Random November Pickings

Heng ah.

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

“Kee Chiu” if you do NOT agree.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

 

 

 

 

Guidelines Of Fees (GOF) Revisited

This Hobbit must be getting really old. He seems to be revisiting a lot of stuff lately. First was residency, now the Guidelines of Fees (GOF).

On 30 Nov 17, it was reported that the Health Minister announced MOH will issue fee benchmarks. Health Minister Gan has avoided the use of the word “guidelines” and has chosen to use the word “benchmarks”. This hobbit agrees with him. Face is of paramount importance in this island. “Benchmarks” is less face-losing. “Guidelines” means someone made a grave mistake in 2007 when they killed the SMA GOF.

But there are differences. Benchmarks can be totally passive and clerical. Or benchmarks can be prescriptive, in which case, there is no big difference between “benchmarks” and “guidelines”. Passive benchmarks would be like publishing the 25th and 75th percentile price for a procedure such as angiogram. You really don’t need a committee for this. Just get a statistician to collect data, run through a software and the figures will come out. It’s passive because there is no judgement or wisdom involved because the data is totally dependent on what the cardiologists are charging and the dataset that ensues from this pool of angiograms done.

That is already being done to a large extent as MOH has been publishing bill sizes for common procedures on its website for years.

Therefore, this hobbit thinks that the benchmarks that will come from MOH soon will be “active” benchmarks, akin to the SMA GOF.

The red herring excuse is that the SMA GOF was bad because SMA represents doctors, i.e. service providers and hence there was a conflict of interest and service providers wanted to keep prices high. In face, SMA was labelled a “trade association” by the Competition Commission of Singapore (CCS) and the GOF was deemed anti-competitive by CCS in 2010.

There are two issues here, and let’s not conflate the two issues:

  • GOF are bad for competition per se, hence bad for patients, regardless of who issued them
  • GOF issued by a body of doctors are bad for patients

A sceptic can perhaps believe that because the SMA issued the GOF, it must be bad. If so, perhaps one that is issued by MOH can be good. This is the position today. If not, Minister Gan will not say that MOH will issue fee benchmarks.

But that is NOT what the CCS said on 19 Aug 2010 in a media release. It said “CCS understands that the GOF is an attempt to address information asymmetry in the medical sector. However, CCS notes that there are more effective measures in place today”.

CCS went on to describe measures such as publishing of bill sizes, itemised billing and financial counselling. Obviously, if CCS was right in 2010, there would be no need for MOH to issue fee benchmarks NOW.

If the issuing party (SMA) was the main problem, what the authorities could have done in 2007 when SMA reluctantly withdrew the GOF, was for some party to step in quickly and issue a new GOF or fee benchmarks and not wait 10 years to do so.

So what happened?

Somebody screwed up. Plain and simple. And it was a painful ten years for almost everyone from 2007 to 2017 before someone had the intellectual honesty and humility to admit this.

If you read the proceedings carefully between 2007 to 2010, MOH then did not lift a finger to keep the SMA GOF alive. Neither did MOH approach another party to issue a new GOF of sorts. And CCS firmly decided that the SMA GOF was illegal under the Competition Act.

In other words, CCS killed the SMA GOF and the SMA GOF’s death was contributed by neglect from MOH.

In 2007, just on the eve of the world financial crisis, many believed in the power of the free market, just like the then Chair of the Federal Reserve, Alan Greenspan. Market fundamentalism was at its peak. The term “market fundamentalism” was coined by George Soros, and implied that free markets provide the greatest possible equity and prosperity, and that any interference with the market process decreases social well being. In case you are wondering, Soros meant it in a pejorative sense.

That was what many believed in 2007, including many policy wonks in this island. And this adherence to dogma that free-market forces, of which competition was a key component of, led to the demise of the GOF.

But it was not always so. Certainly, in the eighties, wiser minds occupied important jobs than 2007 which resulted in the SMA issuing the first GOF in 1987. These wise minds  were the late Dr Andrew Chew and the late Dr Kwa Soon bee, successive Permanent Secretaries of Health and Directors of Medical Services. Dr Chew went on to become Head of Civil Service. They met SMA leadership and finally persuaded SMA to come up with the GOF to provide guidance for fees charged in the private sector. Obviously some geniuses in 2007 thought they were cleverer than Drs Chew and Kwa and wanted to absolutely dismantle what these two gentlemen had facilitated – the SMA GOF.

It’s a strange case of SMA never wanting to have the GOF in the first place in 1987 and never wanting to withdraw the GOF in 2007.

But what happened in these twenty years, between 1987 and 2007? These geniuses forgot that the only true test of how good a public policy is, is not dogma but what finally worked and benefited the public; i.e. “increased social well being”

The free market is not an end in itself, it is a means to an end. Likewise, competition is not an end in itself, it is a means to an end. Public benefit or policies that benefit the well being of the majority if not everyone (we can argue about long term or short-term benefits) is the end in itself when it comes to policy-making.

The other dogma is guidelines of fees that are issued by a trade or professional association, such as the SMA must be bad, because trade and professional associations MUST be self-serving. Its interesting that even communist Deng Xiaopeng was more pragmatic – he believed and declared that it doesn’t matter if the cat was white or black, any cat that caught mice is a good cat. But for overly-dogmatic people, the cat cannot be a trade or professional association cat, even if this cat caught mice.

