The “Unbalanced” Hand of the Private Health Insurance Market

A recent letter from SMA to The Straits Times Forum brought to surface some of the unsavoury if not unjust and even unsafe practices of certain private insurance companies offering Integrated Shield Plans, usually called “IPs”.

Newly minted Chairman of the GPC (Government Parliamentary Committee) for Health, Dr Tan Wu Meng also quoted this letter in his recent Parliamentary Speech on 1 Sep 20 highlighting the problems facing people who have bought IP Plans.

He said,

“In a Straits Times Forum letter published on 29 Aug this year, the Singapore Medical Association shared that That some insurers are no longer allowing claims for diagnostic endoscopies even when medically necessary. This is a serious development. Implications for patient care. implications for patient safety. It is also a very visible sign that Individual patients, individual customers do not have bargaining power to stop insurance companies from such practices. When an insurance company moves the goal posts for an Integrated Shield Plan, it is not so easy for a patient to switch provider, because existing conditions become pre-existing conditions under the new policy”.

He further made the call for the authorities to step in, “The invisible hand of the market appears to have become unbalanced. And so I call upon MOH and MAS (i.e. Monetary Authority of Singapore) to look at this and to see if the visible hand of the regulators need to come in, to level the playing field and our people”.

Dr Tan is a medical oncologist, and he knows better than anyone else what are the consequences when a diagnosis of cancer is missed or delayed because people cannot get a diagnostic endoscope done because there is no cover under an IP. Some of the commonest cancers in Singapore need endoscopies for accurate diagnosis – colorectal, nasopharyngeal, stomach, bladder and so on.

As we all know, many Singaporeans buy such IPs. In the October 2016 Report of the Health Insurance Task Force (HITF), it was reported that about two-thirds of Singapore residents have an IP Plan, of which half (i.e. one-third of Singapore residents) have bought IP riders that pay for the co-payment and deductible requirements of IP plans. These IP riders are paid with cash while IP can be paid for by Medisave. This is a big-money business by any measure.

History

The precursor of IP was called PMIS or Private Medical Insurance Schemes. The first to offer PMIS was NTUC Income. By 2002, AIA and Great Eastern also offered PMIS. PMIS was a standalone product that was unlinked with Medisave or Medishield. They paid for expenses incurred when a patient consumes medical services in private hospitals or in unsubsidised wards (i.e. B1 and A Class) of Restructured Hospitals.

In 2005, Medishield was reformed and PMIS was renamed IP, IPs were linked to Medishield and Medisave in that they could be funded by Medisave monies. So far so good.

The problems really started when one IP provider started providing as-charged plans in 2005 and by 2006, all IP providers followed suit. In 2006, IP providers also provided the aforementioned IP riders, which paid for the deductible and co-payment parts of the bill. This is called “first-dollar” coverage in the insurance industry because the policy holder doesn’t even have to come up with one dollar before the policy kicks in to cover you. Someone dropped the ball on this in MAS and MOH obviously because the experience of this the world over is that first-dollar coverage will lead to more frequent claims. This is not rocket science.

Then in 2007, the SMA Guidelines for Fees (GOF) was outlawed by the then Competition Commission of Singapore (CCS). Which meant there was now no clear guidance really for private sector doctors on how to charge. And with as-charged plans being offered by all IP providers, this expectedly led to higher claims, as well as more frequent claims.

Looking back, this Hobbit thinks the main root cause was both under-regulation and over-regulation. The insurance industry was somehow under-regulated, leading to proliferation of undesirable IP products such as as-charged plans and first-dollar coverage riders. On the other hand, CCS over-regulated the SMA GOF to its eventual withdrawal by SMA. It is this Hobbit’s opinion that these two events led to both an increase in number of IP claims and IP bill sizes.

It wasn’t before long the IP providers realised the error of their ways and then as the Hokkien saying goes, these providers “Cry Father, Cry Mother” about rising healthcare costs associated with IPs, especially those that come with as-charged and first-dollar coverage plans. But who came out with these IP products in the first place? Not doctors. Not patients.

Certain IP providers (i.e. members of the Life Insurance Association or LIA)!

Their trade association, LIA then wanted to address this problem. The Health Insurance Task Force (HITF) was thus formed in early 2016, with representatives from LIA, CASE, SMA, MOH and MAS.

The Report of the HITF was published in Oct 2016. Some of the major recommendations included:

  1. Have a new set of Fee Benchmarks or Guidelines
  2. Introducing Panel of Preferred Providers
  3. Pre-approval of Medical Treatment

The government kept its side of the bargain and MOH came up with its Fee Benchmarks for the commonest procedures in Nov 2018, after extensive consultations with stakeholders including LIA, doctors, hospital administrators, CASE and even the unions. So after 11 long years, the role that SMA GOF served in controlling healthcare costs was resurrected as the MOH Fee Benchmarks in a wonderful act of policy necromancy.

The Current Situation

You would think that all IP providers, being members of the LIA, will support the fee benchmarks. After all, this is what we would expect out of good faith and especially the benchmarks were from the government, no less. But it turns out that several IP providers have since reimbursed doctors at rates that are at the lower end or even below the low end of the fee benchmarks. Those that now go below the fee benchmarks make a mockery of the process and maybe even a betrayal of the hard work that has gone into making the fee benchmarks a reality.

Next, we look at the issue of IP providers coming with panels of preferred providers. A few IP providers have done so. One or two have done so in the wrong spirit. In the original HITF report, it was written that these panels are to be appointed in the hope of “Enhancing Insurance Procedures and Products Features. To achieve so, IP providers are  “To enhance and ensure transparency of the arrangement (e.g. disclosures on the healthcare provider selection process)” (Page 16 of HITF Report)

The exact opposite has happened. No IP provider has come clean to state what are the exact criteria they are using to select and empanel doctors. Some panels are restrictively small. Some specialties, especially the smaller ones, have no representation on the panels at all.

Many IP providers say they have many doctors on their panels, but on closer scrutiny, many of these are actually specialists from restructured hospitals (RHs) and very few are actually from the private sector. It is obvious that many IP providers are trying to shift work from private hospitals to the RHs by having panels that are heavily weighted towards the RHs and sparsely populated by private sector specialists.

In the current climate, all healthcare providers are functioning at reduced efficiency when compared to pre-Covid. The appointment and waiting times at RHs are already more trying during this Covid-19 pandemic. Do the RHs need any more business? On top of that, some IPs guarantee that their policy holders can get a specialist appointment within 48 hours, which as we all know, is practically an impossibility in most RHs.

So let us now get back to the centre of healthcare, the patient. The IP patient to be exact. He or she has paid good money to get an IP. Half of these folks have even forked out cold, hard cash to get these IP riders.

What does he get in return? Well, it all depends. If you are an Incomeshield IP plan holder, (like this hobbit), you can sleep reasonably well. Because as long as the specialist adheres to charging to within the fee benchmarks, there is little fuss. But woe be unto you if you have signed up with the “wrong” IP provider. You may well discover that one or more of the following:

  1. The doctor you have seen in the past is not an empanelled doctor
  2. You have to jump through hoops to see him,
  3. Your non-panel doctor has to justify at length why some admission or procedure is needed and what are his estimated charges, and seek approval from the IP provider
  4. The approval may take days which leads to anxiety and delay, or the approval may never come and you are forced to see someone else if you want coverage or ease of coverage
  5. Now you have to pay cash up-front to see a non-panel doctor and wait for the IP provider to reimburse you later, and there is no assurance they will do so
  6. The panel does not even contain a private specialist in the hospital or speciality that you need or want
  7. Certain things you assumed were covered no longer are – like diagnostic endoscopies such as colonoscopy. Even though you have a family history of colorectal cancer and needs periodic screening
  8. You cannot change IP provider because no new IP provider will cover you for conditions related or can be associated to e.g.  a small benign polyp that had been taken out 5 years ago during a colonoscopy

even though you have been paying years of riders for first-dollar coverage and covering as-charged bills

It is the “unbalanced” hand of the market at work, unbalanced in favour of the IP provider.

What is really the point of having IPs?

But let us take a step back and ask what is the policy intent of having IPs offered by private insurance players in the first place?

This hobbit thinks IPs were allowed by the government so that more Singapore residents can receive private healthcare. Private healthcare means primarily private hospitals, but for completeness’ sake, will also include the unsubsidised care in RHs. But RHs’ private or unsubsidised patients were not and is not the main intent or focus of IPs. Why is this so?

Think about it, the government owns MOHH which in turns own the clusters and RHs. They have great influence over how cluster boards are run and how top hospital management are appointed.  In other words, there is great influence (if not a strong degree of control) over both costs and pricing.

There is really no need for the private insurance companies to participate in IPs if the intent was for IPs just to mainly cover consumption of B1 and A class services in RHs. The government can definitely do a better job and save patients money by cutting out the middleman (i.e. the private insurance companies).

So the apparent strategy by some IP providers to try and shift work to RHs is doomed to fail in the long run.

This hobbit thinks it is perhaps time to exclude private companies from offering IPs that cover RH services. After all the government has done a good job running Medishield Life which covers C and B2 classes (i.e. subsidised classes). It doesn’t take much more to extend Medishield Life to B1 and A services.

Then, we can leave private insurance companies to only offer private insurance plans that can be partially funded by Medisave monies for those Singapore residents who wish to be served in private hospitals only. And that we can stop these IP Plans from trying to shift work to RHs and derive big profits from doing so when this was probably never the policy intent of IPs.

Regulatory Lacunae

What about the un-covered diagnostic endoscopes that we talked about earlier on? Well, we hope the guy with the regulatory muscle, MAS, will do the right thing and sit on these IP providers who are obviously doing the wrong thing. Now that it is out in the open and even discussed in Parliament, this hobbit thinks something will happen. Some authority will tell the insurance company or companies that this is not right and these companies will comply and cover diagnostic scopes once again.

This is the nub of the problem because with such a regime, people are motivated to try their luck every now and then and come up with money-making ideas at the patient’s or doctor’s expense.

Part of the problem of regulating IPs is that it perhaps falls through the cracks. IP providers and insurance companies are licensed and regulated by MAS. But really, MAS has no expertise in healthcare. And perhaps they have bigger fish to fry than IPs. On the other hand, MOH has the healthcare expertise of course, but they have little or no regulatory muscle to compel insurance companies to do the right thing because MOH really does not administer any law that can punish insurance companies.

There is thus no real punishment for the party that comes up with these unethical and dangerous ideas that compromise patient rights, patient safety and clinical standards. Today it is diagnostic scopes, tomorrow it may be biopsies.

Today, if a doctor does something that compromises patient safety or autonomy like taking a patient consent that does not meet the basic standards of the SMC Ethical Code and Ethical Guidelines (ECEG), he may be sanctioned by SMC. But will MAS, the regulatory body of insurance companies sanction or punish an insurance company for forcing doctors to adopt clinical practices that compromise patient interests (like treating patient with hydrogen pump inhibitors before scoping)? They probably do not know what are correct clinical practices in the first place.

So clever insurance people will continue to exploit this lacunae in health insurance regulation and try to push their luck. I don’t blame them. The system is performing exactly the way it is designed to. There is no downside other than the IP provider being told to withdraw the undesirable practice.

The way forward is perhaps for every IP provider to have a registered medical practitioner as medical director before an insurance company can be accredited as an IP provider. This medical director is like the head of compliance in a bank; he has double reporting lines, one to the bank CEO and one to MAS, the regulator of banks. Should the CEO of the bank try something funny, it is his duty to advise the bank CEO. If the bank CEO doesn’t comply, then he can report the CEO’s plans or deeds to MAS. If he fails to report the CEO to MAS, the head of compliance can be sanctioned too. I am told by a banker this is how bank regulation works in Singapore and every head of compliance of a bank has to be approved by MAS before he can be offered the job by the bank.

