Angry Doctor

Saturday, May 05, 2007

Fair and Obvious

A reader left a comment on an earlier entry which got angry doc thinking. angry doc reproduces the parts in question below (emphasis mine):

"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."

angry doc must confess that it is neither obvious nor fair to him that someone in a subsidised ward cannot expect a better quality of care just because it is more expensive.

If we defined a system of healthcare financing in which care (note that I say care, not service) directly correlates with ability to pay as one that is fair, then it would be obvious that the situation above is fair.

But we need to ask ourselves the question: Is that system fair?

If there was no alternative to a healthcare system where care is only given to those who are able to pay, the question would be purely academic. However, what we have here is a system of healthcare financing in which tax-dollars in the form of subsidy can be used to (as it were) 'artificially inflate' a patient's ability to pay and thus allow him (or rather her?) to 'afford' to pay for that care.

And that raises the next question: Why shouldn't we pay for her care?

The 'official' answer is clear:

The financing philosophy of Singapore's healthcare delivery system is based on individual responsibility and community support. Patients are expected to co-pay part of their medical expenses and to pay more when they demand a higher level of service.

OK, maybe it's clearly stated, but the underlying philosophy is hidden: moral hazard, or the idea that people will abdicate their individual responsiblity to take preventive healthcare measures to keep themselves from falling sick, and/or that they will utilise the healthcare system unnecessarily if they did not have to pay for at least part of the cost.

Let's address each part in turn.

Now angry doc thinks a patient who had a heart attack from smoking, eating too much, and not exercising enough effectively 'asked for it'. He might even say that he 'deserved' it. But should he say that that patient obviously should not receive the best care for a heart attack there is if he cannot afford it?

Or if he could afford it, does that mean that angry doc is going to stop thinking that he did not 'ask for it' or 'deserve' it?

Given that there is a well-known cause-and-effect relationship in lifestyle choices and pathogenesis here, and in the context of a subsidised healthcare system where risk is pooled, angry doc might be persuaded that he should be given less subsidy for his treatment, but he would be reluctant to deny him the treatment altogether.

But what if it was a disease where there is no effective preventive measure against, or what if the patient had done all that was possible to prevent that disease, but is nevertheless afflicted?

Currently the system does not make that distinction. All it says is: if you can afford it, you can fall sick all you want; but if you cannot pay for it, you cannot expect to receive the most expensive (and presumably best) care whether or not you are responsible for your illness.

With regards to the second part of that philosophy, angry doc's question is: is cost a determinant of abuse?

In other words, between a man who goes to a polyclinic and feigns an illness to obtain medical leave for the cost of $8, and a woman with Her2-positive breast cancer who requires Herceptin at the cost of $30,000 a year, who is abusing the system?

angry doc believes most of his readers will say that the man is abusing the system, but as it stands the system puts minimal barrier in the way of the man, and a very high barrier in the way of the woman. Is that fair?

You may argue that a high fee at the primary care level may deter people from seeking primary healthcare, but if that's the case, why let cost be a deterrence to someone seeking life-extending secondary care? Why would anyone ask for Herceptin if she didn't need it?

Fairness is a moral concept, and angry doc thinks it is vain to think that we can use economic means as a substitute for moral judgement to try to achieve fairness.

angry doc cannot claim that he has a workable system to use fairness as a measure to ration healthcare all figured out, but until then, he doesn't see why we should regard the current system as obviously fair, or as fair at all.


  • Let me stick my neck out here. I have never studied economics nor business. But just using simple logic & reasoning; we know that:

    a) Health care is expensive
    b) Health care should be accessible to everyone no matter how rich or poor they are
    c) The government is trying to make it such that they don't have to subsidise every single eligible person in Singapore
    d) People do not want to pay too much for healthcare

    We can't change a) without affecting quality.

    And it's only fair & ethical that b) remains status quo.