When the GOF was killed, you can see that people were not thinking through the basics. They were just interested in ensuring there was competition and free-market forces were allowed to roam and the cat cannot be trade or professional association cat. Dogma overtook common sense.

Just read what CCS said in the above said media release in 2010, “In general, price recommendations by trade or professional associations are harmful to competition because they create focal points for prices to converge, restrict independent pricing decisions and signal to market players what their competitors are likely to charges. This is a common position adopted by many competition agencies in the world, even for the medical sector”. (Paragraph 6)

From this short passage, you can draw four quick conclusions:

  • As you can see, there was group-think here – “common position adopted by many competition agencies in the world”. A case of monkey see, monkey do?
  • Dogma religiously subscribed to – Competition is an end in itself – “harmful to competition”. What happened to the patient? Should harmful to patient take precedence to harmful to competition?
  • Another dogma adhered to without question – “In general, price recommendations by trade or professional associations are harmful….”.- The cat must go even if the cat caught mice.
  • Government’s position has changed in 2017. But it doesn’t matter who issues benchmarks and guidelines, the results are still the same, they create the same three effects which are harmful to competition, which are “focal points for prices to converge, restrict independent pricing decisions and signal to market players what their competitors are likely to charge”. What was anathema in 2007 is now acceptable in 2017 save for the fact that now the cat is the government itself.

So who really benefited from a world without GOF between 2007 and 2017? If you really think about it, only one group of people – the doctors who charged more than they otherwise would have, if some form of GOF, issued by SMA or another party, was in place

So this big hullabaloo between 2007 and 2010 which was supposed to benefit the public ended up helping some doctors make more money. You can’t get more ironic than that.

Let’s hope 20 years from now, some wise guys won’t come around and say fee benchmarks or guidelines are bad and let unbridled market forces make a mess of things again. This hobbit has lived long enough to know folly is often repeatable.

 

 

 

The Petition

Let’s cut to the chase: more than 1000 doctors signed a petition for a fellow doctor. That’s serious business. 1000 highly individualistic and opinionated doctors. Normally, it is hard to even get three doctors to agree on anything like what to eat for lunch, let alone 1000 on something so complex. And the 1000 included more than a 100 paediatricians. So, history has been made, in a way that well, may well unsettle a few people, as it was meant to be, this Hobbit supposes.

Yes, we are talking about the unsuccessful appeal of Dr Chia Foong Lin to the Court of Three Judges against a SMC judgment and the petition that followed which was signed by more than 1000 doctors.

The petition to MOH stated, “We respect the judgement but we strongly feel the punishment was too harsh”.

The background of the case was that a one year-old child was seen by Dr Chia four times and Dr Chia did not manage to diagnose Kawasaki Disease (KD) on no less than 4 (follow-up) occasions and did not do the necessary investigations to exclude or diagnose KD.

Para. 37 of the Grounds of Decision by the Disciplinary Tribunal (DT) stated “Given the clinical presentations of the Patient and the significant risks of adverse and severe consequences resulting from delayed or missed diagnosis of KD, it would be reasonably expected of the Respondent to order such tests during the course of the Patent’s hospitalisation at Gleneagles Hospital. The Tribunal was of the view that such a failure amounted to a serious negligence on the part of the Respondent”. KD is while not extremely rare, is also not a common disease in Singapore. About 50 to 80 cases are diagnosed in Singapore each year, going by estimates.

Having read the Ground of Decision by the DT and the Judgment by the Three Judges, this Hobbit feels that the management of the patient by Dr Chia was indeed suboptimal. There are a few legal tests and standards in force today in Singapore – the Bolam Test, the Bolito Addendum and now the Modified Montgomery Test are used to see if a doctor is guilty of professional misconduct.

The Hobbit, being totally untrained in the law and also congenitally stupid, uses a simpler test – it’s called the MBBS Final Exam test. If this patient was a long case in the MBBS Finals, would I have passed the final-year student and unleash him to be a house officer had he behaved the way the doctor did?

The short answer is probably “no”. If you are a particularly merciful examiner, you would have at best given a borderline pass to this student. This standard or test would apply to medical officers and GPs. But since this case actually involved a paediatric specialist, the answer is still “no” (held to a higher standard than a final year student taking MBBS final exams or a GP). That’s why specialists are called specialists and are better paid than GPs and medical officers.

But would that alone warrant a 3-month suspension? This Hobbit suspects this is the biggest question that is on the minds of most of the 1000 doctors that signed the petition. This Hobbit doesn’t think it warrants a 3-month suspension either. Maybe a censure and a fine or even a shorter suspension period of say, 2 weeks.

But wait, the Medical Registration Act (MRA) which empowers the SMC DT, doesn’t allow for anything less than 3 months [section 53(2) of the MRA allows for suspension of “not less than 3 months and not more than 3 years”].

