Angry Doctor

Monday, April 30, 2007

Subsidy and Other Preoccupations 13

Yet another letter to the press on the subject of means testing:

By all means, add subsidised beds
Letter from Lan Zhong Zheng

I concur with the opinion of the reader who wrote the letter, "More hospital beds the remedy" (April 26).

Indeed, from my fleeting hospital attachment at one of the restructured hospitals in Singapore, I managed to catch a glimpse of the crunch faced by government hospitals here.

There was an appalling paucity of available beds in the heavily subsidised wards, while the exact opposite was obvious in the "paying patient" wards.

There were even instances where subsidised patients in the Intensive Care Unit (ICU) were transferred to a Class A ward, just to squeeze out a bed in the ICU for someone whose condition was believed to be more dire and life-threatening.

The ultimate solution is not to carry out means testing on Singaporeans but to increase the supply of beds in the subsidised wards in hospitals here. Implementing means testing infringes on the right of the people to choose.

Does it mean a tycoon should be barred from a superior room and can only stay in a suite? Similarly, why should the middle-income not be given the option of staying in a Class C ward? Being in the middle-income group does not definitely mean one has the money to splurge on a class B1 or A ward.

Looking into supply should be the long-term solution in addressing this shortage. However, as we all know, land is scarce and government hospitals are stretched to their full capacity in terms of facilities and resources.

Rather than diversifying interests by trying to usurp a slice of the burgeoning medical tourism market, the Health Ministry should draw on the HDB model, which sets out to provide public housing to Singaporeans first, especially the less well-off ones. Drawing on this model, healthcare should be focused on catering to the individual needs of Singaporeans, in particular the subsidised pool of patients rather than having to attract foreign wealthy "paying patients" at the same time.

Means testing may bring instant temporal relief to the current situation but with an ageing population and such uncertain times, no one knows when epidemics like Sars will rear its head again. The bed crunch in hospitals may pose a more serious problem then.

Despite our low beds ratio, angry doc is still not convinced that the root problem here is an absolute bed shortage. In fact, the account given in the letter of subsidised patients being lodged in A-class wards tells us that there are beds available in the hospital.

Nor is the problem one of relative bed shortage alone.

In its currently proposed form, means testing does not forbid one from staying in a C-class ward: it merely reduces the percentage of subsidy a patient who fails the means test receives (to less than 80%, but presumably more than 65%). If the patient accepts the lower subsidy, he may still stay in a C-class ward.

So what is the purpose of means testing then?

Is it "to better target our subsidies at those who need them most"?

If so, does that mean that subsidy for those who pass the means test will be increased to more than the current 80%?

Or, is it to achieve "right-siting"?

If so, means testing seems to be too imprecise a tool to achieve that, since it does not take into account whether or not a patient needs to stay in an acute hospital.

angry doc is, once again, confused. Perhaps all the letters to the press published in the past few weeks will prompt a reply from the ministry which will answer all his questions.

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  • Hi angry doc, I think you are over analysing.

    The purpose of means testing is to ensure that MOH does not have to pay subsidies for people who can "afford it".

    In simpler terms to allow MOH to spend less on healthcare. And in more simpler terms to pass the cost back to the people and rely less on the government. Less of a crutch mentality etc etc etc


    5 years from now remember that I said this.

    By Blogger Dr Oz bloke, At April 30, 2007 9:39 pm  

  • I agree with dr oz bloke. With an aging population, healthcare financing can become the black hole that increasingly sucks at our economy. Singaporeans are not prepared to pay more in taxes (and only 40% of the population pay taxes in any case. The government does not want to spend more in subsidies. It means that those who can afford it must be made to pay more so that subsidised healthcare is only given to those who absolutely needs it.

    By Anonymous Anonymous, At May 01, 2007 4:21 am  

  • anon,

    Yes lets all be worried about this black hole that will "suck our economy". Before it begins to "suck our economy", I'm sure our beloved govt has prudently cut waste in rising defense and R&D spending which has not shown any tangible results. Losing several billion in Shin Corp will also not "suck our economy". But giving medical subsidy to the old will definitely sink our economy.