This hobbit thinks it is high time that the health insurance industry is regulated in a similar way. The medical director can report to the insurance company CEO and  to someone in MAS, perhaps a Health Insurance Commissioner seconded to MAS from MOH. If the medical director fails in his duty to ensure that the insurance company does not put up practices and policies that compromise patient safety and interests, then the medical director himself can be reported to SMC for investigation and possible punishment.

Simply put, we have to put in place a regulatory regime that has a deterrent effect, one that stops people from pushing their luck to try something that is bad for patients and the healthcare system.

The Reopening

Give yourselves a clap. We have successfully emerged from a tight CB period. In case you have forgotten, it was the Prime Minister no less who announced the “tighter CB period” on 21 April 2020 which would last until 1 June 2020 (inclusive).

The gov.sg website actually stated,

“PM Lee on 21 April 2020 announced tighter measures to the Circuit Breaker period, to further reduce the transmission of COVID-19. He also announced that the Circuit Breaker period will be extended by another 4 weeks until 1 June 2020 (inclusive)”.

This hobbit was thinking to himself on 21 Apr 20, “Wah. I thought the CB already very tight. Now even tighter and must be inclusive too”.

You really have to give it to those wordsmiths in the civil service and political leadership.

Anyway, we are now in Phase 1 of “The Reopening”. That’s when you realise nothing much more has reopened. Except the schools, car and air-con servicing, hairdressers and basic pet grooming. Interestingly, animal rehab and physio are allowed too.

That brings us to our pet peeve today (pun intended). What is allowed and what is not allowed in The Reopening: Phase 1. In medical school, when we construct a research study design and draw conclusions, we are told to make reality checks. These are called internal validity and external validity checks. Internal validity checks are checks that ensure the conclusions from the study drawn make sense within the aims and methodology of the study while external validity involves comparing study conclusions with what was already known in the external environment to also see if the conclusions make sense.

Policy-making is no different. There should be internal and external validity checks. Now let’s come to the subject of aesthetic medicine. These are largely banned. Aesthetic doctors are only allowed to treat organic diseases like acne and eczema. I suppose there is some internal validity when you compare aesthetic practices to what is allowed in the practice of Western Medicine. But when you think of what is allowed in other areas, then you will probably wonder where is the external validity?

Is aesthetic medicine less essential or more dangerous than basic pet grooming? Or complementary medicine such as TCM, Ayurvedic practice or chiropractic and osteopathy? Can we allow “basic” aesthetic medicine without allowing invasive or aerosol-generating aesthetic practices? So many questions arise when you look at the aesthetic medicine issue from an external validity angle.

To top it off, even HDB may be into the act of regulating aesthetic medicine. Apparently, a GP was told by a HDB officer that he had to close his HDB shop-lot clinic because it was named “XYZ Aesthetic Clinic” when all he was doing was just opening it to see common GP ailments and treat severe acne.

(For the avoidance of doubt, this hobbit has no pecuniary or physical interest in aesthetic medicine. He is an ugly, old coot who doesn’t practise the stuff and he hasn’t received any form of aesthetic treatment).

A whole-of-government to fighting the Covid-19 pandemic is largely a good thing. Because no single ministry has enough resources to do this alone. But from observation, this hobbit suspects that one of the problems of a whole-of-government approach could be what the age-old adage says, “When everyone is in charge, then no one is in charge”. The other problem with this approach is that when everyone in authority can make rules, then they indeed do, but no one is looking over their shoulder and having a helicopter view of what each and every department is doing. The result is that people on the ground are saddled, if not crushed by a mountain of regulations and requirements issued by a myriad of agencies.

An example is the construction industry. The BCA announced that construction workers in dorms can begin work again once they are tested. But I guess they didn’t check with MOH when they said this. Because none of the folks out there who provide testing, i.e. the polyclinics, PHPC clinics, hospitals, are allowed to offer Covid-19 testing to anyone unless there are clinical and/or epidemiological indications. I wish I could, but I cannot offer a swab to a billionaire even if he paid me $100,000 for a swab, unless he possessed some indication for swabbing. The same applies for construction workers. So many of us were swarmed with requests by construction industry bosses, supervisors last week in the first few days following end of CB for their workers in dormitories to be swabbed. All this angst, frustration and disappointment could have been simply avoided by coordination between MOH, BCA and MOM. They could have issued a joint statement in the last week of May that goes like “All construction workers would be allowed to start work again after CB if they are tested. However, please note that construction workers will be notified through their employers or dormitories by MOM/BCA/MOH as to where and when they should go for testing. In the meantime, please be patient”.

The same considerations apply to the Malaysian workers who are stranded here. The Malaysian government has said these returning Malaysians may avoid quarantine if they are tested negative for Covid-19 in Singapore. But again, there is no testing available here. Meanwhile some of them have had their pay cut or even retrenched. This has been reported in the mainstream media and this hobbit won’t elaborate here. But the point is, there have been many such requests and the PHPC GPs have to be the bearer of bad news to these stressed-out folks.

Instead, the various agencies had to run around and do service recovery. The 2nd Minister for National Development had to announce in Parliament on 5 June that BCA would be the one-stop agency for these workers and their employers to go to with their concerns and queries. He said “BCA will be the point-agency in Government or the one-stop shopfront for all matters regarding construction restart”. This could and should have been said before 1 June, before the end of CB, so as to avoid the chaos that ensued from 2 to 5 June. And of course front-line GPs and PHPC doctors had to manage the demand for testing when there was effectively zero supply at the frontline. As if though we don’t have enough problems of our own, huh?

Yet another example is the announcement of swab stations in the community, e.g. One Farrer Hotel about a week ago. Again, there was a small rush by some folks to be swabbed there when these places are meant only for people who need to be re-swabbed. Again, people at the frontline had to face irate members of the public.

The message is not getting through. In other words, the people must be told they will not be tested unless they meet specific MOH criteria, e.g. they are sick. Please do not just say we are ramping up testing capacity to many thousands a day. That is only one side of the story. There are ministerial speeches going on now every few days. Can one of the ministers say this out loud and clear that there is NO testing for the public unless they meet MOH criteria? Because there is great demand for testing from the public which healthcare providers cannot meet because of regulatory prohibition. We have to give the good news and the bad news to the public and manage expectations on this subject of testing. It will save the public and us healthcare workers a lot of grief. Thank you very much.

Even in MOH itself, it appears no one is taking a look at regulation from the end-user’s perspective. Today, if a 75-year-old patient comes into my PHPC clinic for flu, do you know how many forms I have to fill? I have to

  • Fill up the Flu Subsidy Scheme (FSS)  once a day for the clinic for all FSS patients, which in itself is a lot of work.
  • Fill up a swab form if I performed a swab or fill up the Swab Referral Form which is two pages-long per patient if I refer the patient elsewhere.
  • Fill up the Patient Risk Profile (PRP) form through the Patient Risk Profile Portal. Many of the fields in this PRP are already filled in the daily FSS submissions. It will save everyone a lot of work if MOH can merge the databases of FSS and PRP.

On top of filling up forms and making submissions up to my goggle-encased eyeballs, I have to remember a phalanx of policies like

  • What drugs are reimbursable under the FSS
  • Suspect Case definitions
  • Who to send for enhanced Swab and Send Home (SASH)
  • Advise irritated patients who are given 5-day MCs that the MC is essentially a 5-day Stay at Home Notice (SHN).
  • Social or physical distancing in my clinic

Another side but important point about enhanced SASH is that certain patients “should” go for swab if they qualify under certain conditions. But the key word is “should”. “Should” is not a “must” and many patients have refused to go for swabbing. What does a GP do? The PRP form does NOT have an option for this. No one seems to know the answer.

I suspect all these different requirements and regulations are issued independently by different departments within MOH and no one is putting themselves in the GP’s shoes and realising how collectively these demands will drive private sector doctors and their clinic support staff nuts.

I know if I take your money for FSS I must suck thumb and take all this. But can you just cut me a little slack?

There is a lot of fine-tuning of language in policies and circulars that frankly, the busy and tired doctor find difficulty in grasping. Put it simply, enhanced SASH should be mandatory and not a “should”. This pussyfooting is doing no one any good. Most doctors at first instance understood it to be mandatory anyway. It was only on second or third reading that they realised enhanced SASH was not a “must” but a “good to have”. There are no penalties for refusing enhanced SASH. Such nuancing creates difficulties on the ground. By now, doctors are so tired, we are long past the stage where we can perceive and appreciate linguistic finesse.

Another example is in the language used in some circulars. If we doctors were so good with language we would have become lawyers. In a MOH circular dated 19 May, it is stated in para. 3, “MOH proposed 2 phases for the resumption of more of the healthcare services”. In para 10 of the same circular, it stated “This circular is for your compliance”.

I don’t get it. If MOH “proposes” then maybe it is something that can be discussed? But if it is “for your compliance”, then there should be no discussion; we just get on with it. It’s like Mr Tan Ah Kow proposes to Ms Ong Ah Choo, but Ong Ah Choo must marry Tan Ah Kow.

This hobbit is stunned like vegetable.

Finally, as this pandemic wears on, the authorities must explain why certain policies are necessary and how they are effected in a fair and transparent way. For example, till today, people do not understand how the number of essential workers are arrived at in clinics. People also do not understand why aesthetic medicine is less essential than pet grooming, rehab and physio. People who do not understand why unlicensed and largely unregulated treatments like osteopathy and chiropractic have higher priority than certain treatments and interventions offered by doctors (and dentists too, I guess).

Sometimes things are so complicated that maybe even public institutions cannot keep up. According to a GP friend, he referred a 13-year old patient with ARI to be swabbed at the polyclinic. The parent reluctantly did bring the teenager there, only to be told they won’t perform a swab on the student. Another GP referred another teenager to polyclinic for a swab. She was accompanied by the grandparent. The polyclinic staff said the teenager must show her birth certificate as documentary proof. A student pass is not good enough. The clinic staff actually called up the polyclinic to double-check and confirmed that a birth certificate was necessary. Imagine what these GPs had to endure from the patients and their parent/grandparents consequently. With polyclinics like these, who needs pandemic-causing viruses?

In summary, this hobbit sees three areas that need to be dealt with:

Regulatory Fragmentation – e.g. the construction industry is pulled apart by different regulatory requirements by BCA, MOM and MOH; clinics regulated by MOH and MTI; polyclinics making up their own rules.

Regulatory Redundancy and Overlap – e.g. many forms and submissions for one single patient for one diagnosis, e.g. PRP form, FSS submission, SASH form

Regulatory Opacity – who decides and what is the criteria for decisions? Any external validity checks across ministries and agencies?

The sum of all these problem areas is

  • Confusion and bewilderment (directives and policies should be short, simple and clear. Avoid “coulds” and “shoulds” if possible; what do you do with a patient who declines enhanced SASH?)
  • Extra and unnecessary work is created (multiple form filling)
  • GPs and frontline healthcare workers are made to bear bad news (“I can’t test you”…..I have to give you 5-day MC…..)
  • The public and certain industry stakeholders aren’t happy
  • The doctors and their support staff aren’t happy

We all know we need to make sacrifices and endure pain in this pandemic. But let’s not make it more painful than what is absolutely necessary.

CCB – The Good, The Bad And The Mysterious

We have been in Circuit Breaker (CB) mode for about four weeks. The original CB period was supposed to end on 4 May. But this mode is going to continue for another 4 weeks, until 1 June. We are therefore now in CCB mode – Continued Circuit Breaker Mode. Hopefully it will not be extended or tightened again. Somehow only my gynae classmates find tightening of CB measures amusing.

There are encouraging signs on the data front. While Covid-19 rages on in the dormitories, such that 500 cases a day is now considered not bad news, numbers in the community have been coming down. These can be seen in the daily Situation Reports put out by MOH. This hobbit finds these Reports interesting and informative. There is a mountain of data in the Reports but let us just concentrate on two aspects – Unlinked Community Cases and Unlinked Work Permit (WP) Holders Not Residing in Dorms. These two sets of numbers are found in Table 1.1 of the daily Situation Reports.