This is the problem. And it has been noted to be so since 2011. But nobody who could amend the law did anything about it. Here are the facts: In another unsuccessful appeal case involving Dr Eu Kong Weng against the SMC in 2011, the Three Judges (which included the then Chief Justice) wrote in their Judgement

“We agree that a suspension is called for, and if we had the discretion, we would have imposed a shorter period of suspension. However, the law does not allow us to do that as the 3-month suspension is the minimum mandated by s 45(2)(b) of the Act”.

So, despite the Judges’ statements in 2011 which is on public record, nothing has changed since then. The law was not amended. If a doctor is suspended, it is for at least 3 months. It is noteworthy that in the Grounds for Decision for Dr Chia’s case, the DT did state in para. 65 “Accordingly, the Tribunal ordered that the Respondent be suspended for the minimum period prescribed by law” (emphasis mine). Had the law allowed for a lower minimum period of say, 2 weeks, would the Tribunal have also given the minimum period? And would 1000 doctors have signed the petition if the suspension was just for 2 weeks? All these are of course, speculative and we will never know the answer.

The other issue is with the conviction itself. Many doctors (as does this Hobbit) believed that Dr Chia committed what was essentially cognitive errors which led to suboptimal management of the patient. Should cognitive errors be classified as “serious negligence”? And since there is serious negligence, by logical inference, there must be “non-serious” negligence. This hobbit’s reading of the Grounds of Decision is that Dr Chia had at least 4 occasions to follow up and diagnose or exclude the differential of KD, which she did not. This is regrettable. But a few questions remain:

  • When does cognitive error cross over from “non-serious” negligence to “serious” negligence? What is the legal test for this, to separate the two groups of negligence?
  • Do all cognitive errors equate to serious negligence?
  • Does the disciplinary and appeal process involving the Complaints Committee, DT and Court of Three Judges even recognise this concept of cognitive error?
  • Of even more fundamental importance, is there any room for the realm of honest mistakes, of which cognitive errors is a subset of?

A secondary issue with this case is that of expert witnesses. Expert witnesses called by both sides were noted to be “eminently qualified”, “knowledgeable and objective”.  But the DT preferred the opinion of the expert witness from SMC in the end. The DT noted that the Respondent’s (i.e. the doctor’s) expert witness “took a more sympathetic and charitable view of the case at hand”.

This is a tough one. If an expert was abhorrent of what the doctor had done and was not at least mildly sympathetic and charitable, would the expert even agree to be an expert witness for the defending doctor in the first place? So, if being sympathetic and charitable discounts the expert’s witness weight in the eyes of the DT, then the doctor and his expert witness is already always off to a bad start.

Finally, what are the take-home messages from this case for the doctors on the ground seeing many patients every day? Here’s a few:

  • Investigate and exclude differentials promptly, especially differentials with potentially serious complications, as in KD with cardiac complications.
  • Repeated cognitive errors or repeated honest mistakes may amount to serious negligence.
  • We don’t really know what differentiates non-serious and serious negligence. Better err on the side of caution
  • The fact that the patient did NOT suffer any long-term complications (because the child was diagnosed and treated with intravenous immunoglobulin by another paediatrician a few days later) is NOT a mitigating factor.

Does this mean this Hobbit is advocating defensive medicine? Actually, I am not sure what is defensive and non-defensive medicine. It’s better to say this Hobbit advocates practising “survival medicine”. If my registration as a medical practitioner doesn’t survive, all other points are moot. So first and foremost, if I am to do any further good as a doctor in this country or just put bread on the table, I must first remain a registered medical practitioner. Being unregistered, temporarily or otherwise, is no good at all. Therefore, I just have to do what it takes to stay registered.

 

 

Black Hole Trek: Into Darkness

SMC’s new requirements on doctors with regard to Third Party Administrators (TPAs) are finally in force. But not before some frantic and often bewildering announcements by many stakeholders; including the SMC, the three professional bodies (PBs) and of course, the TPAs themselves.

Many of the TPAs announced some new charging system that did not involve percentages but in fact, still looked like they were fee-splitting, thereby undermining the spirit and substance of the new SMC requirements. Of course, SMC had to respond with a last-minute Advisory and the three PBs also then added in their bit to remind doctors. Finally, several TPAs then responded with a literally last-gasp amendment to the charges and contracts they were offering doctors. A handful of TPAs were issuing new charging schedules on as late as 30 June 2017 – the eve of the new SMC requirements’ implementation.

All these last-minute jostling and positioning maneuvers underlined several hard truths which this Hobbit would like to point out now (and not earlier, as we all have just recovered from brain-freeze and acute attack of attention deficit arising from the FamiLEE saga):

  • TPAs’ primary reason for existence is to maximise profits (like any other commercial entity)
  • There is much ambiguity in the SMC requirements.
  • Indirect regulation of TPAs via SMC is highly unsatisfactory

The first point is obvious. That’s why many TPAs, while removing percentages from the schedules, actually charged more from the doctors and also allowed the doctors to raise their fees. They are there to maximise profits first, then try and save money for their corporate and insurance clients. Nothing wrong with that. But we need to recognise this. TPAs exist to maximise shareholder value (which usually means maximise profits).

The second point is TPAs were prepared to protect or even enhance their margins by eliminating percentages from the charging schedule, but in essence, they were trying to get doctors to skirt the fundamental intent of SMC requirements – which is to prohibit fee-splitting. In the first instance, almost none of the TPAs gave any detailed justification as to how their charges were arrived at on a cost-plus basis. If they gave, it was only the barest and skimpiest one or two-liner justifications.