    And I can understand c) because healthcare is only going to get more expensive with time & an aging population, so I could see the concerns facing the govt.

    And I don't see d) changing much either.

    One possible solution that I can think of is perhaps the government should promote the concept of using medical insurance especially to those who can afford to pay the premiums. I know that Medisave & Medishield is in place now which does provide some kind of coverage. I honestly don't know the details of how comprehensive this coverage is as I haven't had the need to use it (touch wood) & I also have private coverage which makes me a bit complacent as far as finding out more about this is concerned.

    But perhaps, there should be greater focus now on not only insurance for inpatient care but also for outpatient, so that if a person DOES get struck with an unforeseen illness, he doesn't get stuck with a huge debt to pay.

    A lot of public education will have to come along with this, as people HAVE to learn to invest in their own health (present AND future) & not expect to be spoonfed from cradle to grave.

    So maybe instead of spending all this time & money on all this means testing business, they should look into educating the public on what medical insurance is (as I am sure that most Singaporeans are lacksadaisical about this) & the kind of insurance policies to look for.

    Just my two cents...

    By Blogger aliendoc, At May 05, 2007 9:24 pm  

  • They should have sent us on a Health Economics module instead of that Human Resource one during medical school... as it is I don't even know how money works.

    I agree with your observations on points a), b), and d).

    As you have mentioned, the government deals with point d) by using the 3M system (I'll post on that later), which basically forces all CPF members to keep aside a sum of money for hospitalisation, and from that sum they further use an opt-out system to 'force' them to buy a health insurance policy. What we are trying to do here is a near-universal (90% of working population!) health insurance funded by compulsory savings.

    I tend to want to question the thinking behind c) though.

    There is no explanation as to why the government is committed to wanting to keep healthcare budget low. It is as though the reason is "obvious", but once again I don't see it as so.

    Altruistic socialist considerations aside, healthcare spending reaps definite economic benefit by keeping the working population healthy enough to contribute to the economy, mothers healthy enough to produce babies, and the babies healthy enough to grow up, go to school, and learn things that will allow them to contribute to the economy, and/or produce their own babies, and so on.

    (I concede that this is true for primary prevention, but less so for secondary and tertiary prevention though.)

    'Ideally' every citizen will pay for this expenditure himself, but in reality there will always be those who will not, and then it's a question of whether it is more cost-effective to pay part of that for them from tax-money to lower the barrier to compliance, or to leve them uncovered altogether.

    One would suspect that by and large there is a correlation between expenditure and benefits, even if this is not linear. Question is: what level of expenditure is the most cost-effective? Certainly there must be a way to estimate this and (given that this figure is likely changing with changing technology and disease pattern) track it. Are we doing that? If not, why are we committed to keeping healthcare spending to a single digit percentage of the GDP? I suspect once again we are emphasising cost-savings over quality.

    On the subject of rationing, my current 'stand' is for rationing by need rather than by income or ability to pay. We already do that with the exclusion clauses under Medisave and to a certain extent the "Medically Fit for Discharge" ruling, but I would actually like to see more of that than means testing.

    By Blogger angry doc, At May 05, 2007 10:48 pm  

  • Angry Doctor has made his position clear that he believes rationing should be based on need. I believe that statement, though altruistic, does not address the problem.

    The use of the word 'rationing' itself indicates that resources are limited and that demand outstrips supply. That is why one needs to ration out a limited commodity. 'Rationing based on need' is like saying you will get a meal if you are hungry, regardless of whether you can pay for it. Someone will have to pay if you cannot pay. The question is: who is that person?

    Most would agree that modern healthcare is expensive. If we were to provide every patient with the best, state-of-the-art treatment that we can offer, the money must eventually come from Singaporeans, either directly by paying patients or indirectly through taxes. Raising taxes is always an unpopular move. Singaporeans do not want to pay more. In any case, with an aging population that will consume more healthcare and the fact that only 40% of our population pays taxes, that is just not feasible.