We concentrate on unlinked cases because these are the cases that present the greatest threat to us. With all the dorms under lockdown, new cases found there do not present a significant threat to us in the community. That is not to say we should adopt an indifferent and callous attitude to these poor folks stuck in the dorms, but these do pose a different level of threat to the rest of us. The same goes for linked cases in the community, because containment measures such as contact tracing and quarantine would have kicked in quickly once they are linked, so as to lessen the threat of transmission.

That leaves us with the unlinked community cases and the unlinked work permit holders NOT residing in dorms. To this hobbit, it is the same whether a person has a work permit, an employment pass or even a pink IC – if they do not live in the dorms, they should be considered a community Covid-19 case. Because the virus doesn’t care if you hold a certain type of identity document or not.

In the MOH Press Release dated 1 May, it was said,

“The number of unlinked cases in the community has also decreased, from an average of 16 cases per day in the week before, to an average of 6 per day in the past week. We will continue to closely monitor these numbers, as well as the cases detected through our surveillance programme”.

and

“The number of new cases amongst Work Permit holders residing outside dormitories has decreased, from an average of 27 cases per day in the week before, to an average of 14 per day in the past week”.

This hobbit (like most hobbits) is a lazy fella. Instead of using a 7-day moving average like what MOH has implied above, we can derive a 14-day moving average simply by subtracting the top row from the bottom row of Table 1.1 in the two relevant columns to get the total number of cases in the 14 days up till the day of each situation report. Divide that number by 14 and you get the daily average over 14 days for each day. So here is what the figures look like: (this format of reporting by MOH first started on 17 April):

 

Date Total Cases over 14 days for Unlinked Community Cases Average Per Day for 14-day period Total Cases over 14 days for Unlinked WP holders NOT in dorms Average Per Day for 14-day period Total Unlinked Cases Average Per Day for 14-day period
17 Apr 291 20.8 97 6.9 388 27.8
18 Apr 285 20.4 95 6.8 380 27.1
19 Apr 281 20.1 96 6.9 377 26.9
20 Apr 276 19.7 103 7.4 379 27.1
21 Apr 284 20.3 116 8.3 400 28.6
22 Apr 266 19.0 121 8.6 387 27.6
23 Apr 264 18.9 121 8.6 385 27.5
24 Apr 258 18.4 115 8.2 373 26.6
25 Apr 248 17.7 108 7.7 356 25.4
26 Apr 242 17.3 116 8.3 358 25.6
27 Apr 219 15.6 122 8.7 341 24.4
28 Apr 200 14.3 112 8.0 312 22.3
29 Apr 180 12.9 103 7.4 283 20.2
30 Apr 168 12.0 97 6.9 265 18.9
1 May 157 11.2 83 5.9 240 17.1
2 May 138 9.9 79 5.6 217 15.5

Conclusions:

  • The trends looks promising
  • Unlinked cases peaked on 21 April, which was exactly the day the Prime Minister addressed Singapore which was followed by policies that furthered tightened the CB with barbers and bubble tea establishments closing
  • While unlinked community cases have more than halved since 17 April, the unlinked cases involving WP holders NOT residing in dorms have proved to be a tougher nut to crack, the downward trend in this category is not as pronounced as the unlinked community cases. This is very worthy of our concern.

One caveat is that you have to use the individual daily reports and not rely on just the report of the current (latest) day because figures change for a certain day when cases become linked after several days of investigations.  For example for the Situation Report dated 18 April, the number of unlinked cases for WP holders NOT in dorms was 13 for 18 April. But this same statistic for 18 Apr dropped to 5 by the time the Situation Report for 23 April was published.

The average total unlinked cases for both categories is now 15.5 for a 14-day period. Hopefully, by the end of CCB, this will drop to <5. In places like Taiwan and HK, the total number of cases (whether linked or unlinked) is in the single-digits, so aiming for the same number for us just for unlinked cases alone is not a tall order. For example, since 15 April, HK has not had more than 5 cases a day, linked and unlinked. The same goes for Taiwan, which other than for 22 cases reported on 19 April due to cases found on a warship, they too haven’t had more than 5 cases a day either. In South Korea, new cases a day are now in the single digits, and the highest number they have had since 15 April was 22 cases. But Korea is a country with 51 million people, about nine times the size of Singapore.

There are policies, and then there are policies. As we are now into the 5th month of our struggle with Covid-19, let’s look at some of them. This hobbit thinks policies can be roughly grouped into the good, the bad, and the mysterious.

 

The Good

Recently, the SMC has just modified the requirements for CME in this current cycle in response to a request from the SMA. All Covid-19 related CME activities are now considered Core points for all doctors. Also, the cap for self-reading of journals (Category 3A) has been raised from 10 to 20 points. This is very good.

The locum rates for doctors who work at Community Isolation Facilities (CIF) is $130 per hour. This is a very fair deal. Good too.

In a Webinar, the DMS said MOH was committed to support all PHPC clinics with free PPEs beyond the initially stated 12 weeks. This is to be welcomed too.

 

The Bad

Let’s imagine this – you are one of the squad leaders on top of Helm’s Deep in Part 2, Twin Towers of The Lord of the Rings Trilogy. You are put in a charge of a squad of 10 elven archers and you and your squad face this sea of orcs, trolls and Uruk-hais marching towards you. You are scared shitless. But you swallow your fear in spades and await the onslaught from these beasts with your small squad of elves as well as the rest of the Elven and Human Army. Suddenly, this guy comes up behind you and says in an authoritative tone, “Dude, I am cutting your squad strength by half. You now only have 5 archers left. Good luck”.

“Whaaaaaat?!?!?” you scream out in anger, fear and frustration. Meanwhile, the orc and trolls army has multiplied further and are marching closer and closer to Helm’s Deep.

Sounds crazy? But this is exactly what is happening in the trenches today with our medical clinics.

To be fair, there are medical services that are obviously non-essential and should be closed, such as aesthetics and health screening. There are even some specialist services that are probably non-essential and should be limited as well, such as stable cataract surgery or joint replacements.

But GP services, especially Public Health Preparedness Clinics (PHPC)?

This hobbit has seen numerous GP and PHPC clinics’ requests for full manpower denied. This whole process of registering your essential staff is so illogically painful it is shameful. The IT system itself is a basket case – it hangs frequently. There is also no clarity and transparency in how decisions are arrived at. Some clinics were given a total of two workers while there is another that is given five. How are these numbers arrived at? What is the criteria? Yet another clinic was given 400+ workers (probably a mistake, but still…)

There is no consensus amongst doctors whether number of employees/workers includes or excludes doctors. Some doctors take it to only include non-doctor workers. Some doctors think it excludes cleaners who come by for an hour a day to do cleaning.

The number of staff allowed – are they for one shift, or for the whole clinic per day? Nobody really knows. What if you have different staff for different shifts? Can you have six workers in a clinic working three shifts? i.e. two workers per shift or must it be the same two workers in all 3 shifts?

This is one big royal mess. A GP running a PHPC Clinic is very clear in his mind – He says  “I have four clinic assistants. If they give me only two, then I will reduce my clinic opening hours by 50%”. I know a few senior GPs who told me they will close their clinics altogether because they can’t take this anymore. If all these GPs cut their opening hours by half, then the combined effect would be a significantly diminished PHPC capacity. Is this really the policy intent of enforcing worker limitations in GP and PHPC Clinics? To cut capacity in the PHPC system? Instead of mustering all the elves and humans to fight the orcs, you tell your frontline warriors to stay at home? How does this gel with the Health Ministers saying “healthcare workers are our most important resource?”. Clinic assistants are also healthcare workers, aren’t they? And yet we want them to stay home….

The usual answer one gets is “you can appeal”. But to appeal is unnecessary work at best and demeaning at worst. If I am truly frontline GP battling Covid-19, why should I have to appeal? Why don’t you reduce the opacity and tell me what is your criteria for deciding on how many workers a clinic may have?

One wonders, is there any other country in the world that wants to decrease service capacity in the primary care system during this Covid-19 pandemic? We may be the only one.

My clinic’s workload has come down by at least 50%. Most GP clinics I know have seen their workload cut by between 50% to 75%. So on one hand, it is true you may not need so many staff from this perspective. But due to current infection control measures, efficiency and productivity also drops significantly, so less patient volume may not correspond to a tandem reduction in manpower needs.

In any case, pre-Covid, GP clinics running out of 600 to 700 square feet shop-lots are already some of the most efficient healthcare providers on this island. How much more productivity do you want out of each of them? Do the authorities actually think GPs hire more workers than they need in peacetime? Especially when they are paying each and every of these clinic assistants out of their own clinic takings?

But moving beyond numbers, we need to have more empathy with what the GP is going through while fighting two fronts:

  • The GP is risking life and limb with his clinic team to continuing serving his patients amid the Covid-19 pandemic (Physical Threat and the Disease Front)
  • He is very stressed by the loss of patient load which translates to very diminished income. (Financial Damage and the Economic Front)

He doesn’t really need to have a third front, which is to contend with the authorities on justifying why a clinic assistant is needed on the Regulatory Front. As one PHPC family physician said, “You are supposed to help me make my life easier as a frontline healthcare provider, not add onto the stress and psychological trauma by cutting down my staffing and threatening to fine me or put me in jail, especially when I am supposed to be helping the country battle Covid-19”. He followed through with a string of expletives which this hobbit has censored. (Sorry, bro, cannot post lah).

Interestingly, this same doctor told me he has seen his clinic staffing cut to 2 but he knows a lawyer has been given a quota of 5 essential workers. He rationalises that maybe there are many people who want to have their wills written in a hurry.

So what is going on with the GP is that he has to fight the virus, stave off economic ruin and contend with the most unfriendly GoBusiness IT system and live in fear of the threat of being punished under the ID Act should he offer some service that is deemed non-essential.

But that is not all. We also now have additional interpretations of what is essential medical services and what is not.

For example, in a directive dated 30 April, it was said some of the non-essential services that were discovered in medical clinics included:

  • Consultation for skin and hair conditions which are stable and on long-term follow up;
  • Provision of botox, fillers and chemical peels for aesthetic purposes; and
  • Supply of facial cleanser, lotion and cream refills over the counter.

As previously said, banning of provision of aesthetic service is straightforward enough. But the other two points are not so simple. The main issue for GPs is that we really do not know who walks into my clinic beforehand every day and what are their reasons for seeing me. I do not have a triage to sieve cases out, and even if I had, it is gone now, thanks to GoBusiness who just halved my number of clinic assistants.

A patient who comes into my clinic say for diarrhoea may at the end of the consultation ask me for another tube of steroid cream for her stable eczema. Do I give it to her or not? And why would any patient pay for delivery charge for medicines when he walks into my clinic to refill his acne medicine after buying takeaway food from the hawker centre which is located 30 metres from my clinic? Do I deny the patient his bottle of cleanser for acne or the diarrhoea patient her tube of steroid cream?

Many non-essential services are offered opportunistically together with essential medical services given in the same sitting, and often so at the patient’s request.

Somehow I think all these directives are written by people who do not understand GP practice and have not practised as a GP in the heartlands. This hobbit suggests that these powerful directive folks read up on Stott Davis Model and Pendleton Model of Family Medicine consultation models in addition to their usual work of writing and issuing directives. Or as suggested by a general surgeon – perhaps talk to a real doctor.

 

The Mysterious

Immunisations. MOH considers adult immunisations as non-essential and that influenza and pneumococcal vaccinations can be given only if the patient is also “being seen for essential routine chronic care”.

WHO does not make a difference between adult or childhood immunisations. Here is what the WHO says in its website:

One of the “Guiding Principles” states…

“Immunization is a core health service that should be prioritized for the prevention of communicable diseases and safeguarded for continuity during the COVID-19 pandemic, where feasible. Immunization delivery strategies may need to be adapted and should be conducted under safe conditions, without undue harm to health workers, caregivers and the community”.