Some of the TPAs made assurances that actually meant little to the doctors. They told doctors they had consulted their lawyers and their lawyers had assured them their fee schedules were in-line with SMC requirements. The interpreter of any SMC requirement are the Complaints Committee and Disciplinary Tribunals of SMC. The FINAL interpreter of SMC requirements is the Court of Three Judges. If I get hauled up to a SMC Disciplinary Tribunal and get suspended for three to six months, is the TPA going to indemnify me for my loss of earnings, legal costs etc? Not to mention my loss of professional reputation and emotional suffering? Remember, a company can indemnify you for civil damages, but it cannot (and should not) indemnify you financially for the consequences of SMC disciplinary proceedings that are “quasi-criminal” in nature. So as far as this hobbit is concerned, whatever the TPAs’ lawyers said to the TPAs is not worth very much to me unless I am given a copy of the lawyer’s advice in writing. And even then, what redress can I get from the lawyers? They are the TPA’s lawyers, not mine. The lawyers owe a professional duty to the TPA, not me.

This whole episode of last-minute and frantic issuance of advisories and TPA fee schedules and contracts reflects the painful fact that SMC is NOT the correct body to regulate TPA activities and TPAs should be directly licensed and regulated as healthcare institutions. And this hobbit is still wondering why the authorities are so reluctant to do so.

The full weight and risk of this approach of indirect TPA regulation now falls on the doctors and not the TPAs themselves. The uncertainty of SMC’s new requirements, and hence regulatory risk, falls on the doctor, not the TPA. That is why the TPA is willing to take risk by issuing fee schedules that followed the letter but not the substance of SMC’s requirements initially. If the doctor gets hung, the TPA still gets away scot-free (unless the TPA is run by a doctor). It is an unfair playing field manifestly. A simple principle of regulation is that the party who gets the most benefit should be the one that gets punished most severely, but all parties that benefit should be punished. This is the approach taken by MAS (Monetary Authority of Singapore) when they punish both the rogue bankers and the bank if there are money-laundering activities. This was well put by the Managing Director of MAS, Mr Ravi Menon, recently.

But if you take the example of TPA, there is nothing remotely close to this level of thinking. The doctor may get punished severely by SMC, then the TPA changes the way it charges. But can anyone fine or suspend a TPA? Probably not. Who gets the money? Yes, the doctor, but also the TPA. The regulatory risk and downside is fully loaded onto the doctor. TPA – practically ZERO.

Politically it also doesn’t make sense (And this hobbit doesn’t make any comments about politics usually, but he will make an exception here). If the authorities regulate TPAs, they may just displease a few folks who own and operate TPAs. The current regime of loading 100% regulatory risk onto doctors probably irritates and angers thousands of doctors. So the political math just doesn’t add up either.

If you think this is bad, well, things just got worse and darker. We now move into the area of  medical concierge. We are going into pure darkness here. There is no light. We are into the stuff of black holes.

Firstly, medical concierges are not new. They have existed for a long time and there is a role for them, especially for foreigners trying to get medical care here. They help foreign patients find the right doctor, book air-tickets, hotels, service apartments and conduct other support activities etc. They may charge the doctors and/or the patients.

But two new developments have led to a new phenomenon – medical concierges for local patients! One must wonder why would a local need medical concierges since Singapore is so small and connected.

These new developments are:

  • Dwindling number of rich foreign patients, due to our high costs and charges in the private sector
  • As-charged Integrated-Shield Plans (IPs) (especially those with first-dollar coverage riders)

In the recent past, many of these medical concierges were actually insurance agents. Insurance agents are regulated by the authorities through the regulation of insurance companies (“insurers”). These insurance agents/medical concierges were referring patients to specialists and asking for a percentage-based admin fee, not very much unlike what TPAs were doing.

The authorities then reminded these insurers that their agents CANNOT take a fee for such activities. The agents can get paid commissions when insurance policies are bought and premiums paid, but certainly not for referring patients for episodic care.

So the insurance agents stopped doing so, which is good. But then some agents realised “hey, healthcare fee-splitting for referrals is better business than selling policies!”. Quite a few of them promptly left the insurance industry. They are now full-time medical concierges and no more insurance agents. Medical concierges are completely unregulated.

Apparently, these concierges can demand up to 25% of the doctor’s and hospital bills as admin fees. For example, for one inpatient episode: professional fees may be $10,000 and hospital portion is another $10,000. Total: $20,000. The concierge will ask for 25% which is $5,000. This amount may be split between the hospital and the doctor, or more often than not, paid fully by the doctor (i.e. Out of the $10,000 professional fees portion, the doctor takes $5,000 and splits the other $5,000 with the concierge).

The concierge, who is no longer an insurance agent, may work with his former colleagues in the insurance industry to get a steady stream of patients who bought IPs. The specialist bumps up the professional bills to cover the admin fee, knowing that for IPs that have first dollar coverage and as-charged riders, the insurers will pay what is charged. The patient doesn’t feel the financial pain, the concierge gets paid and the doctor gets paid for work. Nobody gets hurt ostensibly (except the insurer).

