Angry Doctor

Friday, June 16, 2006


Interesting letter from Dr Tan Min-Han in the ST Forum today.

June 16, 2006
How to keep Singapore health-care top-notch

IN THE two overview articles published in Review (ST, June 9), the Singapore health-care system came in for high praise. Few doubt that Singapore has a top-notch health-care system, allowing near-universal access to high-quality services.

Both articles alluded to, but did not expand upon, the forces for change in the Singapore health-care system.

While Singapore has developed a very successful health-care system over the last two decades, our changing environment demands equally nimble adaptation on our part. Upcoming challenges include an ageing population, steeply priced new technology and drugs, rising public expectations and the need to develop clinical research infrastructure to accompany investment in basic life sciences.

Even as we seek to maximise each dollar spent, our national expenditure on health is likely to continue its inexorable rise over the next few decades.

Today, novel drug regimens and surgical intervention can easily cost tens of thousands of dollars. It is no surprise that health-care costs are one of the main concerns of the man in the street.

With ever-increasing demands on national resources, a transparent and independent forum for technology and pharmaceutical appraisal is urgently required at the national level.

As cost-benefit ratios vary from society to society, Singapore must develop its own system for technology appraisal, possibly modelled after the National Institute of Clinical Excellence in Britain.

This forum should examine not just the clinical usefulness of a particular new drug, but also the societal benefits and costs in the local context from implementation.

For this to happen, substantial investments in health-policy research must occur, together with greater visibility of socioeconomic, financial and health-care data for accurate determination of societal outcomes.

Critically, an approach integrating both clinical and accounting principles will have the dual benefit of addressing both the supply and demand sides of expanding health-care costs, as organisations and the public are likely to respond to independent guidelines which are perceived as impartial.

As there is wide acceptance in Singapore of the premise of shared responsibility, this forum can be a basis for establishing degrees of co-payment for the pillars of our 3M health-care system: Medisave, MediShield and Medifund.

Non-governmental organisations such as charities will find this helpful in appropriate fund allocation and avoidance of wastage.

If truly worthwhile interventions can be distinguished from the over-hyped, funding and subsidy should be allocated correspondingly, ensuring that the dollars of the Government and the patients are well spent.

Dr Tan Min-Han

Dr Tan (if he is the same Dr Tan I am thinking of) is an intelligent person, and I used to enjoy reading his posts on an online forum. Heck, anyone who says 'drug regimens' instead of 'drug regimes' is in my good books.

He mentions the National Institute for Health and Clinical Excellence in his letter; I think I will be browsing through their site over the weekend.

Locally, a similar system in the form of MOH Clinical Practice Guidelines issued to all doctors has been in operation. But as Dr Tan noted, these guidelines do not yet go into cost-effectiveness in the context of our subsidised healthcare system.

Let's wait and see what the Ministry's response to his letter will be like.



  • A very well written letter by Min Han (as always :))

    Angrydr you know Min Han personally as well?

    By Blogger Dr Oz bloke, At June 16, 2006 7:18 pm  

  • Haha. Not telling, Oz Bloke.

    By Blogger angry doc, At June 16, 2006 7:46 pm  

  • Who knows, you might very well be Min Han himself!


    By Blogger Dr Oz bloke, At June 17, 2006 7:18 am  

  • NICE operates in a very different environment from Singapore. When NICE approves a drug, like Herceptin recently, all the trusts are legally obliged to offer it. What is the point of such a body in Singapore? If it approves Herceptin like NICE did recently for early breast cancer, are the public hospitals obliged to offer it? Who's paying for the subsidized patients?

    By Anonymous Anonymous, At June 18, 2006 9:47 pm  

  • Very relevant questions, anon.

    The way I see it, a Singaporean NICE (SpICE?) hs two main jobs:

    1. To appraise evidence in relation to local demographics and disease prevelance.

    2. To calculate cost-benefits in the local context.

    As the body deciding on healthcare subsidy, I suspect MOH will have still have the final say on whether a mode of treatment will be considered cost-effective and that it should be subsidised. Even as it stands certain treatments and drugs are subsidised by MOH, while others (cosmetic procedures and second or third-line drugs, for example) are not.