    Something else must give. We can rob Peter to pay Paul: cut defence funding for the health ministry or charge paying patients more to subsidize patients in C class wards. The former will render us vulnerable and the latter will make us less competitive as a medical hub.

    What about medical insurance? Insurance companies are not charities. You cannot expect them to pay for Herceptin and Gleevac unless you are paying much higher premiums, which the poor can ill afford.

    This is the real world. Much as doctors refuse to acknowledge it, medicine is a commodity like any other. The best treatment for breast cancer in Ethiopia is surgery and radiotherapy because that is all they can afford. It is the same in Singapore. If you are poor and have Her2+ breast cancer, the best treatment you will get is the best that society can afford to subsidize. To me, that is fair.

    Singapore can push the boundaries of what we can afford by cutting costs. If we can hire Indian MOs and registrars for half the cost of local doctors, we may be able to subsidize more of their medication. Manpower costs comprise a large part of healthcare spending. If doctors and nurses are willing to take bigger cuts in their salary, hospitals can make their block grant from the government go further. More poor patients can get better subsidized treatment. To me, that is obvious.

    Is angry docto willing to cut his salary?

    By Anonymous Anonymous, At May 05, 2007 11:36 pm  

  • Apparently there is only one radiotherapy machine in the whole of Ethiopia...

    I'll admit that I don't have a proposal for a system for rationing by need, but I will maintain that rationing by cost is not fair. It may be a system we settle for, but from a moral stand-point it is not fair.

    Using the food analogy, rationing by ability to pay will mean that we will give the food to the rich who want to buy them even when they are not hungry, and leave the poor to starve.

    That may be the way the real world works, but it is not fair. And in a commonwealth, in a system where we already implement a system of healthcare financing based on pooled risk, why should the poor starve?

    The world may not be fair, but fairness is a moral ideal we want to work towards even if we cannot achieve a perfectly fair world. Not receiving life-extending treatment because society decided it cannot afford to subsidise you is not fairness, it is a tragedy.

    As for whether or not I will take a pay-cut, it is an unfair question because I can tell you that I will or even that I have taken a pay-cut, and there would be no way for you to verify my claim, so I won't answer that.

    By Blogger angry doc, At May 06, 2007 12:30 am  

  • Fairness is a moral ideal? Then perhaps the entire world does not conform to your system of morality.

    Humans have acquired the right to rule the earth by driving other humanoids into extinction. It is survival of the fittest that selects for the best genes and thereby ensures the survival of the species to the exclusion of all other competitors.

    If you believe in God, then God is not fair. We are not created equal. Some are born with more talents and intelligence than others. The talented genius who has the misfortune of being born to an Ethiopan mother dies from starvation instead of winning the Nobel prize had he been born in the United States. That's not fair. The poor farmer in rural China who works 12 hours a day and yet not earn enough to feed his child two meals a day...that's not fair. In fact, if you believe in God, then God is the most unfair of all and the architect of the greatest injustice.

    The economic pie must not and cannot be equally divided, because those who contribute more in the making of the pie must get a larger slice. That is fair and equitable. Despite his belief in moral ideals, even angry doctor is not prepared to cut his pay so that the poor can get a larger slice of the pie. Nor should he.

    For the poor who have little because they contribute little (whether it is due to the lack of skills, illness or plain laziness), we can only assist them by enlarging the pie. They keep the same percentage but they get more if the pie is larger. That is all we can do.

    The NHS system in the UK is an example of healthcare financing based on pooled risk. Taxpayers pay a significant percentage of their income to finance it. Yet the NHS is also finding it impossible to fund expensive drugs such as Zevalin. Pooled risk also means shared outcomes. The banker who paid thousands into the NHS over the years in the end has to seek private medical treatment if he wants the latest drugs. That is not fair nor equitable.