    Lets talk about 'affordability'. It means different things to different people. What is the maximum size of an affordable medical bill for a family with per capita income of $1000? How do we discuss affordability without defining what affordable is? How can means testing make people who can "afford" to pay more do with less subsidy when "affordable" hasn't been defined?

    On my blog is a $70K medical bill (class C) the unsubsidised bill is much higher no need to talk about . This family would have failed means testing if implemented. The household income is less than $5000 with 4 people. Is this bill affordable? If it was $100K is it still considered affordable? What about $150K???....

    It is meaningless to talk about affordability in a vague ambiguous manner. A $100K bill is clearly affordable for Wee Cho Yaw and our millionaire ministers but for ordinary families? ...Until today the govt has not established what is affordable for those who fail means testing.

    By Blogger Lucky Tan, At May 01, 2007 8:32 am  

  • Hi lucky,

    I would like to put it to you that healthcare is never going to be 'affordable' for the middle and lower income classes.

    Put it this way, no one wants to spend on healthcare. Not even the rich. Who is happy to pay when they are sick? No one.

    To the govt healthcare expenditure is a drain of resources and bad for the economy. The less spent the better.

    Healthcare to most people is a necessity. And it is an expensive necessity.

    There are no solutions to this problem. To me the issue is simple. Someone has to pay for the bills. Unless we force drug companies, doctors and other healthcare workers to become a vocation (yes that means companies like Pfizer, MSD and GSK etc should be non profit), healthcare costs will be high.

    Someone has to pay. If it isn't the government, then it's the people. Then again the govt gets money from the people, so it is still the people who pay anyway.

    Or you have a rich king that pays for the people.

    If no one wants to pay....well maybe we should just abolish healthcare. What say you?

    I'm sick of hearing everybody saying they don't want to pay. Might as well close down all the hospitals right?

    Our leaders talk about good dose of incompetent government. Hence we have to pay.


    By Anonymous Anonymous, At May 01, 2007 12:01 pm  

  • anon,

    "Somebody has to pay". Yes of course nothing is for free. Nothing. Money has to come from somewhere. The question is how to allocate scarce resources.

    ::::Health care is NEVER going to be affordable to the middle and lower class::::

    Yes, I would like to hear this with some honesty instead of the repeated mantra by Minister Khaw- "it is affordable, affordable, affordable". What you said is not what out govt said. In the USA, it is very simple, you buy insurance or you become bankrupt when you get sick. There is no ambiguity. The govt doesn't go and tell the people 'don't worry it is affordable' only to shock them later.

    I'm glad you agree with me that healthcare is NOT AFFORDABLE in Singapore..... That was what I was trying explain.

    ::::Someone has to pay. If it isn't the government, then it's the people. Then again the govt gets money from the people:::

    Do other govts take the money and build huge reserves for investment overseas? What about the $10.6B & billions in R&D spending in defense spending? Isn't saving the lives of the sick a priority?

    I never said that it is magic - money has to come from somewhere. It has to come from the budget and trade-offs have to be made. Should tax payers' money be used to fund scholarship of foreign students who use Singapore as a stepping stop to the US? ..."Money has to come from somewhere" doesn't mean we have to have less subsidy. It can come from other parts of the budget. When the subsidies are reduced, where does the money go to? Overseas investments?

    Subsidies for sick is reduced but spending on minister pay rises. Spending on defense rises, spending on R&D without tangible results rises. Why can't it be the other way around? Who will be the winners and losers.

    ::::I'm sick of hearing everybody saying they don't want to pay. Might as well close down all the hospitals right?:::

    I'm sick of people not being able to understand that no one is saying they don't want to pay. I'm also sick of listening to people who say things cannot be improved. I'm also sick of people underestimating this great govt of ours, surely they can do better and improve the care for sick people. Surely they can fix the cracks in our system that people fall through. Who say they cannot afford to insure babies with congenital just take a 1% cut in the defense budget to do this. It is a choice not an impossibility!

    By Blogger Lucky Tan, At May 01, 2007 2:16 pm  

  • Hi lucky,

    Yes it's a choice. Everyone has a choice. The majority made their choice in government in 2006.