Where does the admin fee go to? This hobbit hopes that it only goes to the medical concierge. But if one is intellectually honest, one cannot exclude the mathematical possibilities that the admin fees can also go to the insurance agent and/or the patient, in terms of cold hard cash or just a good meal or even a few cans of abalone or bird’s nest. You never know.

These medical concierges here are also acting as one-man TPAs essentially. They are even more difficult to track than the usual TPAs which are companies. This hobbit is told that several concierges are behaving haughtily in the private hospitals because they bring so much business to them. They are not to be messed around with.

How should the authorities address this new front of medical concierges benefiting from local patients with Integrated-Shield Plans? Should SMC now issue advisories on medical concierges?

Frankly, the answers are obvious. But it is not for this hobbit to say them here.

It’s getting really dark, and maybe it’s time for this hobbit to take Flight NCC 1701 to the Undying Realms.

Do not kid ourselves……

Mr Toh Han Li, CEO of Competition of Commission of Singapore (CCS) recently said “High prices in itself is not an infringement of the Competition Act…. we are not a price regulator. But it’s important to understand the reasons behind high prices.”

“Sometimes there are situations where players in the market may not have infringed the law, but there are some features in that market which are not making it work as well as it should be and I think the formula milk study is a good example.”

This was reported in The Straits Times on 5 June 2017. The CCS exists to ensure there is competition. But to the average person in the street, having competition is not an end in itself. Prices are. Yes, more competition usually leads to lower prices. But the key word here is ‘usually’. In many cases, it does not. There is no evidence yet that there is collusion or anticompetitive behavior in the milk powder business in Singapore. It appears all that has happened is that several milk powder brands have tried to improve their branding and position themselves as premium products so as to charge higher prices. There is nothing wrong with that. Singapore Airlines has been doing that for decades, and therefore commands premium pricing. Why can’t milk powder companies do the same?

But while this may intellectually satisfy people who dwell on economic calisthenics, the common folk are interested mainly in prices of products and services.

The same applies to healthcare, While the intellectuals and “competitionists” may scream with indignation that SMA’s Guidelines of Fees (GOF) were anticompetitive and hence rightly abolished, experience has shown that private sector prices have risen much faster since 2007 (when the GOF was withdrawn) when compared to the 10 or 20 years when GOF existed. And it is not just the professional fees, but hospital charges as well. Some reckon that private sector bill sizes (professional fees and hospital charges) have risen by about two to three times since 2007.

So where does this leave us? Higher and higher prices spiraling quite out of control, for one. And naturally, a less and less competitive private healthcare sector. It’s quite ironic isn’t it? The GOF was removed to spur competition but instead led to higher and higher prices rendering the sector uncompetitive as a regional healthcare hub. It is no secret that our private hospitals and specialists depend more and more on local patients with integrated shield plans and private healthcare insurance to sustain their earnings while the number of foreign patients continue to drop as a percentage of total patients seen by individual specialists and private hospitals.

Speaking of earnings, it is now time to talk about earnings of doctors vis a vis Third Party Administrators (TPAs). The new SMC requirements for doctors working with TPAs come into effect in days, from 1 July 2017 to be exact.

As expected, all the TPAs this Hobbit knows about have moved away from percentages. Because the guidance from SMC and the Three Professional Bodies (3PBs) was specific – A fixed fee is better and percentages should be avoided. So there are no percentages in the new TPA contracts offered.

But that’s where the good news ends. Many TPAs have taken the opportunity to raise their charges so that doctors have to pay even more to the TPAs. And many TPAs have missed the woods for the trees, or perhaps they have deliberately followed the letter of the law so to speak, but are still making doctors contravene SMC requirements in spirit and soul.

Time for a friendly recap –

Guideline H3(7) of the SMC Ethical Code and Ethical Guidelines (ECEG) states:

  1. the quantum of administrative fee should “reflect their (i.e. TPAs’) actual work in handling and processing the patients”
  2. “not be based primarily on the services you provide or the fees you collect”
  3. “not be so high as to constitute “fee splitting” or “fee sharing” or which render you unable to provide the required standard of care”,
  4. “If you pass on such fees to patients, you must disclose this to your patients”.

Here are some examples. One TPA has said it will charge $100 for a Table 1 operation and this goes up by between $100 to $200 per table until it reaches $1000 for Table 6B or above.

Of course, there is no mention of percentages. But doesn’t it smell like it’s still “based primarily on the services you (i.e. the Doctor) provide or the fees you collect”? The TPA does not explain in any detail how the resources and effort spent by the TPA to process a Table 1 procedure goes up by 10 times when it comes to a Table 7 procedure.

Apparently, there was another example whereby a repeat consultation charge by the doctor was $45. The TPA wanted to charge $40 with effect from 1 July, which leaves the specialist with $5!. Naturally, many doctors quit and the TPA had no choice but to revise their charges. But for discussion’s sake, had the doctors not quit and the TPA persisted in charging $40 out of $45, would this not amount to “so high as to constitute fee splitting”?