    By Anonymous Anonymous, At May 06, 2007 2:34 am  

  • Yes, the natural world is unfair and without mercy, but that is no reason to reject fairness as a moral ideal or virtue worth pursuing. You can also view fairness not as a moral ideal, but as a value societies (consciously or unconsciously) adopt to maintain cohesion.

    In the larger context I agree with you that a totally equal distribution of wealth and power regardless of merit or abilities is unrealistic. However, what we are discussing here is the narrower context of distribution of healthcare resources in a part-private-part-subsidised healthcare financing setting. You see rationing by ability to pay as fair, I don't. I see rationing by need as being fair.

    Let's a take a step back and ask ourselves: what is the aim of a state-funded healthcare system?

    Is it to generate revenue for the state? Or is it to maximise the health of the population (for moral and/or economic reasons)?

    If it was the former, then it makes sense to have rationing by ability to pay.

    But if it was the latter, then rationing by need makes sense.

    (In our context though, it is probably both.)

    I think maximising health of the population is more important, and I think we can do it better if we have more rationing by need. If we have to moral courage to implement more rationing by need, we can make better use of existing resources, and there will be less objection to increasing subsidy on grounds of moral hazard and abuse of healthcare.

    (Of course, carrying this line of argument to the extreme can result in a dangerously utilitarian system that denies healthcare to people who fall outside the definition of 'need'. I continue to advocate a healthy dose of moral judgement in healthcare decision-making.)

    By Blogger angry doc, At May 06, 2007 3:26 pm  

  • Don't misunderstand me. I do not object to provision of healthcare to all based on need. That's the ideal of all healthcare systems. The fact is, that is not tenable when resources are limited. There will be new drugs and new treatment coming out every year and all of them will be expensive. Healthcare costs will escalate if we give everyone the best treatment money will buy.

    You want the state to fund the healthcare system, but that will require a tremendous increase in taxes. In Singapore's context, the impact will be far greater because we are starting from a low base in terms of health spending. Given that only 40% of Singaporeans are paying taxes, will we be prepared to see our taxes doubled? Given an aging population, that tax burden will only rise as more elderly needs healthcare and less young people are there to pay taxes. Call me selfish, but I certainly do not want to pay more taxes. I would rather move to Hong Kong where the taxes are lower. Businesses will also move elsewhere to avoid paying the high medical fees for their employees. Employers will be less willing to employ if their business costs rise, as we see in France. With more unemployed, the tax burden falls on a smaller group of people. They leave as well and a vicious cycle is set up.

    I do not object to your ideals. I respect it, although I don't believe it works. But the government cannot act based on ideals. It must enact policies based on what works and avoid the adverse effects of a good intention.

    By Anonymous Anonymous, At May 06, 2007 5:49 pm  

  • I think while governments should not act based on ideals, they should act towards ideals.

    Rationing by need does not require us to abandon our current system of co-payment and have universal free coverage, it requires us to apply judgement on how current resources are rationed. If we can identify and stop abuse of healthcare, we may be able to free up resources for those who need it. But until we decide to and set up a system to identify abuse, we cannot even begin to quantify how much resources are currently being 'wasted'.

    By Blogger angry doc, At May 06, 2007 6:27 pm  

  • With regard to getting people to buy medical insurance as a way to resolve the affordability of healthcare problem...

    It's a zero sum game. Someone has to pay for it. Insurance companies are profit driven. Any premiums calculated are bound to ensure profit for the insurance company. I really doubt it works in the patient's benefit at the end of the day. Pressure will be applied to restrict use of more expensive treatments and investigations (as seen in USA) or premiums will rocket sky high such that it is impossible for the man on teh street to buy it. What happens then is we end up at square one. You can only afford the insurance premium that covers the basic healthcare items and not the expensive cutting edge stuff.

    What's the difference?

    Here's what I think the future will be like everywhere in the world.

    There will be a basic standard of care (which is highly debatable but will be the "standard" by virtue of cost rather than actual "best" option of treatment) which will be available to almost everyone.

