Game of Moans

The Health Insurance Task Force (HITF) has released its report this month. It has made many recommendations that have been widely reported in the press. Many doctors are understandably concerned.

The full report and appendices can be found at

http://www.lia.org.sg/files/news/2016/10/ManagingSingaporeHealthInsuranceCost_HITF_20161013.pdf

Some of these recommendations include

  • Setting up of fee benchmarks or guidelines
  • Insurance companies setting up of panel of preferred healthcare providers

The Ministry of Health has mostly welcomed and supported these recommendations.

What was not reported very well but was also released as Appendix D to the Report is The Study done by LIA Singapore (Page 27). LIA stands for Life Insurance Association and LIA Singapore is a key member of the HITF.

The study by LIA Singapore found that private hospital bills are increasing at a much faster rate than public hospital A Class or B1 bills. This comes as no surprise. Many people will point the finger at the doctors. But actually if you look at this study (Page 39), the conclusion is that hospital operators are also responsible.

The two-year compounded annual growth rate (CAGR) for room and board charges for private hospitals was 8% (compared to 4% for A Class public hospital patients). The corresponding figure for surgical implants were 13% and 0% respectively. Surgical fees increased at a 2-year CAGR of 10% for private hospital patients and 1% for A Class.

Please note that for surgical fees, the figure includes facility fees which doctors have no control over. So as anyone can see – the FASTEST growing component of private hospital bills are implant charges. Not doctors’ fees. And even if we consider the surgical fees, how much of that are doctors’ fees’ and how much of that comes from facility charges?

The next interesting observation is that median bill sizes for the commonest 100 conditions in private hospitals have hovered just below two times that of A class bills. But in recent times, the figure has crossed beyond two times (Page 37).

The question that needs to be asked is that why should private hospitals charge twice that of A Class bills, bearing in mind A Class bills are already unsubsidised. The answer is simple. A Class bills are subsidised because the land costs of public hospitals are never fully reflected in the bill sizes. Mount Elizabeth Novena Hospital is literally a stone’s throw away from TTSH. But if we imputed the cost of Novena (true and current market cost, especially in the form of clinic suite prices or rentals) into TTSH, this hobbit suspects TTSH A class bills will increase dramatically. The same goes for other public hospitals which are located in superb locations, e.g. SGH or even the newer NTFGH.

And of course, since specialists (cannot use the meaningless term ‘consultants’) in the private sector are generally more senior than those associate consultants and consultants in public sector, their charges should also carry a certain albeit limited ‘seniority’ premium.

Anyway, there are many more nuggets of information to be found in the LIA Study (Appendix D) which bear reading again and again.

The next interesting bit is found in Appendix C (page 26) which is a List of Countries with Medical Fee Structures. Medical Fee Structures is just another term for Guidelines of Fees (GOF). It was stated that Canada, America, Japan, Taiwan and Malaysia all have fee structures for the private sector. The ones that do not have are the UK, HK, Australia and Singapore. Appendix C acknowledged that UK (by virtue of the NHS) has a very limited private sector. The same logic applies to Hong Kong which modeled its system after the NHS in the nineties. Australia has legislation that sets prices for its universal healthcare insurance framework while leaving the private insurers to set prices with private healthcare providers.

That leaves mighty Singapore with looking embarrassingly under-dressed in this department of “fee structures” for the private sector.

Do the rest of the world know something we don’t?

Actually we once knew. We had a SMA GOF, remember? In fact, some of us old coots will recall the GOF was put in place reluctantly by SMA because MOH wanted SMA to do it in the eighties. (Folks who ran MOH in the eighties were smart people who knew a powder keg when they saw one – they passed the powder keg to SMA) Then market fundamentalism (read: sclerotic dogma) took hold and the GOF was outlawed. And we are now exactly where we shouldn’t be.

But there is still hope. The fact that the HITF recommended that fee guidelines and benchmarks be set up and this hasn’t been thrown out by MOH recently means MOH may be inhabited by smart people (again)?. But perhaps MOH has to do the heavy lifting this time since SMA cannot do issue any guidelines (The geniuses at the Competition Commission of Singapore considered SMA a ‘trade association’ and hence the SMA GOF was deemed anti-competitive).

Finally, we need to go back to the main item of the day with this HITF Report – the insurance itself. Insurance is a product, and like all products, can benefit or suffer from good or bad design. So let’s look at how a disaster is constructed from scratch….

In 2005, one insurance company introduced “as-charged” policy plans which meant the insurance company will pay whatever the hospital or doctor charged. Of course, to compete with this new development, other insurance companies quickly followed suit.

Then the government outlawed the SMA GOF in 2007.

Everyone in the developed world has known for a long, long time that health insurance policies with no deductibles or copayments carry the risk of moral hazard (commonly called “buffet syndrome”). That is why Medishield and now Medishield Life have always carried these two aspects. However, as-charged plans quickly evolved to the point where one can purchase riders that removed the need to pay both copayment and deductible. The patient is now totally disconnected to how much his healthcare costs once he has bought an as-charged plan with the appropriate riders. The private sector doctor providing care is also now under practically no restraint when it comes to charging – he knows the patient is not paying but the insurance company is; on top of that, with no GOF, he can practically charge anything since overcharging can only be proven in the most egregious of cases and after much effort.

Someone clearly did not have his eyes on the regulatory ball when insurance products that carried these three characteristics were allowed to be sold:

  • As-charged
  • Riders removing need for copayment
  • Riders removing need for deductibles

And now the genie is out of the bottle. How do we put it back?

The solution is simple. Insurance companies can just stop offering these products and insurance costs and claims will return to more reasonable levels. But that is not going to happen. Because every insurance company is now behaving exactly according to what behavioral economists have described as “Game Theory”. No one is going to stop offering these products because if one company does so, there is no guarantee that the others will follow suit. In fact, the likely scenario is that the brave/stupid company that does this will see all its customers migrating to the other companies that continue to offer such health insurance products. And because all companies want to avoid the calamitous situation where it loses all its customers to its competitors, no one will take these products off the market even though all the companies are locked in this unsustainable embrace of steep rising claims and costs.

So while the private insurance companies will moan and lament, they are stuck in a Game of Moans because all these companies are behaving as expected, according to Game Theory.

In case you think this is just a game, Game Theory is serious stuff. Several economists have been awarded the Nobel Prize for Economics in the last few decades for work related to Game Theory. You may remember Russell Crowe starring as the famous Game Theory Nobel Laureate economist John Nash in the movie “A Beautiful Mind”.

Allowing such insurance products is a mistake of omission. Killing the GOF was a mistake of commission.

The saying, “Every system is perfectly designed to get the results it gets,” is used very commonly nowadays in management and business. Actually this saying was coined by Dr Paul Batalden, an American physician. It is ironic that our private healthcare system and private healthcare insurance are now in this unsustainable trajectory precisely because some people who could have made the right decisions at critical junctures in the past did not. The results we now see in the health insurance industry did not happen by accident.

 

 

Meaningless September

 

September 2016 is not over yet but it has already been a breathtaking month so far. We have seen the arrival of Zika to our shores which has caused much alarm with the number of cases rising from one to 41 over the first 24 hours. The alarm was due more to bad communications than the infectivity of the virus. As investigations have shown, the Zika strain discovered here is the Asian strain and different from the one in South America which has led to microencephaly.