But nonetheless, the $45 charge-limit remains (and it is $70 for a first consultation). These charges are considerably lower than what the Restructured Hospitals charges for an unsubsidised patient. Which means to cover costs, the specialist has to prescribe drugs and order tests to breakeven (“over-servicing”) – This is the slippery slope that no one talks about.

The mathematics of this is quite easy. A specialist hopefully sees 200 to 300 outpatients a month or 8 to 10 patients a day (25 working days a month and many do not see this number). His rental can range from 10K to 25K a month (depending on whether he shares the unit or not with another specialist). His manpower and other costs come up to at least 15K a month. In other words, his fixed cost (conservatively) is at least 25K a month. It could well be as high as $40 to $50K a month. Let’s say his fixed costs is a modest $25K a month and he sees 250 patients, the cost per patient is about $100 a month, way more than the $70 or $45 for first and repeat consultation this TPA is paying. To make sure he doesn’t lose money from seeing patients from this TPA, the specialist needs to order (maybe unnecessary) investigation treatment to cover costs. And in case you haven’t noticed, he hasn’t even paid himself anything to see this TPA patient!! The $100 fixed cost per patient does not include his own pay!

This phenomenon arises because in trying to secure a particular contract, the TPA has to quote a very low consultation fee. The HR manager or insurance company staff is not wise enough to know that the consultation fee is so low and the TPA charges are so high such that in the end, the scheme is not sustainable unless the patient is over-serviced. In other words, the scheme renders the doctor “unable to provide the required standard of care” – the standard could well be a consultation without ordering investigations or treatment.

It’s a sad state of affairs that is not likely to go away anytime soon even though the new SMC requirements will come into force on 1 July. This is mainly due to four factors:

  • Subtle over-servicing is very difficult to prove.
  • Lay people are still interested only in (quoted) price (HR managers and Insurance companies who sign up with TPA)
  • TPAs only take money from doctors and not from insurance companies or employers
  • The authorities are unwilling to regulate TPAs directly and wish to influence them indirectly through the SMC and doctors

The last two points are peculiar to Singapore and hence very important. In most countries, TPAs charge insurance companies and employers as well and not only doctors for TPA services. In Singapore, almost all of a TPA’s revenues comes from the doctors paying them. Obviously, as previously described, there is a strong degree of moral hazard to such one-sided arrangements.

But the biggest problem of all is that at the end of the day, TPAs are unregulated. The common argument is that TPA charges are not a public health or patient safety issue. But if a private sector specialist is only paid $45 or $70 ($60 after TPA fee deduction) for consultation, way below what the restructured hospitals charge (and the same principle applies to GPs and Polyclinics), this will inevitably lead either to over-servicing or poor quality of care- isn’t this already a public health or patient safety issue?

The new fee arrangements proffered by many TPAs clearly demonstrates that TPAs are hell-bent on keeping their profits and margins while paying a cosmetic observance to the new SMC requirements. Doctors are still (if not more) exposed to these new and probably unethical fee arrangements. The attempt to influence TPA behavior through SMC guidelines has not borne real fruit, only the most annoying of obsequious superficialities. One wise gynaecologist compared this approach to a “trans-rectal THBSO” (i.e. theoretically can be done, but hardly the correct or best approach). In short, this approach failed miserably.

Let’s not kid anybody, “no percentages” does not mean there is no fee-splitting. “No percentages” also does not mean that the charges are not “primarily based on the services you provide or the fees you collect”. Let’s not smother ourselves in flaky semantics.

May Musings

As this hobbit writes this column, the world is agog with stories of cyber-attacks crippling services and companies. One of the worst hit is the British NHS. How important is the NHS? If you would be let to believe, the British, in a poll a few years back consider the creation of NHS to be more important than the defeat of Germany in World War 2. So crippling the NHS is a big deal.

The underlying problem is really that of over-optimisation. In a bid to optimise the operations of the NHS, patient records were all made electronic and centralised. That made it ripe for a mighty cyber-attack. It’s the phenomenon of “optimisation to vulnerability”. One cannot escape this phenomenon. It is a trade-off. The question is whether society is waiting to make this trade-off. In Singapore, this question has not been asked. At least not in the arena of a national electronic medical record.

The techies and IT guys do not usually mention this trade-off. They just want to digitalise everything and put it on the cloud, and everyone lives happily ever after. Well, life is not like that, as the UK and NHS are now finding out.

Also, IT is unique in that the IT guys who designed and then operate the system or software are seldom if ever held liable for cyber-attacks. This is in contrast to other disciplines or commercial activity. A company can be sued for designing or manufacturing a car badly or even just a car airbag badly. In contrast, no one has sued an IT firm for lousy software that is easily attacked and crippled.

So to the guys who are rushing to promote some national software or clinical records under the banner of optimisation of healthcare, let the current NHS incident be a warning to them. Especially to the policy wonks who do not really understand what’s happening on the ground. There is some merit still to having dispersed repositories of medical records as a risk management tool as opposed to putting everything in one big virtual cloud. Centralise (“Cloud-ize”?), optimise and digitize comes with risk and consequences. And the more you do so, the greater the risk and consequences.

In the meantime, horror stories of newly minted specialists unable to secure jobs continue to come in to Hobbit Central. Many have been told they will be offered contracts to continue as resident physicians with terms no better than what senior residents get even though they are now fully qualified and registered by the state as Specialists.

