Angry Doctor

Wednesday, May 23, 2007

Subsidy and Other Preoccupations 14

An article from The New Paper brings angry doc back to the topic of means testing.

As he has mentioned many times, angry doc is not a fan of means testing in its current proposed form, but here it is not so much the idea of means testing that troubles him as much as the poor arguments for means testing presented by the journalist here. angry doc will interspace his comments (in blue).


Monthly salary $9,300 Hospital ward C CLASS
S'pore's top earners make up 1 in 10 patients in subsidised wards. Time to start means testing?
By Leong Ching

WOULD you give public assistance to the boss of a multinational corporation?

Free meals to a lawyer living in a District 10 bungalow?

Subsidise the Lexus of a coffeeshop towkay?

No?

Then why would you be against means testing? It is just a way of making sure that anyone who needs a subsidised bed will get one.


Wrong, because means testing in its current proposed form will not make sure that anyone who needs a subsidised bed will get one. A rich man can still stay in a C-class ward even if he fails means testing, provided he is willing to accept the fact that he will receive less subsidy than someone who has passed the means test.

And wrong also because means testing does not test "need"; it tests "means". A poor man who passes means testing can still stay in a C-class ward and enjoy the full subsidy even if there is no compelling medical reason for him to be there.

So between a rich man who needs a bed and a poor man who does not need a bed, who is denying the poor man who needs a bed his bed?


Without means testing, some of the rich, and even the very rich, are enjoying government subsidies by choosing to stay in lower-class wards.

Yesterday in Parliament, two vital pieces of information emerged about health care here. First, we are short of hospital beds. Second, we are throwing government subsidies at certain well-off people.


The two issues are actually not directly related: a rich man who needs to be admitted will take up one bed regardless of how much subsidy we give him, just as the poor man. The amount of subsidy a man receives has no direct impact on the total number of beds in the system.


Said Health Minister Khaw Boon Wan: 'Our current bed situation is tight, particularly in the Tan Tock Seng Hospital as it is the only hospital serving the large population in the north besides its own catchment area.

'The over-crowding in TTSH in turn causes spill-over to the other hospitals, especially National University Hospital and Changi General Hospital.'

There will be relief, he noted, when the new general hospital in Yishun opens in three years' time. There is also another general hospital in the west being planned.

Each year, Singapore will need another 60 to 100 new beds - many in subsidised wards.

Beds in B2 and C Classes are heavily subsidised, the latter to the tune of 80 per cent.

How do we make sure that these wards go only to those who need them?

Another way of saying it - how can we make sure that those who can afford it, do go to the less-subsidised wards?

The policy objective is the same - but the political nuance is vastly different.


Nuances indeed. Here the writer continues to make the error of equating ability to pay with (non-)need, and that the bed situation is a result of "those who can afford it" taking up the beds of "those who need them".


The second way of saying it leaves it open to those who want to score political points.

'Sure, I can afford to go to a better class, but I don't want to,' they say. 'And you are wrong to make me.

'I may get a higher pay, but I want to spend less on health care.

'And if the next guy doesn't pay taxes and I do, I would be even more entitled to a C Class bed.'

These arguments are very appealing to the sandwiched middle class, who may be struggling to raise kids, care for ageing parents and find hospital bills an onerous expense.

This by itself does not contradict the principle that the rich should not get handouts. It merely tells us that we ought to be careful whom we call 'rich'.

For example, a family may earn $5,000 from two incomes, but they might deserve some subsidies if there are three little children and four old folks to take care of.

The devil is in the details. And here are more details to light the way.

The Ministry of Health yesterday released numbers to show the profile of the people who used CClass wards in 2004.

They were startling - they showed that 9 per cent of C-Class patients were from households whose earnings were in the top 20 per cent.

That is to say, nearly one in 10 patients who used C-Class wards came from a household earning close to $10,000 a month.

One-third of all C-Class patients were from the bottom 20 per cent of households.


Ironically, these statistics suggest to angry doc that we have too many C-class beds, not too few. Otherwise, why are only one-third of the beds occupied by the poor people?


According to the Department of Statistics, the top 20 per cent of households earned $9,300 a month, whereas the bottom 20 per cent earned $1,180.

So, in the democratic environment of a C-Class ward, a man who earns $9,300 a month enjoys the same handouts from the Government as the one who earns $1,180.

Is this fair?

Another quarter of C-Class patients come from the lowest 20th to the 40th percentile.

So, by and large, more poorer Singaporeans are using the most highly-subsidised ward.

But why are rich Singaporeans there as well, and in numbers as high as 9 per cent?

ALLOTMENT VS RIGHT

Some may argue that they are there because they are as frugal as the next guy. Why deny them the right?

Well, because a government subsidy isn't a right - it is an allotment, in the same way that public assistance and food rations are.