This whole incident may be akin to something like an Italian ‘discovering’ pasta or an Englishman ‘discovering’ tea plants in China. Zika came from Asia just as tea and noodles probably came from China. So there.

The chances of a foetus actually developing microencephaly is also pretty low anywhere outside of South and Central America so far. So seriously folks, we still need to recreate and procreate like Diego, the super-stud Galapagos turtle who has fathered 800 offspring single-pawedly and ensured the survival of his otherwise endangered species Chelonoidis hoodensis. With a total fertility rate of about 1.3, we really need to stand up for Singapore. And of course, do it with a smile.

I had actually wanted to write this month’s column earlier but I had suffered acute backstrain a week ago. But thanks to the timely arrival of the 2016 SMC Ethical Code and Ethical Guidelines (ECEG) as well as the SMC Handbook on Medical Ethics (HME), my acute backstrain has disappeared. This is mainly due to the fact that I had used hardcopies of the two publications (which together number around 220 pages of A4 paper) as weight for back traction over the last two days. Due to the substantial materiality of these two publications, my back muscles have been pulled out of its otherwise spasmodic state. However, I have also developed early symptoms of carpal tunnel syndrome from lugging these publications around. As you can see, the ECEG and HME are ethical, therapeutic and aetiological at the same time.

The requirements of the ECEG and HME now weigh on my brain instead of my spinal cord previously. The common refrain I have heard from many of my fellow doctors is “The ECEG and HME are so long, who is going to read it?”

I have news for you. You may not read it because it is too long, but many lawyers in town are reading it cover to cover accompanied by paroxysmal fits of rapturous joy that are interspersed with episodes of carnal excitement. You see, even though SMC has rightfully pointed out that the HME doesn’t apply to all situations, most situations will still apply. In other words, you will still have to follow the HME almost all the time and you will have the legal burden of explaining and convincing the SMC disciplinary tribunals why the requirements of the HME do not apply in your particular case.

This Hobbit foresees that much time, effort and of course, legal fees will be spent on arguing whether the HME will apply in the context of a particular case. And it will be tougher to argue for why it doesn’t apply than why it does apply. Remember, the ‘default’ mode has to be “it does apply”.

I repeat – Do not be fooled or lulled into complacency, the HME requirements do largely apply to you in most circumstances. If not, they would not have been included in the HME in the first place. And the lawyers will throw the book at you accordingly. From 2017 onwards, with 64 pages of the ECEG and 154 pages of HME, they have a lot more “book” to throw at you legally, literally or physically.

Some of the more interesting recommendations and requirements are discussed below.

You should not be having a meal in a “Michelin three-star” restaurant (Page 150 of HME) when you accept sponsorship to attend an event. The Michelin 3-star restaurant example is quoted literally. But thank goodness there is only one three-star restaurant in Singapore although Joel Robuchon should feel upset that he has been singled out by SMC. So if you happen to be a doctor and are invited by Mr Robuchon to his 3-star eponymous restaurant in Sentosa, you should politely decline. Tell him you prefer the 1-star Waku Ghin at Marina Bay Sands which may actually cost just as much or more. But it’s a one star so SMC may not be so upset. Seriously, you may also want to tell Monsieur Robuchon the truth –  you really prefer Tai Wah Bak Chor Mee to his 3-star haute cuisine. Or maybe the Kasoh Restaurant at the Alumni Association Building which is rated “Bib Gourmand”. It is the only Bib Gourmand (or maybe any Michelin-rated) restaurant in the world located next to a big mortuary. These Michelin reviewers sure dig the kinky stuff….

Another requirement is that you should not have relationships with your patients on social media (page 112 of HME). This poses more problems than not eating at 3-star restaurants with drug and implant reps.  Do I now have to “un-friend” all my patients on Facebook? What if the patient is also my long-lost classmate from primary school whom I have been reacquainted with just 3 months ago when he walked into my clinic for URTI?

And what about the several practicing doctors who are also politicians? Many of their social media followers are also their patients who are also their political supporters. Does Dr JP (aka “The Resusitator”) have to unfriend the Finance Minister? You, as a public figure or politician may not even know or keep track of which of the social media friends (which may number in the thousands) you have made in the past are also your patients.

The HME states that “if patients of their own accord initiate social media contact, you may engage although it is strongly recommended that you do not do so”. This is a very unhelpful statement because “strongly recommended” really means “no”. How you defend yourself in a court of law in the face of the HME’s strong recommendation is something that remains to be seen and tested. “Strongly” comes with legal implications that we doctors may not truly grasp.

Anyway, onto lighter stuff. On Page 131 of the HME, it is stated that “The terms Consultant and Senior Consultant or any variations are meaningless outside of public health institutions or large organisations that employ you where it allows the public and patients to distinguish rank and seniority among large number of doctor employees. In private practice, such terms should generally not be used in your formal designation”.

It was a slow day in the clinic so this Hobbit decided to go to the clinic or practice web pages of the private specialists who sit on the SMC as our esteemed Council Members or on the Working Committee for the review of the ECEG (i.e. the guys who probably drafted this new ECEG and HME).

Guess what? Two of these Council members who were private specialists were described as “Senior Consultant” or “Consultant”. One of those sitting on the Working Committee used the title “Senior Consultant” on the practice website. One GP on the Committee used the word “Consultant Physician” but since he is employed by a rather large private organization I suppose it’s OK.

I like the word “meaningless” used in the new HME on Page 131. But then again, the ECEG and HME will not be in force till 1 Jan 2017. So these SMC Council Members who are private sector specialists using these titles may still be doing so meaningfully now. But as sure as the sun will rise on 1 Jan 2017, if they continue to do so using such designations on their practice websites (which are NOT large private sector organisations, for sure), they will be involving themselves in meaningless activities.

This Hobbit wonders if SMC has ever censured or punished any doctor for doing “meaningless” stuff? Surely SMC Council members must be held to the strictest and highest standards since they approved the new ECEG and HME for promulgation in the first place?

Luckily the new ECEG and HME does not state that digging my nose or plucking my long feet hair is “meaningless”….if not this Hobbit will be in BIG trouble….

To be fair, the old ECEG which has been in force for more than 10 years needed to be updated. Nonetheless, in the zeal to produce something updated, did we have to go to such lengths? Seriously, which profession will inflict on itself more than 200 pages of Ethical Code and Ethical Guidelines as well as a Handbook of Medical Ethics? Not the lawyers, accountants, teachers, dentists, nurses, engineers or architects…

Was it not the wise King Solomon who said “Meaningless! Meaningless!”?. That about sums up what this Hobbit personally feels about some of the stuff in the new ECEG and HME, in addition to the use of the titles Consultant and Senior Consultant in private practice.

Scattered Thoughts of July

July has been a very rough month for Singapore. No. We are not talking about DBS, Stanchart or UBS being inadvertently involved in suspected money-laundering activities. We are not even talking about the multiple murders that took place. We are talking about the fury over the first Singapore Edition of the Michelin Guide. Imagine a bak chor mee stall getting one star. Seriously folks, we should get Eric Khoo to do a sequel to his 1995 hit with “Mee Pok Man 2” – with a Michelin/healthcare twist. It can feature a legendary obsessive-compulsive mee pok man who goes into depression and ends up in IMH after he overcooks his mee pok for the Michelin inspectors (How hard is it to spot a few angmohs eating meepok at a hawker centre??).

