Angry Doctor

Tuesday, November 15, 2005

Other People's Money 3

I nearly missed the reply from Touch Home Care:

Nov 15, 2005
Care for elderly: New fees allow more access to wider range of services

I refer to the letter
'Government should relook at the means test for medical subsidy' by Ms Wendy Teo (ST Online Forum Nov 9). We thank Ms Teo for bringing this matter to our attention.

The means test is commonly used by agencies for individuals who wish to apply for subsidies. The objective of the test is to ensure better allocation of resources in providing financial assistance to the people who need it most.

Although the means test has been used by the government to determine its subsidy level to our clients since 2002, TOUCH Home Care (THC) only started charging fees at the beginning of this year as it was able to sustain its free services in the past.

In Ms Teo's case, her mother had enjoyed free services, fully subsidised by THC, for the past three years. However our client base has doubled over the last few years.

To effectively meet the needs of our existing and future clients and to sustain our services, it has become necessary for us to charge fees. We hope to ensure the prudent and efficient use of resources while meeting the needs of the elderly under our care.

We fully empathise with Ms Teo's situation and wish to assure her that THC is committed to do its best to help the elderly enjoy greater independence and better quality of life at home.

We are constantly reviewing our policies to improve our services to those in need and we welcome feedback. For this reason, we have recently developed a new fee structure in which a client pays a flat rate instead of being charged on a per visit basis.

This new structure allows our elderly clients to have access to a wide variety of services, including occupational therapist support, counselling services, visits by doctors and nurses, at a flat rate.

The new fee structure is partially subsidised by THC as we are mindful of the financial challenges faced by families which do not pass the means test.

We are glad that Ms Teo has found our services useful. We invite Ms Teo to meet us for a discussion so that we can better understand her situation and explore alternative arrangements.

Kavin Seow
Programme Manager
TOUCH Home Care

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  • Personally I think health care should be managed with socialist philosophies.

    When a man is sick, and seeking medical treatment, is it ethically right to give him treatment according to his ability to pay for it?

    I think there are certain standards of care that every human being should be entitled to.

    I have always proposed that we have a 2 tiered system of health care. The public hospitals being of a single class (eg B2) across the board. Everyone who enters the doors of public hospitals and institutions gets the same quality of care. It is fair. At the moment this business of NHG and Singhealth trying to make profits from A class patients to fund the C class wards makes some rich people unhappy and they pretend to be poor and choose B2 class. For the matter B1 class is subsidized too. So what gives? And frankly any doctor who has worked in C class wards will tell you it's as good as a dump.

    If patients can afford it, they go to the private sector. The private sector would get all the foreign patients eg from Middle East, Asia etc. This would really push the medical hub of Singapore where the private sector competes with the region and not with the govt Singhealth and NHG run hospitals. The private hospitals should be made to pay a health care tax which the govt collects to fund the state run public hospitals.

    It streamlines everything. At the moment the govt hospitals are a mess in my opinion. Doctors there do not know whether their aim is to make money for the group (which incidentally they use the financial performance of the group to decide the staff bonuses, so if group makes more then bonus is bigger) or to keep overall health care costs low. It makes no sense if saving money for the patients means less profits for the group and thus smaller bonuses. Mind you it is not just doctors bonuses bu admin staff bonuses.

    So what are the public hospitals there for?

    I say use the two tier system and make it clear the public hospitals are there to provide health care period.

    As far as manpower is concerned, public hospitals are training hospitals. There will always be consultants who will want to stay in institution. There will be those who leave for the private sector. All trainees have a bond to fullfill anyway so staffing of the hospitals should not be a problem.

    Problem is I think MOH wants to make money themselves.

    By Anonymous Anonymous, At November 15, 2005 12:39 pm  

  • Good post, but a few points I would argue with:

    "When a man is sick, and seeking medical treatment, is it ethically right to give him treatment according to his ability to pay for it?

    I think there are certain standards of care that every human being should be entitled to."

    The problem is some people consume more healthcare than they 'need'. No one will argue with you if you had a heart attack, but you don't need to be in practice long to realise that people exploit the system for all sorts of reasons like getting medical leave and excuses for non-existent symptoms, or even dumping their parents in the hospital for a week while they go for a holiday.

    Co-payment tries to discourage that. The system as it is has not enough morale courage (and legal immunity?) to deny people healthcare when they don't 'need' it.

    "Doctors there do not know whether their aim is to make money for the group (which incidentally they use the financial performance of the group to decide the staff bonuses, so if group makes more then bonus is bigger) or to keep overall health care costs low. It makes no sense if saving money for the patients means less profits for the group and thus smaller bonuses. Mind you it is not just doctors bonuses bu admin staff bonuses."

    As I understand it as of this fiscal year the clusters operate on a block budget system. Not sure how that affects operations or whether it is viable. Only time will tell.

    "Problem is I think MOH wants to make money themselves."

    I don't work for the Ministry and I don't know the Minister personally, but I think that is probably untrue. The (current) Minister does not appear to harbour any illusion that the ministry will turn in a profit (does any ministry turn in a profit?). I think he is just trying to at least arrest budget if not reduce it.

    As I mentioned in an earlier post I think it's good that we discuss these issues.

    Thanks for posting.

    By Blogger angry doc, At November 15, 2005 1:15 pm  

  • I am actually for co-payment schemes. But what I am promoting is a single class system in the govt hospitals.

    Is there any place for private patients in public hospitals anyway? What SGH, NUH, AH, CGH, TTSH are trying to do is be a ShangRi-La, Marriot, Hyatt with A class, B class and C class rooms. I just can't understand the logic of it. Understood, they need to be there for the poor. But why do they want to serve the rich?

    Let the private sector serve the rich. They are the best at it. It is better to target services for target consumer groups.