One of the “Considerations” for routine immunisations:

“Where health system capacity is intact and essential health services are operational (e.g., adequate human resources, adequate vaccine supply), fixed site immunization services and Vaccination-Preventable Disease (VPD) surveillance should be executed while maintaining physical distancing measures and appropriate infection control precautions, equipped with the necessary supplies for those precautions”

I guess either our health system is not intact or our MOH is not taking guidance from WHO on this.

Another great mystery is of course our Dorscon system. In the beginning, I guess most of us didn’t really understand it. Then many started making jokes about it. Now, nobody even bothers to refer to it except in the most perfunctory way. When it gets to this level of irrelevance and irreverence, it is perhaps time to bury it.

Next we move on this ban on walking pets and exercising in the private estate grounds. The ban was first announced on 28 April by the Building and Construction Authority (BCA) before the decision to reverse it was made on 2 May and the reversal will be implemented with effect on 5 May. It took all of four days to reverse a decision and another 3 days to implement the reversal. Mysterious isn’t it?

To be absolutely clear, this hobbit thinks the original decision didn’t make much sense and caused a lot of grief. Some condo estates may be very big, and a resident needs to walk 100 to 200 metres to the main gate and enter public areas where the dog can walk. So what must the resident do to abide with this directive? A dog lover friend of mine contemplated carrying her dog for 200 metres to the main gate, or putting the dog in a baby stroller and pushing the dog in the stroller to the main gate. Luckily, she owns a poodle which is small. But what if you own a golden retriever or a Doberman? Lug the mutt like an army full-pack for 200 metres?

Next we move on the ban on home-based food businesses such as baking, which was announced on 26 April. You can order fast food delivery to your home but you cannot perform home-based food businesses and get the goods delivered elsewhere by similar professional delivery services. The decision to reverse this was made yesterday (6 days from announcement) and the implementation of this reversal decision will be made on 12 May (16 days from 26 April). Frankly, my public health and epidemiology knowledge is limited at best (I slept through most of COFM class, like many other people), but this hobbit thinks really the additional epidemiological risk posed by home-based food businesses baking is quite limited if you already allow deliveries of goods and cooked food from establishments, restaurants and hawker centres to homes. So why this sudden albeit transient attention on home-based food businesses? Another mystery.

 

The Biggest Mystery of All

And now we will move on to the really important news in our  nation’s mighty battle with the Covid-19 – The Virus Vanguard.

The Virus Vanguard must be the shortest-lived superhero grouping in the history of the galaxy. It survived for as long as SARS-CoV-2 did in my 70% alcohol sanitizer. Which is really a pity.

Anyway, this hobbit has to go. I have an important date with my fellow mythological character, Care-leh Dee, the Virus Vanguard trillionaire philanthropist superhero who can hopefully give me some financial assistance for my loss of income. And I will also ask her to use her empathy to remove all the negativity I have about GoBusiness and my inability to give a tube of steroid cream to my diarrhoea patient with stable eczema.

I also hope to get MAWA Man’s autograph through her. Wish me luck.

 

Gentle Reminder – Do remember to vote in next week’s SMC elections.

 

 

 

 

Part 2: MOAC – The Mother of All Clusters

We are now quarter-way through the circuit breaker (CB) mode, two weeks down and about another six more to go. The situation is not quite encouraging as yet. Of course, this is already by hobbit standards, and hobbits are by nature optimistic, as opposed to elves and dwarves.

For one, as of this afternoon, the number of Covid-19 cases in Singapore has exceeded 10,000.

Secondly, if you look at the doubling time of the epidemic in Singapore, it is now about 5 days. This is shorter that what was quoted previous by WHO when the disease first appeared – 7.4 days.

The other issue is that of unlinked cases. From the MOH website, you can see there are two types of unlinked cases:

  • unlinked community cases and
  • unlinked work permit cases NOT residing in dormitories.

From 8 April till 21 April, the total unlinked cases from these two categories reported each day has varied between 24 and 31. But on 21 April, the number went up to 44 (23+21). We hope this high number of 44 is a once-off aberration.

The largest sub-cluster of the MOAC, the S11 dormitory cluster now has 2143 cases as of 21 April. This dormitory has a capacity to house 13000 foreign workers. Assuming full occupancy, the prevalence of Covid-19 in this dormitory has reached a staggering 16.5%. And this number may get higher as we test more of the dormitory residents. To illustrate the mind-boggling effects of exponential growth, on 6 April (10 days after the S11 cluster was declared), it was reported in The Straits Times that the S11 cluster had 88 cases. 15 days later, it has grown to 2143 cases (21 April 20). The larger picture is also rather discouraging, as clusters are now found in 28 out of 43 dormitories.

There are actually three phases in the local outbreak with respect to the foreign worker dormitories, which this hobbit will call the MOAC War. The first phase was really the preparatory phase which took place in early January till early or mid-February, right up till the Seletar Aerospace Heights Cluster was declared in mid-February. The 2nd phase would stretch from the end of Phase 1 (when we realised that a foreign worker cluster was not a possibility but a reality) to March 25, when the first foreign worker clusters were declared: the Mustafa and Toh Guan Weslite clusters. Since March 25, we have been in Phase 3 for exactly 4 weeks, the phase that entails the entire healthcare system battling MOAC. After 4 weeks, there are now some 7500 foreign permit workers infected, with the 3 largest foreign worker clusters being S11 (2143 cases), Sungei Tengah Lodge (629) and Tuas View Dormitory (519) (MOH report dated 21 April). These numbers are deeply disconcerting if not frightening.

Another key factor is that the number of patients now being admitted into our restructured hospitals has reached about 3500. Notwithstanding that most of these patients are young patients, we only have about 9500 beds in the public acute hospital system, and 3500 is a very sizeable proportion of the total.

What is heartening to note is that the number Covid-19 patients requiring ICU beds have consistently remained in the 20 to 30 range. But I can imagine that the doctors and nurses are now locked in a daily titanic life-and-death struggle against the virus in the restructured hospitals. There are also hundreds if not thousands of doctors and nurses now manning isolation facilities in private hospitals, community isolation facilities and community hospitals. A friend of mine has described his experience fighting the virus akin to the elves at Helm’s Deep keeping waves and waves of orcs at bay. No matter what you do and how hard you try, the virus just keeps coming, relentless and unforgiving. And you fear that sooner or later, you will run out of energy and arrows and be overwhelmed.

All this is rather gloomy even for a hobbit like me that is usually given to a cheery disposition. Let’s move on to something hopefully more encouraging and reassuring.

It was reported in The Straits Times on 22 April that during the press conference given the day before, the Manpower Minister said her ministry had instructed the dorm operators as early as early January to put in place mitigation measures, including asking the operators to “raise the standards of hygiene and sharing information with workers how to protect themselves against the virus”. Later on, further measures were introduced, including safe distancing, and closing non-essential facilities such as TV rooms. These measures would probably correspond to Phases 1 and 2 of the MOAC War that have been described above.

The Minister then went on to say that more stringent measures, which were only recently introduced in the CB period, would “need to have been done in the context of a circuit breaker where most work has stopped” (quoted from The Straits Times dated 22 April 20, Page A6). These more stringent measures that have since been implemented in the CB period, include:

  • not allowing the workers to cook in communal kitchens located within the dorms,
  • not allowing them to go out on their rest days and interacting with their friends,
  • not even allowing them to go to work,
  • dispersing the workers to live elsewhere so as to make the dormitories less crowded (as they are doing now).

The circuit breaker was announced in the first week of April, which would have been in Phase 3 of the MOAC War.

It is interesting that the Minister has said that these measures could only be implemented during the circuit breaker period. Let us take a break to think about this in some detail. For a start, what is a circuit breaker, really? Although obvious, it must still be said that to break a circuit, the circuit must first exist before the breaker can be applied. The pre-existence of a circuit is therefore a precondition for the application of a breaker. In other words, there must be something to break in the first place. This is opposed to say, a lockdown. You can apply a lockdown or like the Malaysians, apply a Movement Control Order, even when there are no infections because the lockdown or MCO could be aimed at preventing any infection or transmission from taking place when they may be no infections at all in the first place. But, a circuit breaker can only be justified when there is something already going around (i.e. a circuit). As you can see from the numbers above, there was already some serious circuitous phenomenon or disease transmission in existence when the CB was applied 2 weeks ago.

I may be wrong, but what the Minister is saying is that really, a lot of mitigation measures had been done before the CB was announced. As such, we need to look at these two illuminating points:

  • Whatever more serious measures that could have been done, could only have been done in the CB period, when the disease was already transmitting so significantly that it required a CB to be applied. These serious measures therefore cannot be preventative or pre-emptive, (before a circuit has taken or is allowed to take place).
  • But in hindsight, we also know that the mitigation measures implemented in Phases 1 and 2 could not and did not prevent a big circuit forming which necessitated a CB.

Therefore, taking these two points together, this would also imply that MOAC was really inevitable.

Yes, in conclusion, it now appears that MOAC is an inevitability. And by logical extension, the war against MOAC is also an inevitable war.

This is a very crucial and enlightening point that bears repeating. This is because as we battle MOAC and CB is extended to eight weeks, it is also inevitable that there will be much suffering and economic loss, despite the Finance Minister announcing a slew of generous assistance measures. Many workers will suffer hefty pay cuts, and many may even lose their jobs. Some businesses will close as well. Many healthcare workers are working tirelessly, exposing themselves to the possibility of mortal harm. The whole country is probably suffering from high levels of emotional stress as well, from the social distancing, as well as coping with the repeated and increasingly severe limitations to personal freedoms that battling Covid-19 demands during this CB period.

But we all need to suffer and put up with this because now we know this has always been an inevitable war. Because it has been implied that MOAC was inevitable, it also means no one should or could be held responsible or accountable for it.

As such, I urge all of you, especially my fellow healthcare workers, to just accept this revelation of inevitability and press on with the fight.

MOAC – The Mother Of All Clusters

We were looking like the smartest kid in the class In February, except for isolated bouts of toilet paper hoarding and mask buying that potentially “sia-suayed” our country and parents. In March, we were still looking rather clever, like the blissful cool GEP kid in RI that still gets to be called gifted and yet not appearing to be a chao mugger.

Now in April, Singapore is looking like the below-average Integrated Programme kid, struggling to complete his hefty homework load and have a decent CCA record as well. He is still an IP student, but if he mucks up anymore, there is a good chance the IP school will ask him to take the O levels.

What happened?

In three words – foreign worker dormitories

This is going to be the Mother Of All Clusters (MOAC) in Singapore. As of today 11 April, the cluster comprises Mustafa, two construction sites and 6 dorms totalling 631 cases. There is another cluster of 5 cases at 31 Sungei Kadut which hasn’t been linked to the MOAC yet. About 20,000 foreign workers work in these affected dormitories. Nationally, it is estimated that there are 200,000 such workers living in foreign worker dormitories.

Just to give you a recap of how fast things have deteriorated, about 2 months ago when this hobbit wrote Part 2: The “Perfect” Communicable Disease Outbreak on Valentine’s Day, we had a grand total of 67 cases in Singapore. Now we have 2108. (Gentle reminder: no more 4D betting during CB period).

The first sub-clusters of the MOAC were declared on 25 March 20: Mustafa Centre and Toh Guan Weslite. The next cluster is the huge S11 sub-cluster which was declared on 28 March 20. Generally speaking, even with our excellent case detection and contact tracing capabilities, transmission probably took place about 10 days earlier. These cases picked up around 23 to 24 March (you need a day or two to wait for confirmatory testing results to be announced on 25 March) already included both the first and second generation of infected cases.

Therefore, the original transmission from the MOAC index case to the immediate subsequent cases probably took place around mid-March, between 10 to 15 March. We started gazetting dormitories as isolation areas (which in effect is a total lockdown of these gazetted areas) about a week ago on 5 April. The period from 15 March to 5 April is about 3 weeks. How will this turn out?