Speaking of stars, this hobbit understands that Managed Care (MC) and Third Party Administrators (TPA) have also started to rate or rank doctors. Nothing wrong with that in-principle. Not all doctors are equal. But ranking should be based on facts and objective measures.

For example, recently, certain doctors were preferred by a certain MC company because these doctors were purported to be experienced with good clinical outcomes and their clinics were equipped with good clinical facilities. Maybe this is true. Maybe this is not. On what basis are these doctors deemed to be experienced or well-equipped? Isn’t this kind of laudatory? And while it is not self-laudatory ostensibly, by allowing such practices to continue in the MC and TPA industry, aren’t we allowing the SMC Ethical Code to be circumvented and hence making the Code nugatory?

Is anyone in power doing anything about this? Probably not. Because the market has frequently triumphed over ethics for healthcare in this country, this Hobbit is not hopeful.

Speaking of rankings and lists, here’s another one. A website which describes itself as “an Ego-Stroking Men’s Lifestyle Portal focusing on empowering Men with the latest updates and news relating to Fashion, Business, Health & Grooming, Lifestyle, Technology and Current Affairs” has just published a list of “Ten GoodLooking Doctors in Singapore”. The list includes both male and female doctors. It’s really quite hilarious and if I were on the list, I would have volunteered to be quartered slowly by a bunch of trolls riding on giant worms. Just in case you are wondering, “good looking” is also laudatory but this Hobbit will let this pass. We live in an increasingly miserable world and everyone needs some comic relief.

We move on to something that is more that affects everyone in the medical profession. This is really important, unlike most of the stuff that goes on in this column. In last month’s column, the Hobbit speculated that the Court of Three Judges overturned the SMC Disciplinary Tribunal’s (DT) judgment on the case of the orthopaedic surgeon giving only two days MC to a foreign worker after fixing his fractured wrist was maybe because the DT had erroneously concluded that it had to find intent on the surgeon’s part before it could find him guilty.

Guess what? This hobbit’s speculation was largely correct. (gloating like Smaug this hobbit is….) No, this hobbit is definitely not legally trained. SMC cases and ethics is still about a lot of common sense and listening to how your conscience speaks and not so much “legalese”, unlike what some what the previous bigshots said in the Ivory Building (note: not Tower) on College Road.

But there is a very important development in this case that EVERY doctor must know. And this is the point regarding how the Three Judges gave a suspension of six months while the SMC lawyers only asked for four. This is quite unprecedented.

The ground for decision for the abovementioned case have just been released and on page 48, under the section “Recalibration in Sentencing Benchmarks”, the learned judges felt the need to deviate from sentencing precedents and give harsher punishments because current conditions are different and warrant more severe punishments. It said that there were several SMC cases where sentencing was inadequate in the past.

This is so important that the relevant paragraph (para. 117) is reproduced here:

“As can be seen from Lee Kim Kwong and Kwan Kah Yee, we have on at least one previous occasion referred to and, on another, exercised our discretion to depart from precedents that do not reflect the prevailing circumstances and state of medical practice. In our judgment, public interest considerations weigh heavily in imposing deterrent sentences on errant doctors who are found guilty of professional misconduct. In this regard, we expressed at the hearing that we found the sentences imposed in the Dr K case, Dr L case and Dr Amaldoss case (“the Relevant Precedents”) to be lenient. We observed without reservation that these sentences should have in fact been longer. We highlighted to the parties that this court has given fair notice of its intention to recalibrate sentences across professional misconduct cases, and would do so in the present case.”

Doctors have to know that the final powers of interpreting legislation passed by Parliament lie in the Courts, and not SMC or even MOH. In this case, the relevant legislation is the Medical Registration Act (MRA) which provides for the existence of SMC and empowers the SMC to punish doctors. While the courts cannot give out punishment that is more severe than what the legislation specifically allows for, it certainly can decide on how severe the punishment should be as long as the punishment is within the limits provided for by the relevant legislation.

So here, the “this court” has, in the name of public interest, interpreted the relevant part of the MRA and within its powers, decided that the surgeon deserves six months of suspension instead of the four asked for by SMC. More importantly, this is not a once-off decision as “this court has given fair notice of its intention to recalibrate sentences across professional misconduct cases….”. “This court” which consists of the Chief Justice and two Judges of Appeal, is for all intents and purposes, the highest court in the land with regard to SMC appeal cases. There is no higher court. Repeat: this is a new development that is not once-off.

All doctors are hereby warned.

You know, just when you thought things are getting so depressing here, it can’t get any worse? Well, it sure can.

Recently, this Hobbit heard of a resident who on realising there is no specialist job available for him upon completion of residency, quit residency with less than a year left to go. He has since joined a bank, I am told. The lack of jobs upon completing residency is now commonplace.

The sort of long-term Confucian relationship between a department and their residents and between the boss and his juniors is now truly gone. Gone by shortsightedness and a utilitarian approach to manpower planning. And it’s about to get worse down the line with the large number of undergraduates we are producing locally and those returning from abroad after getting their MBBS. For those of us not in the know, the three medical schools are now taking in more than 500 students a year. Where are they going to find training and long term jobs beyond their bond period nobody knows.

The public healthcare system thinks it needs a lot of junior medical staff to run the public healthcare system. (undoubtedly exacerbated by the low-efficiency residency system), but it doesn’t know what to do with all these junior doctors beyond the first few years. We need to change direction soon but everyone is mired in policy inertia, much like how our population policy was still stuck in the “Stop At Two” phase when our birth rates had long declined to justify such an anachronistic position.

The legal profession is more responsive and cleverer than us. They clamped down on the list of overseas law schools recognised locally recently as soon as they realised that a glut looked imminent. As for the medical profession, we now have residents with no jobs after finishing residency but nobody is clamping down on nothing.

Maybe in the years to come, we will have another one-star Mee Pok Man; one with MBBS, MRCS. His surgical training is probably more relevant to cooking than to being a banker.

June Speculations

SMC is back in the news again. Like some wild boar that keeps charging back in Kranji and Punggol….the difference is that some will say the boar has comparatively more grace and finesse.

It gives this Hobbit no pleasure to write about this. Some of them are what you call legacy issues. Others are current and the ball is in the court of those sitting there now.

The first case is that involving an orthopaedic surgeon in private practice who was suspended by the Court of Three Judges for six months because he gave the poor foreign worker he operated on for a wrist fracture only TWO days of MC.

Obviously, this is wrong. I was an orthopaedic MO once and I wrote many MCs for patients discharged after such a fracture was fixed. If I gave any such patient only two days of MC post-op, my consultant would have burnt me at the stake during the weekly department trauma round.

But interestingly, the SMC Disciplinary Tribunal (DT) acquitted this orthopaedic surgeon. The SMC lawyers appealed against the Tribunal and asked for the doctor to be suspended four months, citing aggravating factors.

The Court of Three Judges that heard the appeal not only overturned the ruling of the DT, but gave the SMC lawyers more than what they asked for – a suspension of six months!

I am not a fan of the SMC lawyers usually. But I guess they were right to appeal in this case and press for punishment.