On top of that, in response to the glut of residents exiting specialist training, many hospitals are cutting back drastically on the number of new residents they are taking in. This hobbit was told in a certain discipline, the number of residency places being offered has gone down from 12 a few years ago to now 1 or 2 residents.

Obviously, this boom and bust phenomenon is not making anyone happy. The older exiting residents who cannot get a decent Associate Consultant post or the house officers and junior medical officers seeking specialist training are equally miserable and frustrated.

Some disciplines fare better because they were “disobedient” in the past and refused to accept more residents then they could commit jobs to. Others are really suffering now because they listened to the call to suddenly take in many more residents without thinking through the long term downstream effects. In retrospect, unquestioned obedience isn’t such a good thing after all.

The folks who put in place the policy to open up residency places several years ago are still around, just hiding in some corner. They obviously did not read what Milton Friedman said about money supply. A smooth, steady and slow expansion of money supply is key to generating steady and sustainable growth. Printing more money indiscriminately and quickly just exacerbates the boom and bust cycle and creates much misery later. This hobbit thinks the same principles of a “Monetarist” policy should apply in manpower supply planning. We are obviously seeing the similar poor outcomes now due to the irresponsible and rapid expansion of residency places several years ago.

In the longer run, we should even question not just residency places but the actual number of doctors we are producing. The three local medical schools produce about 600 graduates a year. Another 100 to 200 go overseas for medical studies. While no one owes anyone a living, we should still give priority to attracting our Singaporeans back to practice even though they studied overseas. That’s ~750 medical graduates Singapore has to absorb a year.

Singapore has about 35,000 births in a good year. In other words, every year, we have a cohort of 35,000 Singaporeans. Let’s multiply this number by 2 to include Permanent Residents, foreign workers and even tourists. So we have a “modified” cohort of 70,000. Yes, the population is ageing and we need more doctors. But we are also a small country that does not suffer from the inefficiencies of geographical factors such as providing care in rural and remote areas etc. Many developed countries also have ageing or aged population demographics, so a cohort size of 70,000 is about right.

Most developed countries have (practicing) doctor to patient ratios of between 1:250 to 1:400. UK – 1:369; Netherlands – 1:342; France – 1:305; Denmark – 1:287, Sweden – 1:250, Australia – 1:255; USA – 1:400.

Based on a cohort size of 70,000, if we adopt a generous target of 1:250, we only need to produce or recruit 280 doctors a year in the steady state ONCE we have reached the target of 1:250. If our target is 1:400, then we need even fewer – 175 doctors a year once the target has been attained to serve a cohort of size of 70,000. Yet, we are now producing 750 graduates a year (600+150)

Singapore currently has a doctor-patient ratio of 1:430 (MOH data). If we only include practicing doctors, the ratio is probably closer to 1:470, assuming 1 in 10 doctors are employed in non-practising roles or retired but still registered etc. Again, let us be generous here even though the MOH website states that only about 5% or 600 doctors are not in active practice.

At the rate we are going, we will reach the low target of 1:400 in about 4 to 5 years and maybe the high target of 1:250 in 10 to 15 years, assuming the three medical schools keep producing 600 graduate a year and 150 Singaporeans go overseas to study medicine and return to its shores.

When we are at steady state, what do we do with the 3 medical schools? Even if we take the draconian approach that we do not take in anybody from overseas (even if they are Singaporeans), the 3 medical schools need only produce a total of 175 to 280 medical graduates a year.

To have some economies of scale and to maintain quality, an undergraduate school should produce ideally between 150 to 200 a year and a postgraduate school should have a cohort of about 100.

What are the choices then when we have attained our desired doctor-patient ratio (whether 1: 250 or 1:400 or somewhere in between)?

This would imply one or more of the following

  1. We will certainly have to cut down on class sizes in the three medical schools. We may even have to close one medical school
  2. We can make medical education an “export” business, which is what some countries do, such as Ireland. But our cost structures are hardly competitive. If we remove the subsidies for the medical schools, the full cost of medical education in Singapore is probably more expensive than UK or Australia.
  3. There will be a serious and growing oversupply of doctors locally and all its attendant negative consequences.
  4. Medical graduates cannot be trained properly or secure good clinical jobs.

Actually we need to look no further than our neighbour Malaysia. There are now at least 32 medical schools that have set up shop in Malaysia and Malaysians can also get their degrees from overseas, in traditional places such as India or even as far away as in Ukraine.

There are so many medical graduates that they cannot secure house officer positions in government hospitals. There is a waiting list for positions. And even when you do get a house officer job, there are often so many of house officers that each house officer is given just two or three beds to attend to. This is hardly a recipe for good training of junior doctors.

