Angry Doctor

Tuesday, November 15, 2005

"The Best Healthcare that Singaporeans Can Afford"

With the limelight on the issue of healthcare subsidy, I post the link to the Minister's speech on the MOH Budget; it's worth a read.

Here's the bit on Block Budget which I mentioned earlier:

Block Budget

Likewise, if hospitals have the wrong incentives, they may pursue wrong objectives. That is why I am refining our hospital subvention model to include some elements of block budgeting. As Mdm Halimah has pointed out, if hospitals are given piece-rate incentives, they would tend to pursue volume, leading to over-servicing and higher healthcare cost. And as Dr Michael Lim noted, night polyclinics are a reflection of this. I agree with him that it is not a meaningful deployment of limited resources.

But subventing hospitals at a fixed block is also not the panacea. Hospitals may pocket the block budget and do the minimum, pushing patients to one another to shift their costs, resulting in longer queues and under-treatment. In my younger days, public hospitals were in fact on block budget. MOH subsequently switched to piece-rates, not without good reasons.

I am not completely discarding piece-rates for block budget. I am going for both. Where outcomes are well-defined, it would make sense to continue with piece-rate subvention. We have identified 70 medical conditions which form the bulk of our patient-load in the hospitals. We should now go more deeply into the costing of these medical conditions and subvent hospitals based on their volumes for these 70 medical conditions.

As for the rest of the medical conditions, the subvention will come under a block budget. This will be a better way to align our interests. The clusters will then seek to co-ordinate care more effectively. They will "right-site" their patients by treating them at the most appropriate and lowest cost setting.

I must admit I don't understand much of the speech (the bits about Medisave and Medishield), but I am at least encouraged by the fact that he didn't come across as being dogmatic, and had addressed most of the topics we discuss on this blog. Except for the issue of 'heart'.

To me, the system makes it or breaks depending on the heart of the men and women executing it. No system, be it block budget or piece-rates, can ensure that the people in the system put patient before profit. What we need is for the system to recognise people with heart, and if not incentivise them, at least keep them safe from disillusionment.



  • I will tell you why there is no point in having A, B and C classes.

    When your loved one is ill. You want the best for him or her. You want immediate treatment if possible. Yet you are also limited by your financial status whether you can choose class A.

    Invariably there are always bound to be some delays in hospitals. Name me a public hospital without any delays for any condition or service and I'll take back what I say. Some conditions may not require as urgent an investigation as some others.

    Now here's what goes through the mind of a relative : "How come must still wait. The doctor keeps saying it is not urgent. Must be because we are C class lah. If it was rich person, A class or minister will not have delay one"

    And thus the relative continues to hound and pester the staff. The longer he waits, the more angry he becomes and the intensity of his verbal accusations.

    You can't blame him. You can't blame the staff either. It's just the system. But because there are different classes eg A, B and C, there appears to be a difference in the way the patients of each class are treated.

    It's psychology. If there were no classes. Then the relatives would just say "How come there is a delay?" There will not be that accusation "because we are C class right?"

    This is what causes disillusionment among the public who use the services and the staff who provide the services.

    If there is not much of a difference in management protocols as you said angry doc, but only a difference in the way we treat them with luxuries and amenities, then is it cost effective for the public hospitals to be spending on such 3 tiered services?

    I say keep all amenities to an acceptable standard. Uniform across the board. Those who wish to choose can go private. I am sure just like hotels and the hospitality (forgive the pun) industry, there will be private hospitals to cater to the upper class, the middle class and so on. That is a business consideration. So do not worry that private services would be priced out of range. I am sure there will be players in the middle class market too.

    By Anonymous Anonymous, At November 16, 2005 9:38 am  

  • You make perfect sense, but then again sense isn't always the first consideration when it comes to policy, or more impoprtantly the changing of a long-existent policy. :)

    Offhand I can think of a few possibilities why they have a multi-tier system.

    Ministry wants to please customers/voters. (Not say only got cattle class, we give you middle class too!)

    Doctors want to have both the income from private sector, and the security from the public sector. Plus free junior, nursing, and other support staff.

    Hospital admin wants to look good. (We are a world class hospital!)

    By Blogger angry doc, At November 16, 2005 10:03 am  

  • So called right siting of patients means decanting and pushing patients fr one to another or perhaps encouraging the patients to consult the GPs. Good news for them?

    By Anonymous Anonymous, At November 16, 2005 8:39 pm  

  • Haha, you are even more cynical than angry doc.

    Right-siting means you don't need to see a dermatologist if you have a pimple.

    It also means your GP refers you to a cardiologist when you have worsening heart failure for further evaluation, instead of just giving you more diuretics.

    Like I said all schemes make or break at the point of execution. If the doctor has his heart in the right place, he will not hold on to the patient (and his fees) if the condition is beyond him and needs to be seen by a specialist; or if he is specialist, hold on to the patient when he can be seen by a GP at a lower cost and greater convenience.

    By Blogger angry doc, At November 16, 2005 9:05 pm  

  • This will not work as a matter of fact, that is what I believe.
    nice 1 | do not forget 1 | superb 9 you may 1 | also 5 | good 7 do not forget 9 | check 6

    By Anonymous Anonymous, At January 04, 2013 1:23 am  

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