The detailed grounds for decision of the Court of Three Judges for this case is not out yet publicly. But SMC said in its press release that “The Court noted that Dr Wong had considered “irrelevant factors” in issuing the medical certificate and “disregarded the patient’s wellbeing”.

What is significant is that this case is heard under the latest revised Medical Registration Act (MRA) in which every DT must have one member who is a senior legally trained person or legal service officer. I am told there was a very senior or retired district judge on this DT. So what happened? What went wrong even with the mandatory legally trained person on the DT?

Remember when many doctors were unhappy and protested when this provision was made? The then Director of Medical Services defended this provision robustly as if this was the panacea to several SMC’s problematic rulings.

Obviously, with this latest case, it can be seen that having a senior legal officer is no panacea. There is a lot of egg on some folks’ faces.

This Hobbit is no lawyer, but here is some speculation. ALL SMC cases are considered quasi-criminal in nature. This sounds terrible but actually it’s a blessing for doctors. Because it is quasi-criminal, the standard or burden of proof is “beyond reasonable doubt”, as opposed to civil suits where it is just the “balance of probabilities” (>50%).

If the judge finds that you are wrong based on the probability of just more than 50%, you lose a civil suit; i.e. balance of probabilities. But it is much, much harder to prove you are guilty “beyond reasonable doubt”. One of the key factors is intent. That’s why it’s not a bad thing for SMC cases to be considered quasi-criminal.

But the key word here is “quasi-”. SMC cases share a lot of similarity with criminal cases, but the two are not entirely the same. Hence “quasi”. One key dissimilarity is that you do not have to prove intent if the damage done to the patient is so gross and the suffering so great and obvious.

For example, a patient is known to be allergic to penicillin and the junior ward doctor gives it intravenously to the patient due to oversight, fatigue, or whatever. The patient dies. You do not have to prove intent here. The junior doctor is still guilty of professional conduct and would probably have been suspended.

To give another example. If another orthopaedic surgeon accidentally amputated the wrong leg, you do not have to prove intent. The harm is so gross and the suffering by the patient so great that the surgeon should be suspended.

The first part of Paragraph 16 of SMC’s press release on 16 May 2016 is reproduced here:

“Nevertheless, the DT acquitted Dr Wong on the basis that SMC had not proven beyond a reasonable doubt that Dr Wong’s departure from the applicable standard of conduct was intentional and deliberate.”

This Hobbit speculates that the deviation from standards and the suffering of the patient is so great that there is no need to prove intent here beyond reasonable doubt. And that is probably why it is speculated that the Court of Three Judges overturned the DT’s decision of acquittal and even gave a sentence stiffer than what the prosecution had asked for. This is just pure speculation on my part. Let’s see what the Court of Three Judges say when their Grounds for Decision are released in due course.

Enough legal talk. Let’s move back to ethics. It is now out in the open. No, I am not talking about Taylor Swift smooching with Tom Hiddleston (aka Loki). Seriously, if you want to choose a baddie, try Michael Fassbender (aka Magneto). Ian McKellen (aka the old Magneto) is not interested in Taylor Swift, unfortunately.

We are talking about the “admin fee” charged by Third Party Administrators (TPAs) or Managed Care (MC) companies. This came to public light during a symposium organised by The Care Cooperative which was reported by The Today Newspaper on 10 June 2016. Apparently, from the article, the percentage fee can go up to 25%!

It has also been made known that the Singapore Medical Association (SMA) has written to the SMC asking for “definitive advice”.

This Hobbit is not holding his short breadth for this one.

The usual advice we have been getting from SMC is something that goes like “SMC expects all registered practitioners to adhere to the ethical standards as prescribed by their SMC Ethical Code and Ethical Guidelines and to put their patient’s interests first when they discharge their professional responsibilities”.

Of course the actual words may differ somewhat, but the gist is something like the above.

In essence, in Hokkien, it is like “Gong Liao Boh Gong”. (Loosely translated into Singlish – say already like never say).

What doctors at the frontlines dealing with these TPA and MC companies really need is “definitive advice”. Motherhood statements like the above do not constitute “definitive advice”.

Definitive advice in this context comes in the form of “yes” or “no” answers.

Can I give the TPA and MC companies an admin fee based on a percentage of what I charge their patients? There are only two possible answers to this question that can be considered as “definitive advice” – “yes” or “no”.

If the answer is “yes” – then the profession has been definitively advised – which is a useful thing.

If the answer is “no”, can I give an admin fee at all, not based on percentage? Again, the possible answers which constitute “definitive advice” can only be “yes” or “no”.

In fact, not only are doctors hoping for definitive advice, this hobbit thinks the TPAs and MC companies are also wishing for the same thing.

So why isn’t the definitive advice forthcoming?

The problem I suspect is that there are some folks who are tying themselves in legalistic knots that have nothing to do with ethics.

This Hobbit again speculates that the (stupid) logic may go something like this:-

  • The MRA determines that SMC should exist and defines the terms of its existence
  • The terms of existence are such that SMC can only deal with doctors (and their professional practices) and nobody else.
  • Hence, SMC has no say over how TPA and MC companies operate.
  • And if SMC strays outside of regulating doctor’s professional practice by directly (or even indirectly) commenting on TPA and MC matters, SMC may be considered to be out of line and may even get sued or get criticised by the Courts in some test case.

The speculated answers to this speculated stupidity are:

  • In Singapore’s context, no TPA and MC companies will EVER dare to sue SMC, a statutory body. The chance of this happening is even less than Leicester winning the next EPL season. (OK, I submit I may have to eat my hat on this next year)
  • The Courts also need to know what SMC thinks about this.
  • The patients, i.e. the people of Singapore need to know what is SMC’s position on this.
  • SMC may not be empowered to regulate TPA and MC companies, but ALL doctors are regulated by SMC and these doctors DEFINITELY need to know what SMC thinks about this, whether they can pay a commission or admin fee based on a percentage of a doctor’s professional fees. Put it this way, SMC does not allow doctors to have sexual relations with their patients – this does not mean SMC is regulating the patient’s sexual behavior or love life.

Life is really very simple. If you are put into or elected to a position of power and responsibility – then stick your neck out on important issues that pertain to that position. If you are not prepared to stick your neck out and want to hide behind motherhood statements or some legalistic mumbo-jumbo, and all you want is to wear a nice, long gown during ceremonies and bask in the pomp and pageantry, then please do everyone a favour, step down.

And just to be intellectually honest and clear, definitive advice can come in the form of a “yes” answer – it is OK to give the commission or “admin fee”. Then everyone can also breathe easier rather than live with all this uncertainty. Of course, this Hobbit prefers the “no” answer but “yes” is still better than motherhood statements. At least someone is sticking his neck out….

Which brings us to the upcoming SMC elections. People who want to consider running for SMC elections, please be prepared to stick your neck out and give definitive advice when the crunch comes.

Again, this is pure speculation. This hobbit is still hoping definitive advice is coming our way. But it will also not be completely unexpected that we won’t be getting any.

But anything can happen and we should retain some optimism. After all, if Tim Hiddleston (aka Loki) is rumoured to be the new James Bond (aka 007) and is dating Taylor Swift, anything can happen.

Anyway, enough speculation for now. Let us doctors now return to the realities of ethical ambiguities, professional frustration and economic imperatives…..