    If we have a SpICE, it will probably just mean that an independent body will have the job of instituting a set of standards by which modes of treatment are assessed, and then making its recommendations to MOH. Sort of like a National Wages Council kind of role? It is hard to see MOH being legally-obligated to adopt the recommendations of a non-governmental body.

    Seeing as it is SpICE can also recommend that a mode of treatment should NOT be subsidised, it does not necessarily mean opening the floodgates to expensive treatments for MOH.

    In fact, IF the cost of newer, better drugs is currently the only thing that keeps MOH from subsidising them, MOH may actually be losing a lot more money by NOT subsidising them and allowing more people to have access to them when they end up having to subsidise the acute admissions AND chronic rehabilitation of these patients when they suffer the complications of the diseases.

    (A similar change in mindset may be behind the initiative to allow people to use Medisave for outpatient visit - if you let me use $30 each visit to get my hypertension treated, I may not need the $30,000 to pay for my hospitalisation for the stroke I will then not get!)

    In other words, I think what Dr Tan is saying is that currently, MOH already makes the decisions on which treatment/drugs to subsidise and which ones not to. What he is proposing is that we set up an independent agency which will draw up a standard for making that decision (which MOH is already making everyday) based on medical evidence and accounting principles.

    By Blogger angry doc, At June 18, 2006 10:30 pm  

  • If we look at the experience of NICE, we will see that their most difficult problems and the bulk of their decisions relate to cancer drugs, such as Herceptin for breast cancer, Gleevac for acute myeloid leukaemia and GIST, Rituximab for lymphoma and Velcade for myeloma. These drugs make a difference to survival and the quality of life, but very few cures.

    I like your suggested name SpICE :) Private doctors will decide for themselves whether or not to prescribe these new drugs as their patients will pay for them anyway. The remit of SpICE will be the public sector where these drugs are currently considered non-standard drugs. So essentially SpICE will be taking over MOH's role in deciding which drug should be standard. If such a body were set up, I believe it will be the same MOH committee calling itself by a different name.

    It makes sense to pay more for a chronic illness if a more expensive drug can forestall and reduce acute admissions. But in the area of oncology, where an expensive drug merely improves survival by months or a few years and not provide a cure, would SpICE ever recommend it?

    By Anonymous Anonymous, At June 19, 2006 1:50 am  

  • Rituximab is as curative as it gets!

    By Anonymous Anonymous, At June 21, 2006 1:37 am  

  • That's the problem with cost effectiveness, isn't it? Rituximab gives a 95% and 75% 2-year survuval rates in the younger (<60) and older patients respectively. The figures for standard CHOP therapy are 86% and 63% respectively.

    If this is as curative as it gets, some administrators are going to say that the 10% improvement does not justify the cost.

    By Anonymous Anonymous, At June 21, 2006 3:16 pm  

  • Cost-effectiveness is necessarily subjective when it comes to healthcare because it is difficult to put a value on life and health.

    In the context of pooled risk and tax-subsidised healthcare decisions must nevertheless be made, and I suppose having a body to study the evidence behind each therapy and calculating the potential cost and benefits is better than having the decisions made purely on unit cost alone.

    By Blogger angry doc, At June 21, 2006 6:56 pm  

  • 5 year data for rituximab is available. Compares well to many other things we can do.

    By Anonymous Anonymous, At June 21, 2006 11:32 pm  

  • it's the Drug Advisory Committee currently that proposes and decides what goes into the standard drug list.

    but the list looks in urgent need of updating.

    By Anonymous Anonymous, At June 22, 2006 10:34 pm  

  • The DAC comes under the purview of the MOH, doesn't it?

    By Blogger angry doc, At June 22, 2006 11:08 pm  

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