Angry Doctor

Tuesday, March 20, 2007

The Blame Game

Great. Now doctors and nurses are responsible for rising hospital charges?


Hospital costs sneak up as economy hums
Wage increases blamed, but some seek more protection for needy
Tan Hui Leng


DON'T like the heftier numbers on your hospital bill? Blame the economy. Apparently, it is doing too well.

Almost every hospital in Singapore has raised its charges — admittedly by just a handful of dollars. As the demand for healthcare professionals rises with the improving economy, hospitals' manpower costs are going up.

Noting that the majority of healthcare costs goes to human resource, National University of Singapore health economist Associate Professor Phua Kai Hong said: "Every time there is a wage increase, the first to be affected is healthcare because there are many qualified specialists there and you need to keep them from moving to the private sector."

It is not the specialists alone that are benefitting. Nurses have been asked to shoulder some of the responsibilities of junior doctors. But this came with a demand for better benefits, and they recently got a pay hike.

Health Minister Khaw Boon Wan said in Parliament two weeks back that his Ministry had to keep wages competitive to hold on to qualified professionals like nurses and speech therapists. "This is also the reason why medical fees need to be raised periodically as the cost of manpower is a major component of medical costs," he said.

But patients see only the bottomline — and they don't always like what they see.

At Singapore General Hospital (SGH), subsidised inpatients in Class B2 wards will pay $53 a day — an extra $3, or 6 per cent more — from April. Those in Class C wards will pay $26 a day, $1 more than they currently do.

SGH said that the increases are its first since 1993.

An SGH spokesman said that even though its expenses had risen steadily, the hospital had held off any fee increase until now.

And even with the hike, the hospital will recover "just a small fraction" of its rising costs, said chief executive Prof Tan Ser Kiat.

"With an increasing volume of subsidised patients, and facilities at SGH which need updating, any under-collection of revenue would mean fewer resources available for meeting the growing need for improvements necessary for sustaining quality of patient care," he said.

At National University Hospital, the accident and emergency (A&E) fee was increased from $70 to $80 in January — the hospital's first A&E fee hike since 1997.

At Alexandra Hospital, C-class ward charges went up from $21 to $23, subsidised specialist outpatient clinic consultation rates went up from $18 to $20, while A&E went up from $55 to $60; all increases took place late last year. At KK Women's and Children's Hospital, ward treatment fees also increased from last month.

Only Tan Tock Seng Hospital and Changi General Hospital have not raised their fee and now all eyes are on them.

The hospitals, themselves, did not want to comment, but NUS economist Prof Phua felt it was only a matter of time before their fees went up. "These are government hospitals, so they'll follow suit," he said.

Despite the hospitals and the Ministry offering their reasons for the hike, Dr Lam Pin Min, MP and Deputy Chairman of the Government Parliamentary Committee for Health, said he was somewhat surprised. "I was a bit shocked to see the fee revisions for the different hospitals," Dr Lam told Today.

"The timing is not very appropriate — why is there a need to increase prices when the GST hike has just been announced?"

The Government has already said that it will absorb the Goods and Services Tax hike for all subsidised patients. But, Dr Lam pointed out, that is just a two-percentage-point hike, whereas the recent rise in consultation and hospital fees appeared to be more substantial.

The Health Ministry said that the fees would remain affordable to all subsidised patients and the needy would not be denied care.

NUS health economist Prof Ake Blomqvist added that, by international standards, hospital charges in Singapore were not particularly high, especially given the quality of healthcare.

"And if there is concern about the burden that an unexpected major illness sometimes places on low-income people with limited Medisave balances and little medical insurance coverage, it is probably better to work on strengthening the safety net for those population groups specifically, rather than increasing the subsidy to all health care users, including high-income ones," he said.


Certainly wages make up a significant proportion of a healthcare cluster's annual expenditure (just a little more than 50% in both clusters - see here and here), but this is not surprising for a business where the chief commodities being sold are knowledge and skills and not goods.

Moreover, manpower cost is not the only part of the expenditure that is rising (nor the component that has seen the biggest percentage rise - do look through the annual reports for the past few years; you may be surprised...), nor are doctors and nurses the only ones on the payroll.

To single out wage increases for 'specialists' and nurses in the article and to just gloss over the other factors contributing to an increased expenditure is to do these people a disservice.

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23 Comments:

  • If more doctors are going to be hired from overseas to increase the doctor:patient ratio, then the public should certainly expect that hospital bills will increase substantially to offset this huge increase in manpower costs.

    The ministry, or the media, conveniently chose to focus only on the former.

    By Anonymous student, At March 20, 2007 10:15 pm  

  • Indeed. It would be unfair to blame individual healthcare professional for causing a rise in overall manpower expenditure if it is a result of a policy which they have no control over.

    By Blogger angry doc, At March 20, 2007 10:31 pm  

  • And the number of administrators (who obviously contribute to "manpower costs") outnumber nurses and doctors by how many?