    And the govt has made their choice.

    So this is all part of the choice Singaporeans have made anyway isn't it? At least the majority of those who did get to vote.

    Can things really be changed by trying to talk talk talk talk talk about it?

    I certainly don't think so.

    Nobody wants to pay for healthcare in Singapore. Singaporeans don't want to pay. And the government is made up of people who represent Singaporeans right? SO naturally it's the same response lah.

    Go look around. People willing to spend money buying TOTO (mind you they blow a few hundred each time but will bargain over $20 when seeing doctor), cigarettes, beer, mahjong, stocks, property etc.

    But healthcare....

    So why the foreign investments in the billions but not healthcare expenditure? It's the same as the above except on a bigger scale.

    It's a national obsession in Singapore. To make more and more money. Money is the most important thing in the world. No money I no do for you, no money I no care for you, no money I no work for you.

    It's Singaporean lah.

    By Anonymous Anonymous, At May 01, 2007 10:50 pm  

  • anon,

    I concur with much of what you wrote. Money money money, yes it is an obsession and a means to what end?

    Singaporeans voted for this govt. Yes, they gave the govt the mandate to make these choices. It doesn't mean everyone is happy with it, but what the heck we have some kind of democracy here don't we? Well at least there is some kind of freedom in the blogsphere for us to talk about it.

    As for money spent on vices e.g. gambling, women, drinking, we won't know if thoese who waste on vices are the ones who need help. But like I said a person can DON'T spend on vice and still get into a cash crunch.

    At the end of the day, it is still one man one vote. We (collectively) voted for all this that is happening to us. Some of us want to change it, others accept and move on. Many believe we don't have a fair choice because the PAP turned itself into a monopoly. With mononpoly this is what you get not much of a choice.

    By Blogger Lucky Tan, At May 02, 2007 2:43 am  

  • Hi Lucky,

    Yup agree with you. Not much of a choice. Which is why I agree with dr oz bloke comment at the top.

    This means testing is all about trying to reduce MOH's expenditure and increase profits for the hospitals.

    I also think angry doc is missing the point and his hope that means testing would actually help the system and Singaporeans is misplaced.

    There is no doubt in my mind that Singaporeans in general would be worse off with means testing.

    It is just like when the government sayd that increase of GST is good for you.

    Get real man.

    By Anonymous Anonymous, At May 02, 2007 12:36 pm  

  • Large defence spending is unfortunately necessary in view of our geopolitical situation. There have been too many threats against this little red dot and cursory remarks to turn off the tap whenever our neighbours are not happy. If we can rely on someone else for defence like Hong Kong, we would be able to free up a large part of our annual budget. No point wishing for what we don't have.

    R&D is absolutely necessary if we are going to stay ahead of China and India. Our factories will lose out to cheap foreign competition and even our radiologists may lose their jobs to those in Bangalore. To maintain our lead, we have to invest more in R&D and stay ahead in the global race.

    Healthcare costs will continue to rise because we can do more for patients, but there is a price. Healthcare in Singapore is affordable if our expectations are modest. It only costs $4 to see the polyclinic doctor if you are elderly, $8 for others. Hospital care in the subsidised wards is also very cheap by international standards and considering the quality of care, but obviously you cannot expect to have rituximab, Gleevac or Herceptin.

    If you are poor and develop Her2+ breast cancer, you can get your surgery and standard chemotherapy. If you can afford it, you get Herceptin. If not, you get by with what you can afford. That is fair.

    Some talked about medical insurance. We should encourage that, but there are limits to the payouts as well, depending on your premiums. The rich can have a larger payout because they can afford one with a higher premium. In the US, many people have medical insurance policies that do not cover obstetrics because they cannot afford the higher premiums. That is reality.

    By Anonymous Anonymous, At May 05, 2007 4:40 am  

  • anon,

    I agree with your first paragraph, don't know enough to comment on your second, but I can't agree with the third and fourth paragraphs and have written a new post on why.

    Thanks for commenting.

    By Blogger angry doc, At May 05, 2007 5:06 pm  

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