 

Bigger than War on Diabetes

It finally happened.

As it surely must. What we had expected has come to pass.

I am not talking about the sequels to X-men, Captain America or even Chen Shao Mao challenging Low Thia Khiang to be the leader of the Worker’s Party. I am not even talking about the arrival of the Zika virus in Singapore.

Speaking of the Zika virus, I must say that, like our taxation regime, it is a “progressive” virus, (i.e. affects the rich more than the poor). This can be seen by the fact that the virus came through a permanent resident living in the posh Watten Estate area, after he had spent some 6 weeks in Sao Paolo, Brazil. This permanent resident is probably rich to be living in Watten Estate, can afford to spend 6 weeks in faraway Brazil and also sought medical attention with a specialist working in a private hospital.

The bus captain living in a Punggol 4-room HDB flat cannot afford to go to Brazil for 6 weeks or see a private sector specialist.

But this hobbit digresses. What has come to pass is common sense prevailing. For some strange reason, this hobbit has suspected that some folks in Ministry of Health are waging a secret war that is even bigger than the War on Diabetes – the War on Treadmill. I think these folks may have a fetish to see treadmill testing eliminated in this country.

To me, treadmills are a relatively cheap and safe test to investigate a potentially and frequently fatal disease – Ischaemic Heart Disease. But some folks want to regulate it to death, as opposed to using it to prevent death. MOH issued a circular on 14 Dec 2015 saying hat it has finalised the “Guidelines on Provision of Electrocardiography Stress Testing (EST)”. It further said the Guidelines would take effect on 1 May 2016.

The circular and the appended Guidelines are very interesting in at least 3 aspects:

  1. It said it had consulted respective professional bodies and has finalised the Guidelines. As far as this Hobbit knows, consultation indeed happened. But there probably wasn’t agreement. So while it gives a veneer of concurrence because it “consulted”, there probably wasn’t real agreement. This can be seen by the next two points –
  2. Under Paragraph 3 or Section III of the Guidelines, “Patient Selection”, it is stated that should a patient who does not fall under the indicated criteria for a treadmill be offered one, he needs to be given “a cooling-off period of 7 days to consider whether to proceed”. I am not making this up. This hobbit will bet his last pint of beer that the requirement for a cooling-off period of 7 days for a treadmill cannot have come from a person who actually practises clinical medicine or any of the aforesaid unnamed professional bodies.
  3. Lastly, while the circular is titled “Guidelines on Provision of Electrocardiography Stress Testing”, the next page shows the list of people who are purported to be responsible for these Guidelines and the page was headlined “Treadmill Services Workgroup”.

These are incredible times. An 18 year-old girl can get an abortion legally in a licensed clinic in Singapore on the same morning but a purported healthy guy needs a seven-day cooling period to get a treadmill. Where is the sense of proportionality here?

By the way, real doctors call a treadmill test, “A treadmill”, not electrocardiography stress testing, for crying out loud. And even if you do it call by that dreadfully long name, then do not call the workgroup “Treadmill Services Workgroup”. If you want to be annoying, please be consistently annoying.

This hobbit still doesn’t understand what is the fuss about ordering an un-indicated treadmill for a healthy person. What is the big downside? Did anyone get hurt? Yes, the doctor made an extra buck along the way. We may even discover the occasional asymptomatic IHD patient who claims to be very healthy and prevent a sudden death. So why this obsession to regulate a relatively cheap and safe investigation modality to oblivion? Don’t we have better things to do like examine why are people getting 8 to 10 stents inserted into their coronaries electively? Or look into why are people charging $10,000 or more for a colonoscopy? Or as this hobbit has said recently, regulate the Wild, Wild West that is managed care and all the kickbacks, fee-splitting and commission paying that is happening there rampantly?

But some folks just want to have their little private war and make the humble treadmill the Jose Mourinho of medicine. (The Special One). Can’t we just make it The Normal One (like Jurgen Klopp) instead?

Instead of doing real meaningful regulatory work, these geniuses want to stamp out unnecessary treadmills as if the treadmill posed a real great danger to our already battered healthcare system. It’s like trying to stamp out littering and jaywalking in war-torn Syria now. Seriously folks, if you have too much time, go to Watten Estate to swat mosquitoes.

So it is with great satisfaction that on 26 April 2016, an email was sent out to all licensees of clinics with an appended circular that the implementation of the Guidelines, originally slated for 1 May 2016, has been deferred till further notice. For the uninitiated, defer till further notice is the equivalent of  “a Prata” (Singlish).

But even here, the act of informing all licensees could be done far better. ALL the licensees’ email addresses are listed on the “cc:” section of the email in hyperlink mode. This is terrible email etiquette. The least the sender could have done is to put the licensees’ email addresses on the “bcc:” section so that the licensees’ email addresses are not exposed in a long list to everyone on the mailing list. I had to scroll down for what seemed an eternity just to get to the message proper and then open the appended files. Moreover, just because the government is not subject to the PDPA requirements does not give a civil servant the moral authority to share my email address with a few hundred other clinic licensees and vice-versa. What if the entire list of addresses was passed on to some pesky internet marketer or internet conman etc?

A wise wizard once told me that the most dangerous people to hang around are those that are diligently stupid. People who are lazily stupid actually do less harm. I guess this case qualifies….

Anyway, since this hobbit doesn’t offer treadmill services in his clinic, it’s really of little concern to me other than that his email address has been made known to a few hundred other clinic licensees. Time to go to Pek Kio hawker centre to get my prawn mee after the big clean-up so as to celebrate The End of The War on Treadmill (hopefully).

 

Baking April

I have added an afternote to the original posting….

hobbitsma

This is probably the hottest April Singapore has ever felt. And we are not talking about the weather. Although it’s certainly baking this April. We are also not talking about the parliamentary budget debates, which was about as exciting as watching the threads fray more and more on my clinic tourniquet.

We are not even talking about two major earthquakes on opposite sides of the Pacific. We are talking about accusations of dishonor and some very funny monkey business interspersed with relentless reporting of the actress Rui En asking “Do you know who I am?”

Like most hobbits living in shires, I don’t know.

Meanwhile, after years of writing absolute rubbish, this Hobbit is suddenly overcome with pangs of fear that he may have accidentally, unknowingly plagiarized somebody or something (including Wookie-like yawns, Ogre rants and R2D2 beeps).

Since the last column on managed care, many alert readers have asked…

View original post 1,743 more words

Baking April

 

This is probably the hottest April Singapore has ever felt. And we are not talking about the weather. Although it’s certainly baking this April. We are also not talking about the parliamentary budget debates, which was about as exciting as watching the threads fray more and more on my clinic tourniquet.

We are not even talking about two major earthquakes on opposite sides of the Pacific. We are talking about accusations of dishonor and some very funny monkey business interspersed with relentless reporting of the actress Rui En asking “Do you know who I am?”

Like most hobbits living in shires, I don’t know.

Meanwhile, after years of writing absolute rubbish, this Hobbit is suddenly overcome with pangs of fear that he may have accidentally, unknowingly plagiarized somebody or something (including Wookie-like yawns, Ogre rants and R2D2 beeps).