    By Blogger Dr Oz bloke, At March 21, 2007 12:27 pm  

  • Singhealth doesn't specify (I assume they are included in the 'Others' group), but in NHG the total figure is just slightly higher than the number of doctors (1,403 vs 1,389), with most of them in the HQ. But then this figure may include everone from the CEO, COO, CFO down to the admin clerk and MRO staff?

    Nurses form the largest single group in both clusters (36% in SHS, 40% in NHG).

    These figures do not take into account the individual and total pay for each group, so we don't know how much each group 'costs'.

    By Blogger angry doc, At March 21, 2007 12:53 pm  

  • Nurses deserve their long deserved pay rise. The last one was in 2001! If cost of living is going up, GST is going up, why can't nurses pay go up too?

    The Health Ministry now conveniently put the blame on nurses again. Haiz. :(

    By Anonymous Anonymous, At March 21, 2007 3:05 pm  

  • Listening to all this.....it goes to show that the govt and the people of Singapore DO NOT want to pay for healthcare. Nobody does. It is a thankless job. It never feels good to give your best, and then have people come and say "why must we pay you when we are sick? bloody hell!"

    But when they want to watch a movie, have a nice dinner, have a new hairdo, haircut, go on holiday, smoke, drink, gamble etc....no problems paying.

    No fun lah being in healthcare. Esp being a doctor or nurse. Economy do well, healthcare workers cannot have pay rise. Economy no good, healthcare workers should get pay cut.

    But when it comes to those bankers, finance managers, businessmen, politicians and civil servants......economy good they get pay rise nobody pressures them with all this moralistic stuff to keep salaries flat.

    Hello people, healthcare workers also need to eat, need to pay for the SAME HDB FLAT at the SAME PRICES as everyone one else does lah.

    Cut some slack please?

    By Blogger Dr Oz bloke, At March 21, 2007 5:56 pm  

  • Fortunately it does not seem that the article had much impact - certainly not the talk at lunchtime yesterday or today.

    Unfortunately that also means that the message of the article - that specialists and nurses are the main people benefitting from the fee hike - is not challenged.

    I suppose that's the way things are here in Singapore: you don't have patients-rights groups protesting the fee hike, or nursing advocate groups defending the wage increase.

    By Blogger angry doc, At March 21, 2007 8:14 pm  

  • Actually what Doc Oz said is true - Locals pay for the weirdest things but not the essential - I think one meal at a Tung Lok restaurant can pay for several weeks of DM care.

    I think, hospitals like any businesses are also gearing up for the GST hike? Factored into the fees? - sorry ah, I've not seen a hospital bill for a nong nong time already

    It is also unfair to single out healthcare professionals - other pays are rising, why not ours. The draw to the private sector is always there, then people start complaining that there's not enuff people working in hospitals allll ovvverrr aaaaggggaiiiinnnn

    How come people keep missing out pharmacists? Bleaahhhh

    By Blogger OJ, At March 21, 2007 10:29 pm  

  • Be glad that people usually forget about the pharmacist.

    By Blogger angry doc, At March 21, 2007 10:50 pm  

  • I was listening to the radio this morning. Hearing PM Lee Hsien Loong argue about why they have to raise the salaries of civil servants. How the private sector salaries have risen because the financial sector performed well etc....

    Just a question, but when would the PM ever say that health care industry has done well?

    What is done well in the healthcare sector? Earning more money? I don't think so right? Cos if that happens, then healthcare expenditure goes up and their GDP spending on healthcare goes up (which is a bad sign).

    So how?

    What is do well in healthcare sector?

    No wonder healthcare sector never does well. No wonder healthcare professionals in healthcare sector so seldom get salary increases.

    Sigh. No fun lah like that. Never get recognition and appreciation one.

    Be banker make lots of money = do well.

    Be doctor make lots of money = no good cos increased healthcare costs?

    By Blogger Dr Oz bloke, At March 23, 2007 10:19 am  

  • looks like the future is really really bleak.

    By Anonymous m1 student, At March 23, 2007 10:29 am  

  • Bleak in the sense that in Singapore nobody wants to pay for healthcare.

    Not the government. Not the people. NOBODY.

    If they fall sick and they got to pay it's like the worst thing in the world!

    So nobody wants to pay. However the drug companies want to make profits. The medical equipment companies want to make money. And they are listed companies. And the government wants the listed companies to do well.

    So who do you squeeze? You squeeze the doctors, nurses, physiotherapists, occupational therapists, podiatrists, pharmacists, speech therapists, radiographers, lab workers etc (apologies if I left you out) You squeeze their salaries.

    And when prices need to be raised due to rising costs ( eg increased drug costs, increased medical equipment costs, increased oil prices, increased power bills, increased water bills, increased rental bills) you BLAME THE DOCTORS AND NURSES AND ALL THE MANPOWER COSTS.

    So be prepared. You will always be the bogeyman for all the bad news in healthcare. You want recognition forget it. Nobody would ever appreciate you.

    By Blogger Dr Oz bloke, At March 23, 2007 10:53 am  

  • i guess then since this system pretty much works (at our expense), no one is really going to do anything to change anything. not esp our minister who has since introduced some very distressing policies to challenge the jobs of local doctors.

    p.s. then why don't people move out of singapore? aus and nz are actively recruiting right?