    But if you want the treatments that cost more.....well then you're going to have to pay for it.

    Simply put, doctors, governments etc should cut the acting and speak the truth and be honest.

    a) Health care is expensive
    b) Someone has to pay for it
    c) The state can help you pay for some of the not so expensive stuff that can still save you but if you want the expensive latest stuff then you gotta pay for it cos its not going to be us

    What's wrong with that? With all other businesses and industries it's the same. We don't go discounting power bills and water bills for the poor do we?

    Morally it seems really bad and all that jazz. And yes of course it is bad, if you compare it with the old NOBLE MEDICAL PROFESSION and all that jazz. But if you compare it to any other industry...what's the difference?

    So just be honest. Say it as you mean it. Don't beat around the bush.

    If you want to be noble then all doctors should take a HUGE PAY CUT. Earn about $2K a month. You can survive on that kind of Salary even in Singapore you know. Thousands of people do. And dun go saying about how you can't attract the best minds into medicine etc etc cos it's a seperate issue (go read about Minister salary debates)

    Drug companies should deliver drugs at cheaper prices. Not exorbitant ones. But of course R&D costs are high and all that jazz.

    For all it's worth, for all the talk, this is the real world.

    Medicine is already treated just like any other industry by governments and most people. It's just that no one wants to admit it.

    By Anonymous Anonymous, At May 06, 2007 8:38 pm  

  • Angry doctor, I do not understand what you mean by keeping the current co-payment scheme and still have universal free coverage...that seems a contradiction.

    I agree with the other anon. contributor that we must accept a two-tier system of healthcare. A subsidized, public healthcare system that will provide affordable medical care that is as good as society can afford to subsidize; and a private sector that provides the best that money can buy.

    Our current healthcare system is already pretty lean and efficient. I do not think that cutting abuse and waste will enable us to give Herceptin and Velcade to subsidized patients. That must be reserved for those who can afford.

    Primary healthcare will be made cheaper by bringing in foreign competition. Doctors from UM in Malaysia, Myanmar and India will meet the manpower shortage in polyclinics and so eliminate the wage pressure that inevitably builds up when demand outstrips supply.

    Healthcare costs will be highest in the hospitals and with diseases like cancer. It is difficult to cut specialist pay unless we relax the qualifications required to get on our specialist register. For certain disciplines that are overpaid relative to the global market, eg. our surgeons are paid much more than their counterparts in the NHS, we can actively recruit foreign surgeons to Singapore. Market forces will depress their salaries and lower healthcare costs.

    There is not much we can do about specialists who are paid less than their foreign counterparts, eg. pathologists, psychiatrists (in fact, we have to raise their salaries to hold them). We can outsource radiology to India by teleradiology but we cannot send surgical specimens or patients across the internet. We can relax our criteria and introduce local specialist qualifications but the downside is that we will lose foreign patients. Most of our psychiatrists only hold the MMed rather than MRCPsych or the US board certification. We won't expect US patients coming to see our psychiatrists anytime soon. In fact, if our pathologists do not have recognized international qualifications, our labs may lose CAP (College of American Pathologists) accreditation and hospitals may lose JCI status.

    As for drugs, pharmaceutical companies are not going to lower drug prices anytime soon. It is a risky business. Pfizer lost a billion USD when their new drug torcetrapib failed late in the drug trials. We can follow the Thais and introduce local licensing (read, ignore patent rights and just make the drug) but that will kill off our fledging biotech industry. In a fantasy world of the future, if the UN will fund an 'open-source' research institute for drug discovery and development, perhaps we may have a solution to expensive drugs. Until then, patients in the subsidized public sector can only expect older drugs that have lost their patents (ie. 20 years old).

    By Anonymous Anonymous, At May 06, 2007 9:26 pm  

  • "Angry doctor, I do not understand what you mean by keeping the current co-payment scheme and still have universal free coverage...that seems a contradiction."