Since the last column on managed care, many alert readers have asked this Hobbit about the issues of “fee-splitting”, “inducement” and “commission”. To short guys like me, life is simple. When it doesn’t smell right, it usually isn’t. Take dwarves for instance, they don’t smell right. Neither do orcs, they smell even worse.

That is not to say that this Hobbit is super-righteous and adopting a holier-than-thou attitude. Far from it. This Hobbit has its fair share of shadows and skeletons in Storm Giant-sized closets. But that should not prevent anyone from speaking out against something that is poisoning private practice doctors and the private healthcare sector. Especially when it’s early days still and what participating doctors really need is guidance and not condemnation or even criticism.

The issue is that we (and that includes me, This Hobbit) are so enamoured with the money and business of medicine and managed care that we euphemise the sin, make black become grey and increasingly paler and paler shades of grey until it looks a creamy light yellow. But it will NEVER be pure, pristine, 100% white.

We get de-sensitized and refractory to further such stimuli. The originally painful pricks to our conscience have become just what they now are – little pricks. And no more.

Let’s take the example of the 15% fee that managed care and third party administrators demand from participating doctors and clinics. In the normal course of business, a company bills another party for work the company has done. The bill is derived from the work and costs incurred by the company and topped up with a profit margin. There is NOTHING wrong with making a profit. But the point is that the bill is derived from the work and resources employed by the billing company (where work was done and costs incurred).

In this case, the billed amount is derived from the work done NOT by the billing company  BUT by the clinic and the doctor. In business terminology, that is usually called “a commission”. Calling this an “administrative fee” is just a euphemism or circumvention for “commission”. It is a commission dressed up as an administrative fee. When you dress an orang-utan in human clothes, it is still an orang-utan. The Uniqlo, Marks and Spencer or even Christian Dior apparel doesn’t make the orang-utan human.

When you buy or sell or house and use a property agent, you pay him a commission derived from the value of the property transaction, not from the effort the property agent has put in. That’s the way the property sector works. But this is not how the medical profession works (or at least worked in the past and is supposed to work).

Why is this so? Because the medical profession has its own set of ethics and professionalism. The fundamental basis for a patient referral is that we refer a patient to the doctor we think is best for the patient. In other words, a referral must be made based on the patient’s best interests. It cannot be based on whether the doctor gets the referral because he is willing to part with 15% of his fee or not. This giving of a percentage of his fee to the referring party is called “fee-splitting”. A long time ago SMC actually suspended a doctor for fee-splitting (in the eighties) with another doctor. And if you ask this hobbit, it doesn’t matter if the referring party is a doctor or otherwise. The referred doctor is guilty of fee-splitting as long as he gives a percentage of his professional fee to generate a referral (i.e. business). This is inducement to another party to either refer when there may be no reason to, or to refer to the inducer when another doctor is better suited to handle the patient’s medical problems – either scenario is not in the patient’s best interests.

Why is this so difficult to understand? It amazes this Hobbit that very senior members of the profession are finding it so difficult to grapple with such simple ethical principles. Either they have been clouded by money or they are just not getting back to the basics of ethics when they think.

Or let this hobbit put it another way. How will the public react when they find out that doctors give up 15% of their professional fee to another party just to get referrals? Do you think patients will consider it an “administrative fee” or a “commission” or worse, a “kickback”?

I guess to the layman, it depends on the amount. If it is 15% of say, a $60 bill from a GP- that comes up to $9. We can explain that the managed care company needs to deploy resources to administer the managed care or third party administration program and to make a reasonable profit. Most members of the public will say, “Yeah, it’s OK to pay them $9 a case”.

But let’s say it now involves major surgery and the surgeon’s fees is $12,000, the anaesthetist fee is $3000 so total professional fees come up to $15,000. 15% of $15,000 is $2,250. That’s a lot of money to pay a managed care company for one referral and subsequent administrative work. How can you justify that? To the public, this is most likely a “commission” to induce a referral. That’s because $2,250 bears no semblance to what resources that managed care company has used up to link up the patient with the doctors concerned and the consequent administrative work e.g. billing and payment etc. It is a cut (i.e. a percentage) of the professional fees given out as commission to the managed care company. Pure and simple.

It doesn’t matter what fantastic mental calisthenics we doctors play in our minds to try and justify this commission fee and salve our conscience (i.e. dress the orang-utan). It is a commission fee dressed up as an administrative fee, but at its heart, it is still a commission paid by the doctor to the managed care. That’s how the public will in all likelihood see it. Because everyone understands that without this 15% commission paid out, the managed care will not give this referral to Doctor X.

Or put it another way, Doctor Y who refuses to give the 15% but will really pay an administrative fee (which let’s say, can even be as high as twice the amount of the true cost, i.e. 50% profit margin- good by any standards) will NOT get the referral from the managed care company.

Like I said, if it doesn’t smell right, it usually isn’t.

Maybe this Hobbit is just bloody old-fashioned and out of touch with reality. Some folks have told me, doctors need to eat too. What’s wrong with giving up 15% to see more patients and earn more money?

I certainly hope SMC can do something about this. Because if they don’t stop these practices involving doctors, then what is the point of self-regulation? The SMC cannot regulate the practices of managed care companies, but certainly it can decide whether doctors can participate in such practices? Doctors need clear direction and unequivocal instruction from SMC before the collective conscience of the profession ebbs quietly into the night.

SMC and even MOH just need to ask themselves – will public confidence in the medical profession and the private sector healthcare system be diminished, unchanged or improve if the public finds out that this 15% is paid to the managed care companies? If they think public confidence will be unchanged or even improve, then by all means do nothing. If not, they have to do something and fast.

This is because if SMC or MOH doesn’t exercise leadership and give clear direction, then self-regulation will give way to trial and judgment by public opinion. And it won’t be pretty then.

To be absolutely honest, this old coot of a hobbit is gripped by doubt too lately. I am beginning to think that I am that lone voice in the wilderness, like a crazy and paranoid old man raising unfounded fears and unnecessarily scaring little children…..

Maybe the public will think it’s OK to give thousands of dollars to managed care companies which they understood originally were meant to be professional fees for doctors. I don’t know. Maybe…..

Something is baking this April. And it certainly doesn’t smell right.

Afternote:

Since this posting, an alert reader has said that given the low rates of reimbursement by some managed care companies, a surgeon’s professional fee of $12,000 is not possible and hence the grand total of $15,000 is not possible either. Maybe.

This Hobbit has snooped around a bit. Different companies offer different rates. Even within the same company, different doctors get different deals. Some favoured ones get better deals.

Also, this posting is about ethics, not poor rates of reimbursement. You do NOT have to accept poor rates of reimbursement. You can leave the scheme.

In any case, the 15% applies to ALL fees, including ward attendance and outpatient fees.

Most complicated cases will also require input from multiple specialists other than the surgeon and anaesthetist. Assuming you charge a very low $100 per visit and you make two visits a day for 7 days, that’s still $1400 of inpatient fees for the surgeon. And probably another combined total of $700 to 1400 for the other specialists if they visit once a day (Anaesthetist + one or two other specialists) . So it is not inconceivable that for a patient undergoing major surgery with let’s day 2 days of ICU stay, the total professional fees for one inpatient episode will come up to $15,000. (Surgery fees $9000. Surgeon inpatient attendance fees $1400 (2 visits a day). Anaesthetist fees: $2250. Anaesthetist attendance fees: $600. Cardiologist attendance fees: $900. Endocrinologist attendance fees: $900.