    By Anonymous m1 student, At March 23, 2007 11:02 am  

  • Hi M1 student, you wrote "then why don't people move out of singapore? aus and nz are actively recruiting right?"

    Oh yes they are recruiting but for Singaporean doctors, our qualifications are not exactly recognized as equivalent to Aussies qualifications. Also perhaps people don't realise how protectionist most medical boards of 1st world countries are. Few are as open and subservient as Singapore. Government may say "we want more doctors and will give them PR status" but medical boards will say "sorry we won't recognized any tom dick or harry doctor". So either you can't get temporary registration and cannot go to Oz, or you get temp reg but cannot get fully registered and hence get no PR and would have to go back to SG later on, or you get PR but cannot work as a doctor at all cos the medical board won't recognize your qualifications (as in Canada).

    It is very complicated. You can read the older posts on my blog which has more information on this if you are interested.

    By Blogger Dr Oz bloke, At March 23, 2007 4:37 pm  

  • When the healthcare industry does well, we end up with an aging population problem...

    By Blogger angry doc, At March 23, 2007 5:11 pm  

  • "When the healthcare industry does well, we end up with an aging population problem..."

    Which is also in a way "no good" for the government and the politicians.

    It's one of those things lah. My professor in NUH used to say "The government views healthcare as a drain of resources"

    I think that about sums it up. If possible the government would prefer that there was no need to spend a cent on healthcare.

    By Blogger Dr Oz bloke, At March 23, 2007 6:01 pm  

  • Certainly the government would prefer that they didn't need to spend a single cent on healthcare.

    In fact, I am sure they would be delighted if they didn't have to spend a single cent on education or defence either. However, I don't think the government is naive enough to see any of that as a realistic possibility, or that it is foolish enough to see healthcare as only a drain of resources.

    There is actual benefit to be had in having a healthcare system that is robust enough to ensure that your nation's babies survive to adulthood, that your working adults remain healthy enough to contribute to the economy, that your women survive childbirth to help boost the birth-rate again, and your elderly reasonably fit so they don't require expensive healthcare constantly.

    We take the presence of a healthcare system for granted and we oftentimes forget what it might be like if we lacked it.

    By Blogger angry doc, At March 23, 2007 8:09 pm  

  • To: Dr Oz Bloke

    I've read your previous entries and to be honest, i think things are really really crappy. And i'm only in year 1. I don't think my peers think about issues like that. Of what would happen to them after graduation. I think most will begin to think like Gary when they get to M5, of course we must give the altruistic few credit as well. I mean there's little progression, little or no recognition and the govt seems to be milking us for all its worth.

    So for all the doctors that read this blog, how do you all find the drive to move on, i.e. continue serving your patients.

    By Anonymous M1 student, At March 23, 2007 9:06 pm  

  • It would take a rather precocious teenager to know what practising medicine (or for that matter any profession) is truly like at the age he or she decides to enter medical school.

    And regardless of what profession you choose, as long as you are not independently wealthy you will remain subject to the forces of economics and the market, and be just a number in the grander scheme of things which, depending on which country you are in, the government may want to 'manage'.

    (Just out of interest: have you watched the Godfather Trilogy?)

    I rant a lot about 'the system' and the 'cluelessness' of the lay public, but that's mainly to raise awareness (and hopefully to get people like yourself to think about what YOUR practice will be about next time) and does not change what practising medicine is really about.

    You see, if you are a clinician then despite all of the policies and politics at the end of the day the business end of the business is about human interaction. You are a professional with a considerable degree of autonomy in the practice of your craft (as long as it adheres to the tenets of your profession), armed with knowledge and experience, helping someone to negotiate his way through the healthcare system (and in a small way, life), hopefully towards health (though I am careful to not say 'happiness', as health is only a precondition to happiness and that is something the patient must find himself).

    The practice of your craft is challenging intellectually, morally, emotionally, and in some discplines physically. There are always new things to learn, new ways to improve yourself and your practice.

    I guess if I have to summarise all that in one sentence, I will say:

    I get paid for helping people and doing something that is interesting to me.

    By Blogger angry doc, At March 23, 2007 10:44 pm  

  • "I get paid for helping people and doing something that is interesting to me."

    That applies to almost all other jobs.

    Like Zig Ziglar says "If you can help everyone get everything they want, you can get everything you want"

    It's called sales. Sell comes from the norweigian word "Sel" meaning serve.

    That's what we do basically when we work. We serve.

    By Blogger Dr Oz bloke, At March 24, 2007 10:16 am  

  • "That applies to almost all other jobs."

    Indeed. And that's the point. :)

    By Blogger angry doc, At March 24, 2007 8:45 pm  

  • it's not a blame game-the numbers do show that majority of the expenses goes to paying docs and nurses (that's because docs are expensive and nurses are many). there's no 'arrowing' at all, but from this, docs may realise that they have a lot of control in reducing costs-stop asking for all the latest 'toys' and learn to make do with less 'branded' consumables, do not expect 'fedex' services from the pharmaceutical/ implants pple-yes, these cost $$-LH

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