We can take some guidance from the biggest cluster of cases in neighbouring Malaysia: The Seri Petaling Tabligh Cluster. Unlike our MOAC, we do not have to guess when the original infections took place: the Tabligh event took place from 27 Feb to 1 March and was attended by some 16,000 people.

On 18 March, some two and a half weeks after the event, Malaysia went into their version of a limited lockdown – the MCO (Movement Control Order). The New Straits Times reported on 4 April (2+ weeks after MCO) that the cluster had 1545 cases. On 10 April, the cluster had grown to 1701. The growth is slowing after instituting MCO for 3 weeks.

So despite some serious intervention to have social distancing since 18 March, the cluster had grown to about 10% of the original size of the attendees. Of course, not all of the 1700 infected people had attended this event, it is just that their infections could be traced back to the people who had originally attended it

In the Malaysian Seri Petaling Tabligh cluster, most attendees had left and went back to their homes which were all over Malaysia. They had effectively dispersed, which would contribute to the spread to more cases. However, Singapore’s MOAC did not disperse, but really, the spread took place in the cramped conditions of the dormitories where many amenities are shared, which also lead to more efficient disease spread. The disease transmission dynamics could be worse in a foreign worker dormitory than in the community, where living conditions are less congested.

So it should not come as any surprise should the size of our MOAC well exceed 1000 eventually.

Nonetheless, we need to ask some hard questions.

The first foreign construction workers to be infected belong to what is known as the Seletar Aerospace Heights Construction Site cluster. This occurred around mid-February and involved 5 workers. This cluster has no proven link to the MOAC. But this would undoubted have alerted the authorities and the dormitory operators that there was a real possibility that transmission between foreign construction workers could occur.

In large organisations, the management is usually required (sometimes mandated by law even) to perform a risk analysis. They have to identify key risks and have plans to manage away the risks. Sometimes these risks cannot be managed away, but management must then draw up mitigation plans and then implement these plans to mitigate or lessen the risk.

This hobbit has no doubt that the relevant regulatory authorities and the dormitory operators are trained, hardworking and experienced; they would have identified that Covid-19 transmission among dormitory residents living in close proximity to one another is a clear and present possibility and would have instituted mitigation measures at least after mid-February when the Seletar Aerospace Heights cluster came to light.

These mitigation measures in dormitory may include simple things like

  • Temperature and symptom screening of residents
  • Segregation of residents such that different groups have different meal times, bath times, recreation times etc
  • Limitation of movement within and outside the dormitories, for example not letting residents of different floors or blocks mix and interact, or different times for different groups to go outside and buy things etc

Construction site management is also a crucial element. Different workers from different dormitories could have been asked to work in different areas of the site to discourage mixing and interaction etc.

This hobbit suspects most of the above were probably already implemented before mid-March by the dormitory operators and regulators. But yet we now have the MOAC. So it is quite baffling.

If you think about it, both the SAF and MOE have conditions that may facilitate the formation of large clusters – the army barracks in SAF and the schools and hostels in our universities. Yet, they have largely escaped unscathed for now. What is it they have done right and the dormitories haven’t? This hobbit doesn’t have the answers here.

Were the conditions in the dormitories so challenging that the mitigation plans eventually proved to be not as effective as hoped?

Perhaps MOH can conduct an in-depth epidemiological study into the MOAC, and study the transmission dynamics of Covid-19 in these dormitories and compare the results with community spread.

In the meantime, my heart goes out to the foreign construction workers, especially those in the affected dormitories in lockdown. (the rest of us are in CB mode, but these workers are literally under lockdown). We must give them adequate hope, support and care.  We cannot let 20,000 young men lose hope. Because if 20,000 young men lose hope, then the rest of us on this small island will also probably be not far from being in deep trouble as well.

 

 

 

 

Private Healthcare Insurance: Trust & Transparency

In life, there are errors of commission, and there are errors of omission. Dr Alan Ong’s opinion piece in The Straits Times on 7 March is of the latter. His column “The coming healthcare crisis: Unsustainable financing” talks about the dangers of having runaway healthcare inflation and offers several solutions.

He is the medical director of AIA Singapore, a major player in healthcare insurance locally. Therefore he must know what he is talking about. And what he commits or omits glaringly is most worthy of our attention.

What does he commit in the abovementioned article?

  • Singapore needs to have a financially sustainable healthcare system
  • Integrated Shield Plans (IPs) will become unaffordable if current healthcare inflation trends persist
  • We need to maximise the value or healthcare outcome out of every healthcare dollar spent

The healthcare insurers feel that to maximise the healthcare outcome of every healthcare value spent, the following needs to be achieved:

  • Appropriate healthcare behaviour
  • (better) Collaborations between healthcare providers and insurers
  • Greater transparency in outcomes

In providing recommendations and possible solutions to the above, Dr Alan Ong quotes extensively from the recommendations of the Health Insurance Task Force (HITF) Report. The HITF was a Taskforce that comprised representatives from Life Insurance Association (LIA) of Singapore, SMA, CASE, MOH and MAS (Monetary Authority of Singapore) and it was chaired by an independent chairperson. The Report of the HITF was published in October 2016.

He states that MOH’s move to stop the sale of full riders (as recommended in the HITF Report) and introduced co-pay riders for new IP plans will promote appropriate healthcare behaviour.

He further opines that the appointment of certain doctors to preferred provider panels will improve collaboration between insurers and healthcare providers. He gives an example of healthcare screening as an example of how having empanelled doctors will prevent consumption of unnecessary tests. He further states by steering higher volumes of work to empanelled providers is good for these select few who will benefit from more work and policy holders will also likewise benefit as insurers negotiate better treatment pricing for them from these empanelled providers.

Dr Ong then goes on to discuss pre-authorisation, which is also a recommendation of the HITF, and says that with the implementation of this through a standard industry-wide form, the insured will have better peace of mind that their claims will be covered.

On the issue of costs, Dr Ong states that “Singapore already has a fair degree of transparency”. What Singapore needs is more transparency on clinical outcomes and quality indicators so that patients can make better informed choices, providers can improve and insurers can know what they are paying for.

All this sounds fairly reasonable. Now let’s look do a deep dive into the facts.

The whole gist of Dr Ong’s article is that as long as there is no unnecessary consumption of healthcare, financing will be sustainable. Actually, that is one big assumption. Sometimes even when there is no unnecessary consumption, financing is still insufficient or unsustainable, because the premiums collected are just plainly not enough or when the middle-man takes too much. Middle-man being people like Managed Care, Third Party Administrators and even folks like actuary practitioners and insurers.

In any case, let’s give him the benefit of the doubt, since he is a public health specialist (i.e. with specialist knowledge of healthcare policy and financing, presumably). Unnecessary consumption can be therefore divided into two categories – overpricing and over-servicing. Often, it is a combination of both.

HITF’s #1 Recommendation

The HITF report made several recommendations. Two were stated in the article, preferred panels of providers (doctors) and pre-authorisation.

Very interestingly, he failed or omitted to mention the FIRST recommendation of the HITF, which is the recommendation to have Medical Fee Benchmarks or Guidelines. Arising from this recommendation, MOH formed the Fee Benchmarks Advisory Committee in January 2018. In Nov 2018, this Committee published fee benchmarks for 222 commonest procedures covering the vast majority of procedures performed in private hospitals in Singapore.

All IP providers in Singapore are members of the LIA, which in turn was represented on the HITF. The HITF had government and consumer representatives as well, in addition to SMA, which represented doctors. Arising from the HITF’s recommendations, the MOH (i.e. government) formed this Benchmarks Advisory Committee which promulgated the fee benchmarks in November 18. It must be stated that these benchmarks serve as guides, and there is no legal obligation of providers to adhere to them. But nonetheless, doctors, being generally obedient people, largely do charge according to these benchmarks nowadays, since they are issued by MOH.

Therefore, in theory and on moral grounds, all IP providers should respect and subscribe to the recommendations of the HITF (because there were members of LIA), as well as the benchmarks published by a Committee appointed by MOH (MOH being a fair, neutral arbiter). Adherence to these benchmarks will effectively stamp out overcharging and go a long way in making healthcare financing sustainable in the private sector.

An Error of Omission

But this is what actually happened. In a brief survey done in late 2019 for common procedures done by doctors, a year after the benchmarks were published, only ONE IP provider fully respected the fee benchmarks: NTUC Enhanced Incomeshield. Incomeshield will pay its empanelled doctors as long as they charge within the benchmarks. AIA and Prudential reimbursed doctors at the lower end of the fee benchmark bands. AIA basically took the lower limit of the band and added another 10%.

For example, the MOH fee benchmark for gastroscopy was $600 to $1000, AIA’s reimbursement rates was $660. For removal of single breast lump, the benchmark was $2500 to $3200, AIA’s reimbursement rate was $2750.

To be fair, that is still OK, because the AIA reimbursement rate falls within the range of the MOH fee benchmarks, albeit at the lower end. But another 3 IP provider’s reimbursement rates fall below even the lower limit of the MOH fee benchmarks!

Frankly, for the MOH fee benchmarks to work (to make healthcare financing sustainable), everyone needs to play their part and NOT UNDERMINE these benchmarks. This would mean doctors must not charge beyond the higher limit of the benchmarks, and payers, such as IP providers, must not reimburse below the lower limit. If IP providers do NOT RESPECT the benchmarks at the lower end, why should doctors charge within the higher limit?

This hobbit is quite sure an experienced industry player like Dr Alan Ong knows all this. But he has not mentioned any of these practices of other members of the healthcare insurance industry. In fact, he makes NO mention of the MOH Fee Benchmarks at all! It is as if though MOH Fee Benchmarks have no role in making healthcare financing sustainable and averting his “coming healthcare crisis”. Hello, these are MOH fee benchmarks, not the hobbit’s grandmother’s benchmarks, ok?

Incredible isn’t it? I call this an error of omission. And a glaring one. As to why this omission happened, you, the alert reader of this inconsequential column, had better ask Dr Ong yourself. Did The Straits Times run out of newsprint because all the paper has been redirected to make toilet paper? But we do have the online version now after all…..

We now go on to empanelling doctors, otherwise as “preferred providers”. He gives the example of how unnecessary screening can be curtailed with this. This hobbit is confused. Since when did IP Plans cover screening? Also, if you want to curtail unnecessary screening, just state clearly what an insurer would pay (and how much) and what it wouldn’t pay for. It’s that simple.

The second point on empanelling is even more disturbing. He wrote “Patients will benefit too, as panels allow insurers to negotiate better treatment pricing, leading to lower co-payments and premiums”. It means it empowers insurers to extract even lower prices from providers (including doctors) when half the IP providers are already reimbursing below the lower limit of the MOH Fee Benchmarks. AIA is now at “lower end+10%”. How much lower do you want doctors to go, Dr Ong?

In itself, pre-authorisation is not a bad thing. But the information sought for in this standardised pre-authorisation from the LIA members initially did not give the assurance that the information will not be used against policy holders when they renew their policies. It was only after repeated attempts by SMA to get this assurance for patients and SMA’s initial refusal to support the pre-authorisation form that LIA finally clarified and assured that information collected from the pre-authorisation form was to be used solely for pre-authorisation.

The Big Picture

Let’s now get back to the big picture.

Private insurance plays a small part in the health financing of Singapore. 40% of the financing comes from government. A lot of the remaining 60% comes from our savings in Medisave, State-run insurance Medishield-Life, employment benefits and out-of-pocket payments.

While private healthcare insurance plays an important part in the bigger scheme of things, fixing it alone won’t make healthcare financing sustainable. This is important to note, in case anyone gets delusions of importance or grandeur with regard to private healthcare insurance. We are actually not as dependent on private healthcare insurance as many other developed countries.