Assumptions: Surgeon visits twice a day. For the 2 days of ICU stay, all doctors visit twice a day. Otherwise its one visit a day for other doctors

Total 9000+1400+2250+600+900+900= $15,050

This figure excludes outpatient charges related to this inpatient episode

Yes, there are some companies that demand you only charge $70 for initial consultation and $45 for each follow-up consultation. That’s lower than restructured hospital charges. But as the previous posting said – no one is forcing you to join this plan. Again, it is worth repeating – this posting is about ethics, not poor rates of reimbursement. You do NOT have to accept poor rates of reimbursement. You can leave the scheme. Schemes that give good rates with poor ethics is far worse than poor rates with good ethics.

 

 

 

 

 

Storing Up Problems

The government budget for 2016 has just been announced by the new Finance Minister. The first thing you notice is that the new Finance Minister has a lot more hair than the last one. And I mean a lot. In fact, the old and new Finance Ministers lie at the two extremes of the Cabinet in the trichology spectrum. This is the most important and exciting thing about this year’s budget, the new Finance Minister’s super-thick, jet-black hair. Post-politics, he has a great future as a model in the hair industry.

The second most exciting thing in the budget is the MOH budget. The budget for MOH got bigger (as usual). In the space of three financial years, the MOH budget has grown from slightly more than $7B (FY 2014) to almost $11B (FY2016). And that’s on top of the Pioneer Generation Package which is mainly used for health needs too. The MOH budget is growing faster than the hair on this Hobbit’s feet. This is a good thing for us doctors. But one must wonder – is this sustainable? What happened to cheap and good? This hobbit thinks we are getting less cheap and hopefully still good. But more money is always better than less money. So this Hobbit shouldn’t be complaining. Problems will surface in the future. But for now, let’s enjoy the gold rush.

Growing even faster than MOH’s budget is the appetite of managed care and third party administrator (TPA) companies. Apparently the “administrative charge” levied by some of these companies now reach 15% of the total bill. And apparently, the effective rate can be as high as 20% once the managed care companies “moderate” your claims. (I always wonder what they are moderating when the savings are not passed to the patient or their clients but kept by them).

Problems with managed care and TPA companies are not new. After all, managed care companies have been in existence since at least the late eighties and early nineties. TPAs are just a new and more virulent incarnation of managed care, like electronic cigarettes vs good old 555 State Express (OK, now you know I am ancient. For those younglings out there, 555 State Express was THE cigarette brand in Singapore before the Marlboro Man had armpit hair). The point is, they all kill, even though some tobacco is more expensive than others. (As a responsible doctor, this Hobbit has to put out a public health warning whenever tobacco and cigarette brands are mentioned).

But I digress. Let’s return to managed care and its problems. Doctors have many issues with managed care and TPA. I hope the survey conducted by SMA and CFPS recently will shed more light on this. But before the results are published, this Hobbit will give you an overview. Broadly speaking, problems can be divided into two main categories: They either pay. Or they don’t. (Gee, I am a genius, aren’t I?). If they don’t pay after you have done work, you have several choices. You can consult your lawyers or maybe you can write to SMA or CFPS to alert them. If enough of you write to SMA or CFPS, maybe these professional associations can help.

And if they do pay, problems are also subdivided into two categories. They either pay enough or they don’t pay enough. If they pay enough, you can stop reading this stupid column and go back to watching/puking over Descendants of the Sun as you wonder why on earth are women fussing over Song Joong-ki while you drool over Song Hye-kyo. Or vice versa. I mean, if there was a female surgeon as drop-dead gorgeous as the female lead, there will be lots of blood splashed on the OT ceiling, what with all the bleeding from the ethmoid and palatine arteries. And we are not talking about the patient here.

But if they do not pay enough, you can, like all Singaporeans do – complain. You can whine and complain all you like about the 15 or 20% that they are skinning off you. At these rates they are probably taking more than the skin, especially if you are a GP and working on thin margins. You can even approach SMA or CFPS or whatever to complain. But really, you can do better. You can quit the managed care or TPA company as soon as possible.

You see, no one is putting a gun to a doctor’s head to join any managed care or TPA company. You have a choice. But while you remain in a scheme that is manifestly unfair and grovel at the referrals that are thrown your way, or that you hope will be thrown in your way, nothing will change. They offer, you accept. This is the basis for contract law in this country. They only change if enough of you call it quits.

I heard there is a TPA scheme that is offering a $3 consultation rate. Actually I haven’t heard. I have seen a copy of the letter addressed to doctors in the scheme. If you can live with a $3 consultation, go on – take it. And don’t complain. Or you can drop out. Or perhaps you can complain to MOH. The professional bodies like SMA cannot do anything about a $3 consultation because the Competition Commission of Singapore (CCS) may consider this as price fixing. Actually maybe all CCS staff should go under this $3 scheme too to understand what they get for $3 when all they care about is getting the lowest price for the consumer and letting market forces reign. We store up serious problems when dogma reigns without reality checks.

Prices aside, one has to also consider the ethical perspective. Is giving a 15 to 20% cut even ethical? Is this not an inducement to the managed care and TPA companies to refer patient to certain doctors and not others? Is this in the best interests of the patient?

Maybe MOH can do something about a $3 consultation rate and 15% administration charges. But even if they can, it’s obvious they haven’t. Maybe they will just continue to ignore the problems that managed care and TPAs are creating and are left to fester. One day all this will probably blow up in MOH’s faces. But hopefully not on somebody’s watch. Meanwhile, don’t hold your breath for this. Managed care and TPAs remain unregulated as healthcare entities while they retain great powers to influence and direct healthcare provision in this country.

Next we move on to our residents. Residency has been in place for a number of years and its products are now finally leaving the system as qualified specialists in big numbers. Anecdotal evidence suggests that many newly-minted specialists may have problems securing long-term jobs in the restructured hospitals.

The problem is something akin to the Ministry of Transport/LTA and SMRT/SBS Transit problem that we have. LTA funds and builds the MRT lines. Then SMRT (and SBS Transit) operates and maintains the MRT system. The two sets of organisations have different resources, priorities and needs. This disjunction in roles, deliverables and funding had led to many of the problems we now experience.

Similarly in our specialist training system, MOH funds the training of residents, so the hospitals can put up many residency positions and recruit them to be filled. But once training is finished, funding for the employment of new specialists falls on the operating budget of the restructured hospitals. Restructured hospitals have different priorities, less resources and have to look at the bottom line. So they tend to want to hire far less than they train.

But these new specialists have to go somewhere. If they cannot get a job in the restructured hospitals, they either go overseas or they go into private practice. And if you consider the shortened training period that residency provides versus the old system, you really have to think, are they ready for private practice? But they already are fully qualified and registered specialists in every legal sense of the word. It only takes four years to produce a general surgeon post-housemanship now, versus seven in the old speciality traineeship system (one year MO, three years BST, three years AST). In truth, these newly qualified specialists trained under the residency system need more experience and some supervision by heads of departments and professors before they can truly work independently as specialists.

Again, when we rush headlong into something without thinking deeply, we are creating massive problems for ourselves in the future. In the case of the residency, the future is almost here. The chickens are coming home to roost. The day of reckoning is almost here. And the people responsible for this mess have left the room.