    I mean that we can practise rationing by need within our current co-payment system; the bit about free universal coverage is to address the preceeding post which seems to suggest I am proposing free universal healthcare.

    By Blogger angry doc, At May 06, 2007 9:47 pm  

  • Referring to the point about whether angry doctor is willing to take a pay cut to accrue the pool of reserves used for financing medical subsidies given out here, why should this be the case when the ministers here are all getting a pay-hike, while the pittance received does not commensurate the amount of work done by doctors here as compared to their counterparts in places like Australia and Hong Kong.

    Aren't doctors similar to minister in the sense that both are "ideally" in the profession for an altruistic cause and also maintain the efficient running of the country?

    By Anonymous Anonymous, At May 07, 2007 2:59 pm  

  • I think the correct term to describe it is VOCATION.

    This was told to us by our Catholic Priest during a Sunday homily.

    If you look at the occupation as a vocation......versus looking at it as a career.

    If it's a career then fine to go for money, pay rise etc. If you look at it as a vocation then shouldn't think about money.

    It's how you look at it. But you shouldn't have your cake and eat it.

    Which is why I am against doctors and politicians talking about their occupations as vocations and yet want their high pay.

    Just call it as it is lah! It's just a career! And so should the rest of the people at large. It's just a career, dun put anyone on moral pedestals.

    By Anonymous Anonymous, At May 07, 2007 3:20 pm  

  • anon 3:20 - you know, you are quite right. But I don't hear many doctors calling their job a vocation. And I haven't hear any of my colleagues proclaiming to one & all about how it's a calling & so on & so forth.
    But the impression of the general public is that it SHOULD be a vocation, an altruistic contribution to society. Hence they don't like to hear about doctors getting high salaries (misconception here, by the way) & living the lifestyle of the rich & famous, thanks to the media highlighting a minority of the population of doctors who actually earn enough to do so!
    And by extension, I think they feel that it is their RIGHT to expect healthcare for cheap...

    But then that brings us to the crux of the matter, isn't it? Is it a RIGHT for one & all to receive subsidised ( healthcare? Or should one be expected to pay what one can afford, as angrydr is trying to argue?

    Difficult questions to answer, ya?

    By Blogger aliendoc, At May 07, 2007 9:18 pm  

  • If the public wants doctors to take up medicine out of a sense of altruism, as a vocation in the way one contributor described, then to begin with, society must be prepared to bear the bulk of the medical education. If public pays for the medical education, it has the moral platform to call on doctors to work for 2-3k a month.

    No, medicine is a commodity, a trade, a service like any other. There are different tiers of services and you get what you can afford. If you cannot afford treatment, a civilized society may be prepared to subsidize your fees. But the level of service you get is dependent upon how much society is prepared to subsidize.

    I concede that everyone in a civilized society should have a right to basic healthcare, as he is also entitled to basic education etc. But he has no right to expect the best medical care we can provide. What is the standard of this basic healthcare then? It's the best that society can afford to subsidize. If the nation does well economically, the basic healthcare becomes more generous. That's why I said the quality of subsidized healthcare has to be linked to the size of the economic pie.

    By Anonymous Anonymous, At May 07, 2007 11:55 pm  

  • I don't think you get my focus on the issue here:

    Given that society has decided that it can afford to spend 10% of the annual tax collected (about $1.7 billion) on subsidising healthcare, how should we distribute this money?

    Within this pool of money, should we spend $30,000 a year to subsidise a woman with breast cancer, or should we subsidise 100 admissions for COPD patients who persist in smoking?

    How do we decide?

    By Blogger angry doc, At May 08, 2007 12:08 pm  

  • I would like to add y two cents (about what it's worth) as a poor American, with sharply limited access to health care.