Secondly, there are four big stakeholders in the private healthcare insurance space:

  • Patients
  • Government
  • Providers (including doctors)
  • Private Healthcare Insurance Companies (especially IP providers)

Trust

The patient is at the centre of it all. Who does he trust most? In Singapore’s context, it is probably the government, often seen as a fair (albeit stern) arbiter of various stakeholders’ interests

Who does the patient trust more, after the government? I think if you were to poll many patients and ask them to choose between doctors and private insurance providers, most of them will choose doctors.

This hobbit’s hunch is that generally speaking, the public trust private insurance companies less than the government or the medical profession.

And of course, doctors trust the insurance industry even less.

Life is tough when you have a deficit of trust from both patients and doctors. I don’t know how much the government trusts the insurance companies, so I won’t comment on this aspect.

What can the insurance companies do to improve the situation? The answer is in what Dr Ong went to at length in the second part of his column: transparency

Transparency

He mentioned about the need for cost transparency, transparency on quality and clinical outcomes. This hobbit would like to suggest a few more areas in which we can have much more transparency:

  • Can the insurance companies be transparent about the criteria by which doctors are empanelled? And why some doctors cannot be empanelled? No one now knows how insurance companies select doctors to be empanelled.
  • If we extract price savings from doctors, how much of these savings will be passed onto as savings on premiums of insurance policyholders by the insurance companies? How many cents for the dollar? Some listed companies have a dividend policy, promising X% of their profits will go to paying out dividends to shareholders. Can IP providers make such a commitment? If so, doctors may be encouraged to cut fees  to ease the policyholder’s burden.
  • Can we be transparent on what is reimbursable and what is not and publish these online, so that not just doctors, but policyholders can also see clearly for themselves?
  • Can we also be transparent on doctors’ reimbursement rates to policyholders? As a policyholder holder myself, I would like to select my IP provider based on several factors. One of which must be how the IP provider pays the doctors that take care of me. I might want to choose the IP provider that pays the doctor the most, or the least. That choice should be for me to make as a consumer or patient. But this information is now not available to the public.
  • How many doctors are empanelled in each IP provider? Will every IP provider publish this important metric? I think MOH also has a role in ensuring better transparency in this aspect. If the IP providers do not want to publish this individually, for a start, it can publish how many empanelled doctors there are in each of the IP providers. Split the data into two categories: private specialists and specialists in the restructured hospitals. It would empower the public to make an informed choice when they buy an IP Plan.

Trust and transparency. We all need them to make healthcare financing sustainable in the private sector. The private healthcare insurance sector included.

 

 

 

 

Part 2: The “Perfect” Communicable Disease Outbreak

The first case of Covid-19 infection in Singapore was announced on 23 Jan 2020. We are now into the 4th week of the outbreak in Singapore.

The situation in China appears mixed. The number of new infections each day seemed to have peaked. But apparently those happier numbers were due to under-diagnosis. Yesterday the numbers hit the roof with another 15000 new infections and 254 deaths in China in one day. There are now almost 64,000 cases and 1400 deaths in China. The number cases in Hubei province, including Wuhan, continues to outnumber those in the rest of China by about 4:1. This implies that there is still rapid transmission of cases both within and without Hubei. You know the battle is far from won in China when they have just removed the bosses of Hubei Province and Wuhan City (their party secretaries).

We Haven’t Seen The Fat Lady Yet

The current state of affairs in China is such that we really do not know if the worst is over. But there are some folks out there who repeatedly lobby for a softer stance in the fight against Covid-19. They say this is no more harmful than the common flu, which kills a lot more people every year than any coronavirus outbreak.

This hobbit would like to be a bit more cautious. For one, while we know it’s less deadly than SARS or MERS, we just do not know how less deadly it is. Statistics so far suggests so. Outside of Hubei province, the Case Fatality (CF) Rate is below 0.5%. While for Hubei it’s about 3%.

Why is the CF Rate for Hubei (and it’s provincial capital of Wuhan) so much higher? Many theories have been proffered. For one, being the place of origin of where Covid-19 started, the outbreak went undetected for 2 to 3 cycles longer than other cities, which had heightened awareness and sensitivity to the novel disease. By the time the disease reached other Chinese cities, it had already taken root in Wuhan and its surrounding cities. So the number of infections there are much larger.

But this does not alone explain the higher CF Rate. It could be that hospitals there are overwhelmed and the hospital themselves have become great incubators and reservoirs of the virus. They are so because therein lies a great number of sick people with many comorbidities and their chances of dying are much higher than the average person in the street. This is not much different from SARS where hospitals and hospital staff and patients had a much higher chance of being afflicted with the disease.

This is this hobbit’s theory of why the CF Rate in Hubei is much higher than other parts of China. And therefore, it is vital that we do not let our hospitals get hit by Covid-19. But it is only a theory. The truth is, we really don’t know for sure why Hubei is doing so badly in terms of the CF Rate.

The other two important factors are that we do not have drugs that can definitively treat the disease (like Tamiflu for influenza) and a vaccine.

And so, until we know for sure why Hubei is different from the rest, or that we have a drug for definitive treatment or a vaccine, it is best we don’t throw in the towel by treating Covid-19 like the influenza virus.

And besides, it is early days yet. SARS infected 238 persons in Singapore and killed 33. We have about 67 cases and no fatalities for Covid-19. It is too early to give up the fight.

Another factor to be considered is that China is now returning to work after the Chinese New Year extended holidays. Will that lead to another round of infections as hundreds of millions of people go on the road again from their hometowns to their place of work? Only time will tell. It is true that we have effectively closed off China as a new source of infections since everyone that comes to Singapore from China must be given leave of absence for 14 days. But one can still get infected in other countries before coming to Singapore – an imported case, but not from China, so to speak.

So as the saying goes, “It ain’t over till the fat lady sings”. No one is quite sure if they have seen the fat lady yet…..let alone see her sing.

And so, that means we, the ground troops, must slog and plod on in our clinics and hospitals.

Logistic Fog of War

After three weeks, things are really getting a little edgy on the ground in the private sector, to put it mildly. If you are the grunt troops fighting in the trenches, after three weeks, you are going to be in pretty low morale if you have had only 5 warm meals and 3 changes of underwear and socks and you are down to your last 2 magazines of rounds. You are sick of eating combat rations, you have bad body odour and you are starting to get foot rot.

We have learnt from SARS that when we fight a communicable disease outbreak, we are really fighting on at least three fronts: medical, logistic and psychological.

For the front line troops in the private clinics and hospitals, we are failing quite badly on the logistic front, I am afraid. That is, until the Health Minister announced he was giving 1M masks to the private sector doctors 2 days ago. This hobbit reckons these 1M masks will last the private sector for about 3 to 4 weeks.

Simply put, private sector doctors have no visibility, let alone clarity or assurance, of the government’s resupply plans for them. How much of the National Stockpile of PPEs is meant for the private sector? Nobody knows and all of us in the private sector are fighting Covid-19 while blinded by this fog of war on the logistic side.

Let’s Do The Maths

Let’s take a recap. Up till now, assuming you have been on the ball as a GP securing your masks, here is what you would have gotten from “official channels”:

  • From SMA (they obtain their stocks from government): 3 boxes of N95 and 1 box of surgical masks.
  • From Zuellig Pharma (The government authorised dealer): 1 box of N95 and 2 boxes of surgical if you are a GP, 1 box of N95 and 1 box of surgical if you are a specialist

Which means the MAXIMUM amount of masks you could have gotten so far are 4 boxes (80 pcs) of N95 and 3 boxes (150pcs) of surgical masks after three weeks in the trenches.

Zuelling is selling another round of masks now, also along the same lines as the previous round. Assuming you are lucky and get what you want, you would have accumulated a total of 5 boxes of N95 (100pcs) and 5 surgical masks of N95s (250pcs) if you are a GP. And if you are a specialist, it’s a maximum of 100pcs of N95 and 150pcs of surgical masks after 20+days at the front lines.

Most folks out there do not achieve this maximum allocation of masks. And we haven’t even started talking about isolation gowns.

Strangely speaking, or maybe my memory is failing me in my old age, I can’t seem to recall we were so short of PPEs during SARS, other than for N95s. Certainly, we weren’t so short of surgical masks then.

A typical GP clinic will have 3 to 4 working persons, including the doctor. Assuming each mask lasts 6 hours, you will use up 2 masks a person or about 6 to 8 surgical masks a day. You are also required to put a mask on a person with fever or respiratory symptoms as per MOH requirements. That would easily take up 10 to 15 surgical masks. In other words, a small solo GP clinic working 3 shifts easily consumes 20 to 25 surgical masks in a day if not more. Now that we are in Dorscon Orange, a solo GP practice would use up to 4 N95s a day in addition to the surgical mask utilisation (One N95 for GP and one for triage nurse per shift, assuming 2 to 3 shifts a day, so 2×2 = 4 N95s a day. If you go for extended (stingy) use, then maybe 2N95s a day).

Assuming the GP works 6 days a week, the clinic will consume 120 to 150 surgical masks a week and another 12 to 24 N95s a week

But as the records show, in the last 3 weeks, we could only have received 80 pcs of N95s and 150 pcs of surgical masks with hopefully another 20 N95s and 100 pcs of surgical masks on the way from Zuellig. This is simply not enough to keep the GP and his clinic going.

It is understandable that we teach the public to limit the use of PPEs and to concentrate on efforts to improve hand and personal hygiene as well as to limit large group interaction. But it is another thing altogether when we try to squeeze the PPE supply to the private healthcare establishments and their staff, when they have to face people who are sick, i.e. a high risk segment of the population.

We Need An Integrated Approach to Making PPE-Related Policies

There is a fine line between conserving PPEs and keeping morale up, i.e. winning the psychological war. Ultimately when everyone does not know when the next batch of masks will come, morale will suffer. Just like troop morale will drop when they don’t know if they will be resupplied with food, water, clothing and ammunition. Everyone is thinking of getting or have been getting their masks from private suppliers. And prices are going up. A box of surgical masks (50pcs) have gone up from $3.50 to $4 before the outbreak to around $25! That is, if you can find them in the first place.

The truth is that PPE consumption rate is influenced by a few factors:

  1. The epidemiological features of the disease
  2. Dorscon status
  3. Case definitions of the disease
  4. PPE usage policy

We can’t do much about the natural epidemiological features of Covid-19. It is what it is. But case definitions are largely man-made. If your case definitions are too broad and too many persons fall under the suspect category, then the use of PPEs will shoot up. Likewise for Dorscon status. PPE usage policy also heavily influences usage, although admittedly this is also in turn determined by the epidemiological features of the disease. But whatever the case, the resupply operations must support what the case definitions and mask usage policies demand.

To the uninformed, it would appear that the 4 policies are governed by different groups of people working independently of each other. The resupply practices of 20 pcs of N95 and 100 pcs of surgical masks a week is not keeping up with the demands of the case definitions or the Dorscon status. It looks like the resupply guy is still in Dorscon Yellow while his colleagues in the other departments or ministries have moved on to Orange.

Talk about frustration.

What this Hobbit would like to see is that the authorities commit to a certain rate of resupply for GP and private sector community specialist clinics. E.g. 1 box of 20 N95s every two weeks, 3 boxes or 150pcs of surgical masks a week and 10 isolation gowns a week and maybe 2 bottles of sanitizers/hand rub. Then all of us doctors can concentrate on picking up new Covid-19 cases and treating other patients instead of constantly worrying about where their PPEs will come from. We will pay for the PPEs too, we don’t need freebies. And of course, community clinics with more than one doctor should appropriately receive more PPEs than the solo GP.

Public Health Preparedness Clinic (PHPC)

That brings us to what is listed as a MOH National Scheme called the Public Health Preparedness Clinic (PHPC). This Scheme “consolidates the primary care clinic response to public health emergencies such as influenza pandemic, haze and anthrax outbreak into a single scheme for better management”. (www.primarycarepages.sg/practice-management/moh-national-schemes/public-health-preparedness-clinic-(phpc)

For volunteering to be on this wonderful Scheme, MOH is supposed to provide you with “up to 12 weeks’ supply of PPE for staff at no cost”. This sounds great right now because I know some GPs who will pawn their grandmothers for 12 weeks of free PPEs.

