that my TM joint is now permanently subluxated. Let’s face it, IHIS makes SMRT’s “deep cultural issues” look as thin as popiah skin or tissue prata. Each day of hearing was met with cries of incredulous disbelief “Did the guy really say that”? There is so much head shaking and jaw-dropping, the healthcare community looks like a bunch of people high on designer drugs.

But we should have known better. Come on, the signs were all there all along in IHIS or its predecessors:

  • GP IT systems that never really worked well and went down well with GPs despite spending millions and millions on  their development
  • Many years ago, EMRX was launched based on implied consent and nothing much else (the patient was presumed to have read a poster and agreed to have his data shared on EMRX)
  • A NEHR design that did not give the patient privacy rights to NOT store data on the NEHR initially (this has now been apparently fixed, we don’t know for sure)
  • An IHIS Board that changed from having restructured hospital CEOs on it to other folks, that while the latter appear qualified on paper, they would not directly experience the pain when IHIS IT systems broke down
  • An IHIS CEO who also headed IT strategy and policy work in MOH

All these boils down to the fact that IHIS is an organisation that is designed culturally and structurally to achieve its aims with brutal singlemindedness. And the aims are often determined internally.

If you ask around, restructured hospital administrators will often tell you quietly that IHIS is not a joy to work with. You get the feeling that this organisation is not particularly enthusiastic about good governance or stakeholder engagement and empowerment. IHIS answers to MOH Holdings, not to the public healthcare clusters the IHIS was set up to serve.

So when a massive cyberattack occurs, the initial actions and responses of its key people on the ground reflect the culture and structure of the organisation. It’s as simple as that.

Finally, we come to the subject of web-based referral services. Apparently, there are companies that set up websites claiming to be able to help anyone get appointments to see doctors. Often this is ostensibly for free. And interestingly, their websites list just about every doctor registered with the SMC. Most of these doctors have never agreed to have their names listed on these websites. Some of these doctors have not practiced medicine for a long time, like doctors who are now full-time politicians (including ministers, no kidding).

Of course, many doctors are upset about this. The question we need to ask is what is in it for these companies and how do we regulate them. Apparently, by boasting a large database of doctors (i.e. practically the whole list of SMC-registered medical practitioners), they can tell potential investors they have buy-in from lots of doctors. This helps these companies to get richer valuations and raise money from unwise investors. The next thing is the patient’s request to see a particular doctor will likely prove to be unsuccessful (since 99% of the doctors on the list did NOT sign up with the company) and the patient will be given the recommendation to see the 1% that did sign up (“would you like to see Dr ABC instead of Dr XYZ?). In such instances, these companies will probably collect an admin/referral fee from Dr ABC.

The next question then is – how are these companies regulated? Answer: They are not. They are like TPAs (Third Party Administrators) or Managed Care companies. They are not regulated as a healthcare institution under the PHMC Act since they are not a licensed or licensable entity like a hospital or clinic. The Medical Registration Act, which regulates doctors through the SMC, also has no powers over such companies. Again, this is a lacunae in our health regulation framework that needs to be addressed.

For now, to the 99% doctors who did not sign-up with them, these companies are more of a nuisance than a problem like TPAs and Managed Care. But doctors should be aware of the pitfalls. For example, one such company provides video consultation services for patients 24-7 with a SMC-registered doctor. The SMC doctor should be very familiar with SMC Ethical Code and Ethical Guidelines’ position on telemedicine before he agrees to take part in such activities.

But still, there is apparently no law against a company publishing a “directory” of doctors’ names and claiming they can get an appointment for a member of the public to see any of these doctors on the list (which is essentially a directory of SMC-registered doctors). Even when I didn’t “kee chiu” for this.

I don’t know about you, but this somehow comes across like someone stuffed me like a Thanksgiving turkey.

 

 

 

 

 

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