Angry Doctor

Monday, May 07, 2007

Rational Rationing 2

The earlier post on rationing of healthcare has brought some comments concerning the escalating costs of healthcare and how to contain them.

But regardless of how we choose to manage the problem, whether it is by cutting angry doc's pay or expanding our pool of resources by increasing government expenditure or increasing end-user co-payment, or by restricting access to healthcare, we still need to decide how we ration the resources within that pool. angry doc believes that 'fairness' is a factor that needs to be taken into consideration when making the decisions.

(Outside of the pooled risk system, however, angry doc cannot find a reason to object to patients who are able to afford to pay receiving care regardless of their need or individual responsibility.)

Now, leaving aside the source of funding and the absolute size of the pie (to borrow an expression used by a commenter), how do we make a decision on how large a slice of the pie a patient gets, or if he gets any at all?

Our current two-tier system allows those who can afford to pay more to buy a larger slice of the pie at a premium to do so. While this does allow the pie-maker (baker?) to recover a larger portion of the cost, in theory allowing him to make a bigger pie next year from the budget he has been given, it does not change the fact that the pie is subsidised, and that it does not take into account how hungry the buyer was.

Or should that be a concern at all?

Should the baker distribute the pie solely with the aim of minimising loss? Or should he give more of the pie to the hungriest? What if we were in a famine and the hungriest will still die soon even if we gave them the pie? Should we then give the pie to those to whom it will do most good?

Should we take into account individual responsibility? Should those who get hungry from say playing soccer all day pay the same price for pie, or should they be made to pay more because they have made themselves hungrier by playing soccer during a famine?

OK, the analogy is getting ridiculous and angry doc is going to stop milking it now, but he hopes he has gotten his point across: there are many ways to split a pie, and our current system is not the only possible one.

How we want to distribute our health resources is important, because it ultimately gets translated into health financing policy that affects most of us. Our current system seems to have an over-reliance on income and ability to pay as criteria, and not enough on need and individual responsibility.

angry doc doesn't think that is fair.

angry doc thinks we can do better.


  • Go to Breaktalk. Tell them you want a piece of pie. Tell them also that because you are hungrier, you should get a bigger pie and pay less.

    What's with this "misunderstanding" angrydoc?

    The pie is sold to whoever can pay for it. (Yes someone else may offer to pay for this customer's pie but the size of the pie will also be dependent on the actual amount paid regardless who pays it)

    How big and how nice a pie you get depends on how much you are willing to pie. All types of pies will be available but whether you get it depends on how much is paid to the pie maker.

    Simple? Why can't you all see it? it's so straightfoward. That's how it is done.

    Of course in public the pie maker isn't going to say that of course. He'll be saying that even the cheaper pies are also just as good in relieving hunger (although nutritional content may differ etc)

    Who wants to look bad right?

    But the bottomline is the bottomline. Don't complicate the issue. Whether it is right or not is a debate that transcends religion, ethics, politics etc and will never be resolved. But in a capitalist, primarily right wing country the dollar rules.

    By Anonymous Anonymous, At May 07, 2007 8:37 pm  

  • Angrydoc wrote :

    "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?"

    Ah! Now you're making more sense angry doc! I see where you are coming from now!

    I see how this becomes a very tricky situation. How do we decide?

    May I suggest the following model which is used in many other schemes from the government. (Eg child development account.)

    1) Every working adult has a medisave account. Every child has a CDA account. I suggest distributing the $1.7 billion into these accounts by way of dollar for dollar matching to a limit.

    What happens essentially is that every person would be entitled to a max of $X which the govt will match from the 1.7 billion, if the person puts that amount of money into the medisave or CDA account to pay his or her medical bills.

    This is in effect a co-payment scheme.

    So it works out that what level of care you are entitled to will be dependent on how much you can pay in the first place.

    For example a lady who is considering the $30,000 a year breast cancer treatment. If she can only afford $1000 a year for her medical bills....well then even if the govt matched that $1000 to make it $2000, well she can't take the treatment. If she can afford $15,000, well then she can afford it (assuming $15,000 is still within the limit for matching, which I doubt so)

    Same goes for COPD patients etc.