But, according to a circular issued on 11 Feb 2020 by MOH, this Scheme hadn’t been activated yet. Therefore, no one has received any PPE free of charge under this Scheme either. Today it has been finally activated. Maybe it’s about tough love on Valentine’s Day.

Frankly, this hobbit cannot understand why the Covid-19 wasn’t considered a public health emergency until today. The Scheme was increasingly looking like a joke until a powerful necromancer decided to breathe some life into this cadaver of a national scheme today.

Come Down Hard On False Declarations

Doctors and other healthcare workers need to be protected with PPEs. But they also need to be protected against reckless and selfish people who put others, especially healthcare workers (HCWs) and healthcare establishments, at risk. Several people have already been punished for breaking quarantine. But this hobbit thinks there are far more people who give false declarations about the travel and contact history. I think practically all doctors out there know other doctors who have had seen irresponsible people after they had made false declarations, even if they had not met one themselves.

The authorities should protect the public and HCWs by taking these false declarers to task, and charge them under certain provisions of the Infectious Diseases Act. This would send a clear signal that false declarations will not be tolerated, and not just those that illegally break quarantine orders.

The New Battlefront: Private Hospitals

This Hobbit opined in Part 1 that Generals fail when they fight the last war. Generals often assume the new enemy is like the last enemy and they will win against this new kid on the block by bashing him/it the same way as they bashed the previous kid on the block. And they are often proven wrong when they do so.

The recent spate of cases whereby patients and staff have been exposed to confirmed cases underline this point. During SARS, the private hospitals were spared and the restructured hospitals bore the brunt of outbreak. This time is different. The first two hospitals to have unprotected staff exposed to confirmed patients were private hospitals. The first healthcare worker who contracted Covid- 19 was a private sector anaesthetist who was rumoured to have seen patients in more than one private hospital.

It is clear that the private hospitals are at as much risk as restructured hospitals for Covid-19. Some of these hospitals are running very short on PPEs. But this hobbit was told they are expected to source for them on their own. The Singaporean equivalent of the biblical Joseph guarding our National Stockpile should quickly beef up the dwindling stocks in the private hospitals. MOH should also ensure that private hospitals have the same standards of disease control as restructured ones, especially in terms of PPE usage, triage and limitation of doctor movement.

When stocks are running low, private hospitals and clinics have no choice but to make compromises on PPE usage, leading to suboptimal infection control. And we are only as strong as the weakest link, as the saying goes.

Research

Singapore has the most cases of Covid-19 after China. (Other than the cruise liner docked off Japan). It is interesting that Chinese, HK, USA, Germany have all published research papers in reputed research journals and Singapore hasn’t. That’s a shame, given our reputation as a medical hub with top-notch researchers and clinician scientists. What’s happening?

And so…..

Again, as this hobbit has said in Part 1, there will be many twists and turns to this blockbuster saga sequel to SARS. And we are now beginning to see some of these twists and turns.

As Winston Churchill said long ago while fighting another war, “Now this is not the end. It is not even the beginning of the end. But it is perhaps, the end of the beginning”.

Where the 2019-nCoV outbreak is heading….

The situation in China is getting grimmer by the day. Yesterday, some 2900+ new cases of 2019-nCoV infections were reported. With the total number of infected exceeding 17000, this ugly new virus has blew away SARS in this aspect. A record number of people (57) died yesterday, pushing the total number of deaths due to the disease to 361. More lives have been lost in China to 2019-nCoV than SARS. These are breath-taking numbers

Hence, hearing then Health Minister speak in Parliament today was reassuring. The Ministry is certainly working their butts off to try and prevent local transmission of the 2019-nCoV. It is also working out scenarios on how to manage the situation should the virus be found to be transmitting locally.

This novel 2019-nCoV is one mean SOB, you have to admit. It’s as mean if not meaner that SARS in at least 3 ways.

For one, it has been now established that a patient is infectious even during the incubation period. This was published in as a correspondence to the NEJM by German doctors a few days ago.

Secondly, about 80% of patients exhibit easily detectable symptoms or signs such as fever or cough. That means even with temperature screening, 1 in 5 patients may escape detection. This was published in The Lancet a few days ago too.

Thirdly, Chinese health officials suggest that a person may get re-infected with the virus. In other words, one is not off the hook as immunity may be fleeting. If that is the case, it would also suggest it may very difficult to develop an effective vaccine that confers lasting immunity.

Singapore has been gearing up to meet the threat of 2019-nCoV. It certainly warmed the heart of this hobbit to see our NSF boys packing surgical masks for distribution to every household in Singapore.

Since we are on the issue of masks. This hobbit would like to say a few words about our mask policy. The official message is, unless you are dealing with potential high risk patients, such as potential suspect patients, one doesn’t have to wear a mask.

But on the ground and when policies are actually rolled out, there is wide variation in interpretation. This can be observed on the 1 Feb 2020 print copy of The Straits Times. On one page was an article describing how during the ruling party PAP’s Meet-The-People Sessions (MPS), temperature screening is now being carried out. The same article also said that MPs and party activists should not be wearing masks (in line with the prevailing instructions of government then).

Several pages later, under reporting coverage for the recently held Chingay Festival, there was a large photograph showing masked-up temperature screeners checking on Chingay Festival attendees. I think the Chingay Festival is an event sanctioned by the government.

Personally for me, I think the logical thing to do in a gathering of normal-risk people, is NOT to conduct temperature screening and NOT to wear a mask, if we truly believe there is no local transmission of the disease. We should conduct temperature screening when there is a gathering of higher-risk persons, such as patients seeking care (and accompanying persons) in hospitals or clinics. In which case, temperature screeners should wear a surgical mask because they need to be protected in case a suspect case of 2019-nCoV turns up. Therefore, to forbid a screener from wearing a mask suggests that there is practically no chance of the screener meeting a suspect case, in which case, then why screen at all? Does this make sense? In other words, do not screen for fever at all. But if you do decide to conduct temperature screening, please let the screener wear a mask.

Another interesting feature is the definition of a suspect case. The current MOH definition of a suspect case of the 2019-nCoV infection (unchanged since 25 January) is:

a) A person with clinical signs and symptoms suggestive of pneumonia or severe respiratory infection with breathlessness AND travel to mainland China within 14 days before onset of illness; OR

b) A person with an acute respiratory illness of any degree of severity who, within 14 days before onset of illness had:

  • Been to Wuhan city or Hubei Province, China; OR
  • Been to a hospital in mainland China; OR
  • Had close contact with a case of 2019 novel coronavirus infection.

On 1 Feb 2020, Singapore moved to bar all recent travellers to China from entering Singapore (other than Singapore residents). This would suggest that the authorities have deemed that the risk of contracting 2019-nCoV is so high for the whole of China that it makes no sense to distinguish a person who has been to Hubei province from another person who has been to another part of Mainland China in terms of risk posed to Singapore.

As such, this hobbit thinks that the case definition of a suspect case should likewise not make any distinction between Wuhan, Hubei or a hospital in mainland China. I hope someone updates the case definition soon.

A third interesting feature in the latest list of notifiable diseases under Section 6 of the infectious Diseases Act, 2019-nCoV is NOT on the list as of today if you google it. But if you login through SingPass into the CD LENS system, it is there. Can someone please fix this discrepancy? Very confusing to simpleton hobbits.

Finally, back to Epicentre China. This week and over the next few days, Wuhan will be commissioning an additional 2600 beds to treat 2019-nCoV patients in its two coronavirus hospitals: Huoshenshan (fire god mountain) and Leishenshan (thunder god mountain) hospitals. Beijing has also brought out of mothball a SARS hospital with 1000 beds (Xiaotangshan hospital). This probably reflects what the Chinese leadership is thinking now about where the 2019-nCoV epidemic is heading. This is what we call a “lead indicator”, as opposed to lag indicators that tell us about things that have already happened. Health authorities build hospitals and commission beds in anticipation that they will mostly be filled. With such a huge number of beds put into circulation at such blinding speed, it suggests that the worst is yet to come and the outbreak has not been brought under control yet. The daily surging number of new infections and deaths also underscore this point.

This hobbit will be looking out if more such coronavirus hospitals will be built in China soon. If more are built, then it suggests that the epidemic is still growing quickly. If no new hospitals are built, then it may be that growth of the epidemic is slowing down or that the epidemic is being slowly brought under control. Or maybe the authorities have concluded isolating and treating these patients in new hospitals may be futile in controlling the epidemic and other measures need to be taken.

In the Napoleonic era, Prussian diplomat von Metternich said “When French sneezes, the whole of Europe catches a cold”. This was modified in the later half of the last century to “When America sneezes, the whole world catches a cold”, to underline America’s preeminent place in world affairs. Given the current state of the 2019-nCoV epidemic, it may not be out of place to say that “When China catches pneumonia, the whole of Asia is breathless”

We are in this for the long haul, folks.

 

 

 

 

 

 

 

The “Perfect” Communicable Disease Outbreak

Make no mistake, the 2019-nCOV virus is not a remake of SARS. It is a blockbuster sequel. Like Empire Strikes Back. And like all well-made sequels, there should be many surprising twists and turns to the plot. I call this a sequel because both SARS and 2019-nCOV belong to the coronavirus family of viruses.

For other old coots like me, we have fought and survived SARS. I wouldn’t call it a victory, but we survived. That’s enough for me because I know people who literally and physically did not survive SARS. The 2019-nCOV is the big test for the current young generation of healthcare workers.

Like most major and surprising developments, there is good news and then there is bad news.

First the good news. From a case-fatality (CF) rate perspective, the 2019-nCOV is less lethal than SARS. The CF rate for SARS was about 10% (10% of those infected died) while the CF rate for 2019-nCOV is hovering around 3%. The other good news is that the international healthcare community has developed very quickly diagnostic tests that can give you a result in about 24 hours, versus SARS when diagnostic tests took about 2 to 3 days to give a result and these tests were only developed late into the outbreak. But even so, we should remain guarded on this point because we are not sure when the tests can pick up the disease because we do not know for sure when the disease turns detectable. The third piece of good news is that this new disease is spread by droplets (and not airborne) like SARS and a good mask and universal precautions should be enough to break the transmission.

So much for the good news. Now for the bad news, of which there are many.

The 2019-nCOV outbreak (I wish someone in WHO or China will give this bug a more catchy name, like R2D2 or BB8 for example) is designed to perfection in several ways. First, it is perfect in timing. It blew up about a week before Chinese New Year in China, the busiest week of the year when hundreds of millions of Chinese are travelling back to their villages or for holidays, both within China or beyond China’s borders. The size of the travelling population in the week preceding Chinese New Year has been likened to the entire populations of France, Britain, Germany, Italy and Spain going on the road at the same time. Or the whole of USA moving. In other words, timing-wise, it is timed to perfection for maximum dissemination/propagation of the virus. And it is not done yet. These people now in their hometowns have to return back to their workplace – so a few hundred million people have to go on the road again soon in the next one or two weeks.

In comparison, SARS occurred post-Chinese New Year in 2003, in mid-spring, when Chinese New Year travelling had already been done and dusted.

Outbreak-wise, the 2019-nCOV is location-perfect. It has chosen Wuhan, the city right in the middle of the world’s most populous country with the most comprehensive network of high-speed trains, otherwise known as the High-Speed Rail (HSR). Wuhan is a bit like the Toa Payoh of Singapore in terms of location- smack in the middle. From Toa Payoh, you can easily travel to Jurong, Yishun, the CBD or Changi by a network of expressways. Similarly, from Wuhan, you can travel to the populous Sichuan province and Chongqing in the west, Beijing in the north, Shanghai in the east or Guangzhou and the Greater Bay area in the south within 4 to 6 hours by HSR.