    As a GP would you refer a very rich indonesian businessman to SGH or NUH? Or Gleneagles or Mt E? Well the thing is SGH and NUH want GPs to refer such patients to them.

    By Anonymous Anonymous, At November 15, 2005 1:56 pm  

  • just to clarify something.

    I understand and agree with the policy of earning profits in govt hospitals to offset the subsidies in the govt hospital subsidized classes. The principle is sound. However the execution on the ground makes things chaotic.

    I feel it is far better to promote the private sector fully. Ie have no internal competition with the govt sector. Right now the govt competes with the private sector for private patients. Why do that?

    Let the private hospitals take ALL the private rich patients then pay an added tax. I'm quite sure the private hospitals would be happier.

    What is the govt trying to do? Keep PRIVATE health care costs low too? Geez.

    By Anonymous Anonymous, At November 15, 2005 3:05 pm  

  • public hospitals with A and B class wards also cater to these groups of patients:
    1. the middle income earners who can afford a bit of comfort, but not excessive like in private hospitals.
    2. richer patients who can afford private, but are either plain stingy or thrifty.

    in any case, choice is good for patients, even if it means messing up hospital system structures.
    because you can always fiddle with it until it works out right.

    there's no clear cut rich and poor.
    it's more of a continuum of patients that is served by public and private hospitals.

    By Anonymous Anonymous, At November 15, 2005 8:04 pm  

  • I think it confuses the staff on the ground. Because the doctors generally are NOT supposed to treat patients differently whether they are in A, B or C classes. However the patients expect the doctors to treat them differently based on their classes, especially the A and B classes.

    Anyway I guess only doctors who have worked in the system will know what I am talking about.

    By Anonymous Anonymous, At November 15, 2005 8:52 pm  

  • i'm not in the system (yet).

    i don't believe that doctors treat patients based on their ability to pay.

    i think the differential 'treatment' is not (or was not meant) in doctors' attitudes, but in material comforts like air-conditioning, privacy, etc.
    maybe better hospital food? haha

    By Anonymous Anonymous, At November 15, 2005 9:23 pm  

  • OK, I really need to do this.




    No, wait.


    Sorry. Gimme a minute...

    By Blogger angry doc, At November 15, 2005 9:30 pm  

  • OK.

    As a doctor you may MANAGE a patient differently depending on his ability to pay, but you shouldn't TREAT him differently.

    Nothing prevents you from prescribing him an expensive drug that he requires, but if the drug is not subsidised by the system, he has to pay for it himself. If he is unable to, you end up having to prescribe him a cheaper (and marginally less efficacious) drug. That's something you have to live with (for now).

    How you decide to treat him as a person is another thing altogether, but I leave you to observe and conclude if most medical staff base that on the paying status of the patient or not.

    Gosh, COFM isn't teaching you how the real world works, is it? :)

    By Blogger angry doc, At November 15, 2005 9:39 pm  

  • On a slightly unrelated note, a straw poll of senior doctors indicated that if they were ill, most would prefer to be in a C-class bed directly in front of the nursing counter where they are within view of the nurses to a single-bed room.

    By Blogger angry doc, At November 15, 2005 9:41 pm  

  • no, COFM has nothing to do with it.

    it's just basic courtesy to treat people well. (treat as a person, not medical management/treatment/etc)

    ultimately you answer to yourself.
    if you're happy pandering to the wants of rich taitais, it's your business.

    i still like to think there are decent medical staff out there.

    By Anonymous Anonymous, At November 16, 2005 12:34 pm  

  • Anon, I think it's good you feel that way, but like I said do look at what's happening on the ground and conclude for yourself if your impression is largely correct.

    By Blogger angry doc, At November 16, 2005 12:58 pm  

  • Dear Anon,

    I think once you start working in the hospitals you will realise that sometimes you have not much of a choice when it comes to pandering to the whims and fancies of A class ward patients.

    Otherwise be prepared to always answer to complaint letters against you which the admin would call you up to discuss. Trust me it isn't a pleasant experience. You will also realise who's side the admin are on. They are on their own side, just not yours.

    It is not so much how we doctors want to treat our patients unequally but how patients themselves demand to be treated differenly because they PAY.

    I once knew a fellow houseman who had to accompany an A class ward patient down to a hairdressing salon for her hair to be done because the patient insisted on it. The ward sister called him and told him to do it or else she'd call his head of department. THe patients was a VIP.

    So whether you want to or not, trust me, you're not the boss calling the shots!

    By Anonymous Anonymous, At November 16, 2005 1:51 pm  

  • And why did medical students need to be accompanied by consultants when clerking single-bedders but not "subsidized" patients?
    btw, is it still the case now?

    By Blogger andrew, At November 17, 2005 12:38 am  

  • The government is clear that they won't follow a socialist Singapore, welfare is a dirty word.

    I do see their problem. The UK is getting into big problems with their NHS. Public pressure is forcing the government to offer herceptin for early breast cancers. Herceptin is clearly shown to improve cure rates in early breast cancer from 60% to 80%. The cost of that improvement in survival is going to be many millions of pounds and I doubt if the UK can afford it.

    In Singapore, the minister wants to avoid precisely that. He said he will have to moderate the expectations of Singaporeans. In other words, private patients who can afford it will get their herceptin and enjoy a 80% cure rate. Subsidised patients will get standard chemotherapy and have a lower 60% cure rate.

    That's the cruel fact of life...someone has to pay for's either the individual or corporately through taxes.

    By Anonymous Anonymous, At November 26, 2005 6:43 am  

  • Anyone keen to ask for MRI liver for screening for HCC ? the Koreans do it, you know.

    By Anonymous Anonymous, At July 03, 2006 10:39 am  

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