    It's just money right? How you want to distribute it seems to be the problem. Why not do this co-pay system?

    U pay $X then MOH gives you $X as well. How high your bill can go depends PRIMARILY on how much you can pay, not MOH can pay for you.

    It has worked for the CDA accounts. Why not for medical?

    Welcome to debate on this. :)

    By Anonymous Anonymous, At May 08, 2007 12:39 pm  

  • Just to add some points to the above plan

    1) Dollar contributions to the account can only be made after a diagnosis has be made and treatment options offered by a registered medical professional.

    That means that if you are not sick, even if you put money into your medisave or CDA account, there will be no dollar matching from the government. Only when you are sick and a treatment plan has been instituted or you are considering to have a treatment plan, then can you put money in and get the government to match it dollar for dollar.

    2) 1.7 billion divided by 4 million people is only $425 per person and I doubt that is enough subsidy. But I reckon that not all the 4 million people will be sick every year and require medical treatment in the hospital.

    3) Might want to limit to in-patient treatment bills only.

    By Anonymous Anonymous, At May 08, 2007 12:47 pm  

  • Yes, we are finally on the same page.

    Your system essentially works out to a 50% subsidy for all treatment deemed necessary by a doctor. However, it does not take into account cost-effectiveness or individual responsibility.

    By Blogger angry doc, At May 08, 2007 6:29 pm  

  • Yes it does not angry doc.

    But cost-effectiveness or individual responsibility are not issues that lay people take much interest frankly.

    We've been talking for years about how patients should stay healthy etc etc. But it falls on deaf ears.

    Which seems stronger? People's perceptions of certain treatments or actualy cost-effectiveness?

    Besides these are tricky issues to grapple with. There are moral aspects to it. Potential "play god" type of pitfalls as well.

    Let's keep it straightfoward and follow the business model approach.

    If you can pay for it, then you get it. If you're talking about individual responsibility, well the word will spread that if you can't afford it, then better take care and stay healthy!

    As for whether it is 50%, I don't think 1.7 billion can cover 50% coverage for all patients.

    What MOH can do is to get the median hospital bill size and the mean hospital bill size for each diagnosis eg breast cancer, COPD etc and come up with a yearly limit on per dollar matching based on that.

    So the dollar matching is based on the mean/median. Not the highest possible bill. That way MOH will rest easy knowing it isn't a 50% subsidy. $1.7 billion is probably not enough.

    Think about it. Dollar for dollar matching works well for MOH's interests. The rich will spend more but also get more subsidy. The poor will spend less but also get less subsidy.

    Like I said MOH will be happy. But of course there will be detractors that would say the poor should get MORE subsidies.

    By Anonymous Anonymous, At May 08, 2007 6:42 pm  

  • Matching dollar for dollar will bust the budget. Yes, there must be a cap to ensure that the Ministry's health spending will not exceed the current budget. So it's dollar for dollar up to a limit (which I think will be easily reached in most serious illnesses).

    However, with this system as proposed by the previous contributor, some poorer patients will actually have to pay quite a lot more. Currently medical treatment in C class wards are heavily subsidized...definitely more than 50% of actual costs. If we go down the dollar for dollar route, the poorer patients in the cheaper C and B2 wards will have to pay much more than they do currently.

    Do you think this can go down with the population who already complains about high healthcare costs?

    By Blogger pathdoc, At May 10, 2007 4:43 am  

  • "Do you think this can go down with the population who already complains about high healthcare costs?"

    Answer : yes.

    Didn't the people complain about the following only to see it implemented as well?

    a) GST hike
    b) MRT/Bus fare hikes
    c) increase in Minister's salaries

    Anyway the model that I proposed is not new at all. It is a proven model used in many schemes from the government.

    You can choose to look at it in another way perhaps. The fact that MOH is NOT using this widely used model on healthcare testament that they actually do care about poor people and want to help them more than the rich. Hence they choose not to use that model.

    So government is good?

    By Anonymous Anonymous, At May 10, 2007 9:52 am  

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