Wuhan and its surrounding areas are so central that since ancient times, it has been a battlefield for different armies contesting for supremacy of China. This is especially evident in the Three Kingdoms period (at the end of the Han Dynasty in the third century) where the Three Kingdoms of Wei, Wu, and Shu fought around Wuhan and the nearby cities, such as Jingzhou. Wuhan is at the junction or confluent point of these three kingdoms, which underlies the centricity of it’s location. The biggest battle of the Three Kingdom period took place in Chibi or Red Cliff on a tributary of the Yangtze. It’s so famous that director John Woo made a two-part movie about it (Battle of Red Cliff) with a star-studded cast in 2008. Chibi is a stone’s throw from Wuhan and one of the first cities to be locked down together with Wuhan.

You cannot choose a better location than Wuhan in Hubei province to plant a disease outbreak in China. As they say, location, location, location. And Dr Evil couldn’t have chosen a better location even if he wanted to.

Next is the speed of transmission. In the past, a migrant worker may take up to four or five days to return to his kampong from centrally-placed Wuhan – You take a few slow trains, take a bus, hitch a ride and walk etc. Now with the HSR, you are home probably on the same day, within 24 hours, for 90% of China’s migrant working population. China’s HSR and road network is as good as any developed country in the world. That means the spread of 2019-nCOV is several times faster than the 2003 SARS, thanks to great travel infrastructure in 2019. In other words, in terms of coverage, 2019-nCOV beats SARS hands down.

Outside of China, the spread is also of many orders of magnitude faster and bigger than SARS, thanks to the huge number of Chinese travellers going overseas for holidays over the festive period. In 2003, SARS only came to Singapore because the virus travelled to Hong Kong and several Singaporeans caught the infection when they travelled to Hong Kong and stayed at the Metropole Hotel and brought the virus back to Singapore. That took time and quite a few people. Now in 2019, you can see that most countries have the infection introduced to them by people travelling from Wuhan directly to these countries. The number of travellers coming from Wuhan number in the tens of thousands in any given month to major cities in Asia. The number of Chinese travelling abroad in 2003 was a fraction of what we have in 2019. In 2003, we had to “import” SARS from HK, which in turn was imported from Guangdong, China. Now Wuhan has directly “exported” 2019-nCOV to Singapore and several other countries.

SARS lasted quite a few months in 2003. In the end there were about 8000 cases and 800 deaths. Contrast this to 2019-nCOV. Official investigations into this new disease started after the Chinese National Health Commission was alerted to the outbreak on 30 Dec 2019. It took only 4 weeks since then for this new disease to infect about 4000 people, half the total number of SARS patients. It is no surprise that the official (let alone the unofficial) statistics reflect the speed of the spread. This hobbit predicts that many more people will be infected with 2019-nCOV than SARS. Hopefully with a lower CF rate, and better facilities, therapeutic options now than in 2003, not too many people will perish. But I am not betting the farm on this hope…..

These are the hard truths. But there is more. The prospects may be grimmer than the above because of our imperfect understanding of the disease on two fronts:

• We do not know if the infected person is infectious during the incubation period or not
• Simple signs like fever may not be a reliable sign for the disease

These two points dramatically changes the game for us battling this new disease. SARS patients were not infectious during the incubation period and when they were infectious, they had fever. That gave us time and ease of detection. Outbreak fighters were given up to one incubation period (a minimum of ~7 days) to locate close contacts of SARS patients so that they could be quarantined and in doing so, break the chain of transmission. Now, if claims that a patient is infectious even during the incubation period is true, that one-week window of safety may no longer be there. There may be no time to find and round up close contacts. The Chinese believe this is so while local (Singapore) experts think this point is still debatable. We don’t have conclusive evidence on this one way or the other.

The next point is that fever may not be a reliable sign, although according to a study published in The Lancet on 24 Jan 2020 for a cohort of 41 patients, 40 out of 41 or 98% of patients developed a fever, though it was not stated if they developed the fever early or late into the course of the disease. Other reports cite that up to 30% of patients do not develop fever. The jury is still out for fever as a reliable sign. From a study design point of view, the power of a study based on a cohort size of 41 is debatable. We need bigger studies.

In Singapore, there is no evidence of community spread. Strictly speaking, there is no cause for panic. Or even N95 masks. So surgical masks should suffice for front line staff unless you are dealing with a suspect case, pending serological confirmation, in which case you need to get a N95. But if you are dealing with a suspect case, you are probably working in a restructured hospital, armed to the teeth with PPEs (Personal Protective Equipment) and as a SARS veteran yourself or a younger doctor supervised by a SARS veteran, you should be OK.

The problematic issues for now remain on two fronts

• Where do we get surgical masks (and other PPEs) in the private sector?
• How to risk stratify and what responses should we make to different risk levels

For folks in the private sector, surgical masks are getting increasingly if not impossible to get. Strangely, you can still get your box of N95s from SMA. But no one can promise you your supply of surgical masks beyond the odd box of 50 masks here or there. That is hardly reassuring to the GPs in the frontlines. This hobbit would like to think or hope that someone is sitting on a war-chest of surgical masks (and gowns) like Joseph hoarding grain in biblical times, now ready to unlock the supply that will be enough to feed Egypt in a famine lasting seven years. Or at least enough masks for seven weeks lah……

As for risk stratification, policy makers have made it clear that travel to China is a major risk factor.

Returning (from China) students and healthcare/eldercare workers are required to be quarantined. The selection of these groups reflects the thinking that these are people with the potential for spreading the disease to many people quickly, should they be infected.

A much more worrisome point is that it has now been reported that 2000 persons who are now in Singapore have been to Hubei recently. How many of these are already carrying the infection? What are the chances that community or local transmission will arise from these 2000 persons?

The next question we must ask is that how do we enforce a proper quarantine for these groups? Should they be monitored closely like in the past during SARS? Does home quarantine suffice, since fever may not be a reliable sign and they may be infectious during incubation and hence may spread the disease to family members? Should we think about hotel quarantine instead? (Since there are going to be quite a few empty hotel rooms soon, I guess)

There are many questions. But as with any novel disease outbreak, the answers are few. We need to buckle down, keep our morale up, and observe strict discipline in our infection control practices. These are obvious.

What is less obvious, and quite worrisome, is that we must avoid the mistake that many generals make – generals often fail or get defeated when they fight the last war.

These is a new enemy. A new war. We have to think new too.

A Word About Locums

Locums are an important segment of the profession, particularly for those of us who work as GPs/Family Practitioners.

This hobbit used to do a lot of locums in his younger days. Mainly because he had mouths to feed and loans to pay. Old coots like me will reminiscence about the bad old days when we were paid as low as $40 an hour, saw 12 to 15 patients per hour etc.

Times have changed. From the chat groups I am in, I hear disturbing stuff about some locums. They may not represent the majority and it is unfair to tar all locums with the same brush. Apparently, there are locums that:

1. Refuse to see more than 4 to 5 patients an hour
2. Refuse to take blood (or perform any procedure) or give injections
3. Refuse to see female patients
4. Refuse to see children
5. Refuse to review lab and radiological reports (even if ordered by the locum)
6. Refuse to turn up the next day (although already booked for say, the entire week) unless you pay him more per hour because the clinic was busier than what the locum thought.

The last point is particularly galling because it is purely a point about lack of honour and professionalism bordering on blackmail. I wonder if our mammoth SMC ECEG covers such unbecoming behaviour.

There are one or two infamous locums in my time that are still circulating perilously in the market now as full-time locums which many GPs are afraid to engage. But most of these stories involve young doctors. They may be full-time or part-time locums.

But this is not another article by an old coot complaining about the state of young doctors and locums. Other than point 6 above, the other five points beg the question – what is the root cause? Is it just bad attitude? Maybe not.

My guess is that maybe it is also due to competency, experience, and risk-averseness.

One cannot but wonder with today’s residency and workload caps, are young doctors trained to cope with high workloads? Also the breadth of experience that the system affords. For example, other than in polyclinics and A&E, many young doctors never see kids after they graduate. In NHG for example, there is no paediatrics or O&G department. With the three clusters now firmly in place and cross-cluster movement of doctors not happening much if at all, how does one get broad-based training?

After all, it doesn’t take much to be a locum. All you need to be is to be fully registered with SMC. But being fully registered doesn’t mean you are comfortable seeing kids or women. The locum may never have been part of a structured training program if he wasn’t a resident.

The other possible explanation is that due to efforts to improve quality and risk-averseness in our public institutions, many things are pushed upwards to more and more senior people and younger people are less and less trained or exposed. This is not new and has been taking place for decades to be sure. In the past, a second year registrar can perform a gastrectomy himself competently. Now, I am not so sure even a second year Associate Consultant can do a gastrectomy all by himself. It’s not entirely a bad thing and its inevitable as society progresses.

But there is a downside when things are carried out too far. I have been told that some locums refuse to take blood because they are “not confident”. And these are not old doctors suffering from failing eyesight or hand tremors. Maybe, it is because many of these “simple” procedures are now carried out by technicians such as phlebotomists and hence the lack of confidence.

Many locums refuse to perform “risky” procedures now (such as H&L injections, ear syringing) because they are not paid adequately if at all to assume the higher risk. They are after all paid by the hour. This is understandable. If I was still locuming, I would maybe do likewise. But taking blood or giving injections and vaccinations are really, really bread and butter.

The point that really needs to be made is that GPs only hire locums because they want their patients to have continuity of care when they aren’t around and that the locums pay for themselves. Yes, the hard truth is that locums have to earn their keep. With locum rates at anywhere from $100 to $120 per hour, a locum has to generate at least $200 to $250 of revenue per hour for the clinic so that it makes hiring the locum worthwhile.

But if a locum refuses to do many things, or caps his work-rate to 4 or 6 patients an hour then it is kind of difficult to justify hiring him. It is really down to the locum’s productivity in dollar and cents. So if a locum wants to stay in the business of locuming (And it is possible to make a very good living by being a full-time locum), he needs to get repeat business from clinics. To achieve this, he has to make more for the clinic than what he takes. It’s that simple.

All of us agree that the quality of locums are really patchy. Sometimes, you really get a locum from hell, and sometimes you get a wonderful one, and all your clinic assistants tell you the locum gets things done with minimal fuss and is even a joy to work with.

Thinking aloud, maybe it is possible to accredit or certify trained locums on a voluntary basis. Maybe a responsible professional body like the College of Family Physicians Singapore can run courses for people to attend and certify these locums of certain competencies and skills. This training is not about the latest in medical science etc but skills every locum needs – common office procedures, like taking blood, ear syringing, I&D, T&S etc as well as certifying stuff like fitness to drive etc.

One may argue that what the locums really need is to attend the Graduate Diploma in Family Medicine (GDFM) course. But frankly, many locums do not have the opportunity to attend a full diploma course. Maybe a Locum Certificate course is all that he can afford for the time being.

I think many GPs in the market who use locums will welcome such a Locum Certificate course. At the very least, the holder of this Certificate cannot say he does not want to give injections or doesn’t know how to take blood and he may even be able to command a small premium in terms of his hourly locum rate.

This reminds me of an old story. Upon finishing his 5-year bond, a brilliant classmate of mine left town and went for his training in the United States as an internist. He is now professor and head of department in a big hospital there. He underwent training in one of the most famous hospitals there. One night while on call, a distressed nurse called him to inform him she could not insert the IV cannula and wanted to call the phlebotomist on-call (but who was not stationed in hospital). My friend said he will insert the IV cannula. At the bedside, the nurse had an ultrasound machine on standby (thinking that the doctor/resident will insert the IV cannula under ultrasound guidance)

He inserted it on the first try without any fuss, without ultrasound guidance, Singapore style. The nurse was extremely grateful. The next morning, his boss, in front of the entire ward team, clapped his back and congratulated him on his grand endeavour of inserting an IV cannula while on call.

I have a bad feeling Singapore medicine may be heading in this same direction.