    I think the notion of slightly lower quality care for everyone, with a pay to play struture for those who can afford it, is very attractive. Especialy if it includes the idea that the care that is neccesary to sustain life is guarenteed. In the U.S. (I know nothing about the system in Singapore, except what little I have learned from this post), I suggest that care for those who drink, smoke or eat particularly unhealthy foods, be subsidised by high sales taxes on those particular items, rather than rationing care away from the users of those products. This would have the duel effect of covering the increased cost of care, while further reducing the abuse of said substances.

    Too, the same could be applied (though with much higher complexity) to activities that increase the risk of higher healthcare consumption.

    I do not claim that this is a perfect solution to your dilemma of fairness, but I think it goes a long way.

    By Blogger DuWayne Brayton, At May 11, 2007 11:05 am  

  • Given that society has decided that it can afford to spend 10% of the annual tax collected (about $1.7 billion) on subsidising healthcare, how should we distribute this money?

    Within this pool of money, should we spend $30,000 a year to subsidise a woman with breast cancer, or should we subsidise 100 admissions for COPD patients who persist in smoking?

    I believe that 1.7 billion should be spent to provide the best medical care it can buy for the largest number of people (kind of ethical utilitarianism). The Minister will probably say that to make it go even further, it should go to the largest number of people who cannot afford private medical treatment.

    We cannot refuse COPD treatment to the 100 smokers on account of their smoking. Neither can we afford to spend 30k for the woman with breast cancer. She will have to pay for her Herceptin if she wants it and the smokers will get the best quality care that the budget will allow. That level of care will be lower than what is available in the private sector, but the latter should be restricted to those who cannot afford to pay.

    By Blogger pathdoc, At May 11, 2007 3:02 pm  

  • DuWayne,

    As it is we already levy high duties for alcohol and tobacco (a pack of 20 cigarettes costs about US$7, and a can of beer about US$2).

    I think you will find our system of healthcare rather attractive. Primary healthcare is accessible and cheap, but secondary and tertiary care can be expensive depending on the overall bill-size, since the co-payment rate is a fixed rate.


    My criticism of 'ethical utilitarianism' is that it does not take into account personal responsibility in the pathogenesis of many diseases. I am currently leaning towards 'liberal egalitariansim', which advocates a graded co-payment rate. Under this concept smokers with COPD will not be denied healthcare, but will have to pay a higher co-payment rate than say the woman with breast cancer, which will hopefully through the higher co-payment of the smokers be able to pay less for her treatment.

    Of course our poor smokers will be hit with a double whammy (high duties and higher co-payment rate)...

    By Blogger angry doc, At May 11, 2007 4:57 pm  

  • Angry doc, I appreciate your intention to link personal responsibility with health care costs but I don't think your proposal will work in practice. If we do as you propose, just overnight every single COPD patient will claim to be non-smokers but have a spouse or family member who is a heavy smoker. You are not going to penalize them for second-hand smoke, are you? In any case, how are we to tell if the patient is truthful if he claims not to be a smoker and how much he smokes?

    Smokers have to pay a higher premium if they buy private medical insurance. The failure of disclosure will mean that the insurance company can refuse to pay a single cent if years later, it is discovered that the patient was in fact a smoker. That is the deterrent. But what can we do if we discover that a patient had been lying about his smoking status? Do we expect the hospital to sue them?

    Such a system will be a lawyer's dream. I can imagine the number of lawsuits that will arise if we try to charge a COPD patient more because we think he had been a smoker. How many cigarettes a day for how long constitutes a smoker? How long must one stop smoking before he is considered a non-smoker? Is the smoker of a cigarette a day to be treated the same as one who smokes 100 a day? What about the type of cigarettes? Does the nicotine level matter? What about cigarette filters that claim to remove most of the tar? A lawyer will have a field day :)

    By Blogger pathdoc, At May 12, 2007 3:37 am  

  • Very pertinent points, pathdoc.

    I have actually drafted a post on this, and I will clean it up and address some of the points you have raised, and hopefully post it this evening.

    By Blogger angry doc, At May 12, 2007 11:54 am  

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