 

 

 

 

 

Festering February

The Year of the Monkey is upon us. And it is not looking good. For one, the first casualty in the Year of the Monkey is not bananas but fish. The ubiquitous raw ikan parang or salmon found in “yusheng” during Lunar New Year has been replaced by all kinds of stuff such as abalone, jelly fish, and even truffles. “Yusheng” which means raw fish is now replaced by “Yusi” (dead fish) or “Yujia” (fake fish).

What is the connection between raw fish and jelly fish is really beyond me, let alone truffles. Maybe they will serve starfish next. What the fish.

But the real question we medically-trained people need to ask is why is the usual raw fish unsafe to eat now? We have eaten the stuff for decades and until recently, no one has lost an arm or a leg, let alone his life. Why now? An important point to note is that the spate of tragic cases cannot be traced to any food outlet. They occur randomly across the country after eating Chinese-style raw Toman and Song fish (fresh water) from many different food outlets. The infection can be traced to Group B strep infection but no one food outlet has been linked to a multitude of these infections. They are literally “all over the place”. In other words, the problem does not lie with food handling at any particular food outlet such as a hawker stall or restaurant etc. Which is why till now, the authorities haven’t charged any hawker or restaurant etc.

AVA and NEA have said that contamination could have occurred in the food supply chain. This Hobbit agrees with this observation. But these fish are mainly farmed fish. In fact, most of the fish we eat today, cooked or otherwise, freshwater or seawater, are farmed. The imagery of your friendly fisherman at the kelong or rowing his fishing boat into the sea and fishing with a net or casting a line against the splendor of the morning sun is really a thing of the past. Move over, Ernest Hemingway. Fish, like cows, lambs, chickens, pigs, orcs and frogs – are farmed. Has anything gone wrong with the farming process? Is anyone studying the farming processes since these fish are farmed around and near us?

The other thing about this issue is that of food regulation. In some countries, food regulation comes under one department or ministry; example: USA: Food and Drug Administration (FDA). A single agency approach also applies to Korea, Japan and Hong Kong, to name a few. In Singapore, food regulation comes under at least three agencies spanning three ministries. AVA (under Ministry of National Development) which supervises the importation and sale of raw food; NEA (under Ministry of Environment) which regulate food outlets such as restaurants, hawker centres and coffeeshops; MOH which looks at control of communicable disease outbreaks linked to food. And this excludes other agencies such as HPB which looks at promotion of healthy eating habits and HSA which oversees regulation of food supplements.

As anyone can see, this is rather complex. Unnecessary complexity is never a good thing. Which is why it took a rather long time before the conditional ban on selling of raw fish came into effect. And till now, there has been no further news on food chain contamination.

Shouldn’t we put everything under one roof, much like how the regulation of media and telecommunication industries now come one statutory board? Food for thought indeed….

We move onto SGH. The mother and cradle of medicine in Singapore (Although TTSH may disagree). This is where it all began. No, I am not talking about the first dialysis or renal transplant or separation of conjoint twins in Singapore. I am talking about faculty practice and 200% professional fee surcharges. (TTSH will NOT disagree)

Just kidding.

It was exciting to see our Prime Minister unveiling the SGH Masterplan. In all likelihood, when the Masterplan is completely executed in 20 years’ time, only the elves will be around. Nonetheless, it looks like a good plan. But this Hobbit would like to offer one teeny-weeny bit of feedback to the master-planers now if they don’t mind – please WIDEN the pathetic SINGLE-lane two-way roads and build MORE carparks!!!!!

I know there is this national agenda to make Singapore car-light and promote public transport but we are talking about sick people and their caregivers. If these sick people can take public transport or walk or cycle, they don’t need to be in SGH. I know of people who borrow cars from relatives and friends so that they can bring their loved ones to public hospitals on the day of the patient’s appointment. Please EXEMPT public hospitals from any well-meaning but erroneous car-light and walking-heavy transport plan.

And then there is staff parking too. For example, there is no parking space in a huge building such as The Academia. It must be the largest building in Singapore without parking. Seriously folks, what is the use of studying so hard to get into medical school so as to be able to afford a car if you can’t get parking in SGH? What is worse, you know the kind of stress that many of our medical students go through nowadays? Many of them have rich parents who buy them Porsches and BMWs to drive to public hospitals and these public hospitals do not provide parking. Spare a thought for these poor/rich medical students – they need parking lots too. They cannot handle such stress any more than they can handle 30-hour houseman shifts when they graduate (which is why we have 12 hour shifts now).

So if you see a Porsche in a public hospital circling around looking for parking, it is probably not owned by patients, visitor or senior consultants, the Porsche belongs to the medical student. The senior consultant can only afford a Volvo at best. If the senior consultant owns a BMW or Merc, he is probably moonlighting as a Uber limousine driver at night. Or he is from SGH, is on the faculty practice scheme or can slap on a 200% surcharge. (I can hear TTSH groaning)

So in a nutshell – more carparks in the Masterplan please. In any case, carparks make money, unlike proton therapy, cyclotrons and other swanky stuff. Car parks pay for themselves. And definitely not another huge building like The Academia where floors of offices remain largely empty during office hours. They should be converted into office hour parking lots accessible by car lifts. The genius who decided that the Academia didn’t need carparks should be brought onto the helicopter field behind MOH and hung at sunrise. Of course not, we must be more humane; he should do community service by being a valet in SGH campus for 30 days without the use of valet-designated lots. Or we can make him run back and forth from the multi-storey carpark behind MOH (i.e. further than Siberia) to Blocks 1,2 and 3 of SGH ten times a day. His cardiovascular health will improve even as he comes to the realisation that The Academia needs parking lots.

Finally, we move on to Managed Care. There has been a lot of discomfort and grumblings on the ground about Managed Care. They are certainly getting more aggressive. And they remain unregulated, unlike the humble hawker trying to eke out an honest living by selling raw Song Fish salad. Recently, they have even become third-party administrators (TPA) for established insurance companies offering Integrated Shield Plans (ISPs). Be careful when you sign up as a doctor with these Managed Care companies. You may think the relationship is confined to one aspect of this practice but you may be blindsided. You may suddenly find that your ISP patient who signed up for an “as-charged” ISP will not pay you “as-charged”. What has happened is that the ISP insurance company has also signed up with the Managed Care company as a TPA. The Managed Care company now will impose on you their schedule of prices for the services you rendered to your ISP patient who is supposed to pay you “as-charged”. On top of that, the Managed Care company will levy a 10 to 20% surcharge on you as “admin fees” – this amount is automatically deducted “at source” when the insurance company pays you.

In other words, you think you have two independent relations – one with the Managed Care company which is independent from the second relationship with the ISP insurance provider. Well, the Managed Care has conflated the two and imposed the terms of the Managed Care contract onto the ISP insurance company relationship because they have been appointed as TPA by the insurance company. And what is more, if you look closely, in the terms and conditions of the Managed Care contract, they have a clause that states they can change and alter the terms of the relationship anytime and unilaterally. So things can only conceivably get worse.

While these practices are linked to just one or two Managed Care companies now, if these companies succeed, others will probably follow suit.

After all, it is monkey see, monkey do…..