I hope someone in power is thinking about these medical manpower issues now and making the correct policy adjustments and plans in anticipation of the future. The future is often nearer than we think…

Answers to Pointless CME

 

Correct answers are in Bold and Underlined with comments in parenthesis 

1          Which of the following local professional organisations is the oldest in Singapore?

  1. Alumni Association
  2. Singapore Medical Association
  3. Academy of Medicine Singapore
  4. Singapore Medical Council

2          Which of the following is FALSE about Yong Nen Kiong (“NK Yong”)

  1. He is the longest serving President of SMA
  2. He writes a weekly cardiac health column for the Business Times ( he writes a wine column)
  3. He performed the first open heart surgery in Singapore in 1965
  4. He performed the first open heart surgery in Malaysia in 1969

3          Who was the “Agong” of Alumni Association?

  1. Arthur Lim
  2. Chee Phui Hung
  3. Chao Tzee Cheng
  4. WC Cheng

4          Which of the following about LMS is TRUE?

  1. It was a four-year course and was issued by the KE VII College of Medicine
  2. Originally, a LMS graduate was not allowed to take fellowship degrees in UK (i.e. cannot specialise)
  3. It stands for Licentiate in Medicine and Surgery and is a recognised basic medical qualification by SMC
  4. All of the above

5          Which of the following is the odd one out in terms of place of origin?

  1. Soo Khee Chee
  2. Foo Keong Tat
  3. Kandiah Satku (He is from KL/Klang, the others are from Penang)
  4. Tan Seang Beng

6          Which of the following doctors was a paediatric trainee once?

  1. Ho Ching Lin (ophthalmology)
  2. William Chew (endocrinology)
  3. Lee Wei Ling (neurology)
  4. All of the above

7          Who was the first local Professor of General Surgery?

  1. Jimmy Choo Jim Eng
  2. Yeoh Ghim Seng
  3. Foong Weng Cheong
  4. Ong Siew Chey

8          Which of the following about KKH is FALSE?

  1. It once held the (Guinness Book of World Records) record for the busiest obstetric hospital in the world
  2. Was the first hospital in Singapore to perform successfully a IVF procedure using frozen embryos (done in NUH)
  3. The current hospital stands on a cemetery site and the original address of this site is called 1 Jalan Cemetery
  4. It is the first and only public hospital to house a McDonalds fast food restaurant in Singapore

9          Which of the following passed the Part 1 exams of all 3: FRCS, MRCP and MRCOG?

  1. Ng Han Seong
  2. Benjamin Ong
  3. Fock Kwong Ming
  4. Chee Yam Cheng

10        In YLLSOM, there is a Wong Niap Leng Medical Bursary; who is Wong Niap Leng?

  1. He is/was a Professor of Medicine
  2. He is/was a Dean
  3. He was the first person who performed liver transplant in Singapore
  4. He was the canteen operator of the canteen in KE VII Hall in Sepoy Lines

11        Politically speaking, which of the following is the odd one out?

  1. Tan Sze Wee
  2. Chia Shi-Lu (He is an elected MP, the rest were Nominated MPs)
  3. Benedict Tan
  4. Kanwaljit Soin

12        Which of the following is FALSE about Tan Chorh Chuan?

  1. He was Dean of Medicine and DMS
  2. He is an accomplished poet and has published an anthology of poetry 3 years ago (He is an accomplished Chinese art painter, not poet)
  3. He used to be orientation chairman of KEVII Hall (i.e. chief ragger)
  4. He played hockey in KEVII Hall as a block fellow after he graduated

13        Which of the following is FALSE regarding Poh Soo Kai?

  1. He was the first Honorary Secretary of SMA and a founding member of the PAP
  2. He was detained under the ISA for a total of 17 years over two spells
  3. He was released from detention after he confessed to being a Communist (He never confessed to being a Communist)
  4. He was a grandson of the philanthropist Tan Kah Kee and a relative of philanthropist Lee Kong Chian

14        How much did Arthur Lim take home as the founding director of SNEC?

  1. $1,000 a month
  2. $10,000 a month
  3. $20,000 a month
  4. $0 a month

15        The first national specialty centre to be set up in Singapore was

  1. National Heart Centre Singapore
  2. National Skin Centre
  3. Singapore National Eye Centre
  4. National Cancer Centre Singapore

16        Which of the following funded a big part of his undergraduate medical education in Singapore by winning a lottery (i.e. 4D)?

  1. Yeoh Khay Guan
  2. Goh Lee Gan
  3. Teo Eng Kiong
  4. Fong Kok Yong

17        Which of the following is (probably) the richest doctor in Singapore (by value of shares in publicly-listed healthcare companies)?

  1. Lee Hung Ming
  2. Loo Choon Yong
  3. Ang Peng Tiam
  4. Tan See Leng

18        Which of the following is FALSE about TTSH?

  1. The first location for TTSH was opposite SGH on Pearl’s Hill
  2. Tan Tock Seng, the person, was a Straits Chinese born in Singapore (he was born in Malacca)
  3. It set up the first rheumatology unit in Singapore
  4. It was originally called the Chinese Pauper Hospital

19        Which of the following is the odd one out in terms of employment history?

  1. Ang Yong Guan
  2. Paul Ananth Tambyah (The rest were all once “sign-on” regular SAF Medical Officers)
  3. Lam Pin Min
  4. Lim Wee Kiak

20        Which of the following statements about Gleneagles Hospital is FALSE?

  1. After refurbishment, it was opened by Mr Goh Chok Tong
  2. The hospital started out as Gleneagles Nursing Home
  3. It is 60 years old this year
  4. It is named after a valley in Scotland and the valley is populated by many eagles