One MP asked Mr Khaw yesterday whether he was going to implement means-testing.

He replied that it was 'at the back of my mind' but that he had many other issues to deal with - including the reform of Medishield and Eldershield.

'I will come to it,' he said.

One reason for the long percolation could be the political price. After all, the $9,300-a-month man would not take kindly to his low-priced hospital stay being taken away from him.


Except the "$9,300-a-month man" may end up with a $300,000 bill, which even at 65% subsidy (but before Medisave) will take "$9,300-a-month man" a full year's income to pay off. Hardly "low-priced", is it?


Madam Halimah Yacob, who chairs the Government Parliamentary Committee on Health, had warned that an extensive public debate was needed 'so that people are adequately prepared and are not caught by surprise by the change in policy'.

Last month, the Health Ministry said there would be some kind of means testing within a year.

I would say - let's start now, and start with the $9,300 man first, followed by the $5,000 man.


angry doc would say: start with looking at more aspects of the issue first, followed by getting your logic right, then start thinking about whether we should even implement means testing in its current proposed form.

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20 Comments:

  • I am a bit confused.

    Hospitals are short of beds. I presume that refers to all beds in general regardless of the class? Or is there a surplus of A class and B1 class beds and a shortage of C class beds?

    My impression is that there is a shortage of beds regardless of class.

    What has this got to do with means testing? Isn't it a separate issue? But it seems to me that people are linking the two. Why? Even if you means test, if you have 10 patients who need hospital admissions, then you need 10 beds regardless of how much they earn right?

    Get the beds!

    As for means testing. Dr Ozbloke has long maintained that means testing is merely an exercise to cut the government health expenditure and also to put in place some measures to try to earn some profit from people they feel "can afford it".

    Means testing will NOT I repeat will NOT resolve the shortage of beds problem, unless the facts state that we have a shortage of C class beds but not A and B class beds. If that's the case, then I say this is a problem of allocation of beds. If the market for A class and B1 class beds is low in teh government hospitals then you jolly well convert them to C class beds that you need!

    There is a lot they are not telling us.

    I have long proposed that in the public hospitals all the beds are of the same class. If you are willing to pay more for better service , then go to the private hospitals. If you need no frills care, then the public hospitals should be set up in that manner to provide for that.

    All this means testing and what not.....the problem I see is that the public hospitals want to earn profits too. Therein lies a big problem.

    By Blogger Dr Oz bloke, At May 24, 2007 11:26 am  

  • If the market for A class and B1 class beds is low in teh government hospitals then you jolly well convert them to C class beds that you need!

    There is a lot they are not telling us.

    I have long proposed that in the public hospitals all the beds are of the same class. If you are willing to pay more for better service , then go to the private hospitals. If you need no frills care, then the public hospitals should be set up in that manner to provide for that.


    Convert paying class wards to C class wards? Where's the money coming from to subsidize the C class wards then? Remember, C class wards are heavily subsidized. Are we prepared to pay more taxes?

    As for your second proposal, if we keep all beds in public hospitals as C class wards, there will need to be a significant injection of cash. Back to the taxes issue...

    Secondly, it's not just the frills you lose if we get rid of paying patients in public hospitals. If public hospitals only serve subsidized patients, they will have to cut staff salaries to break even. There is no way they can afford to pay the 25k a month salary to some surgeons in our public hospitals, as they do currently. We will lose the most experienced, senior doctors to the private sector. All patients in public hospitals will no longer have access to the best doctors, nurses and advanced diagnostics.

    By Anonymous Anonymous, At May 24, 2007 4:23 pm  

  • Oz Bloke,

    I'll leave you to answer anon since I know you have the answers to the questions he raised ready...

    Yes, the article is a poor piece of journalism. The writer is primarily trying to stir up envy against the 'rich' ('boss of a multinational corporation', 'lawyer living in a District 10 bungalow', 'coffeeshop towkay') without taking into consideration how a bill size may vary while the percentage subsidy for class stays fixed.

    Yes, hospital bed shortage is across the classes, and patients in subsidised classes are lodged in beds of higher classes.

    And just to add another point: C-class wards are probably more cost-efficient to the hospital, since they have a higher patient to staff ratio.

    By Blogger angry doc, At May 24, 2007 5:03 pm  

  • Hi anon,

    I've heard your concerns and arguments many times everytime I suggest this.

    here are the points that may address your concerns

    1) Just like how the government is going to tax hotels a levy during the Formula One season, MOH can institute a pte hospital tax. In other words it is like outsourcing the private hospital work in the restructured hospitals to the private hospitals. Win win situation. The rich would go to the private hospitals for private health care. The private hospitals would be happy with the increased patient load and the reduction in competition from the restructured hospitals for private patients. Yes health care costs might increase. But it would increase only for the private sector. At the moment it is silly that MOH wants to compete with the private sector for the private health dollar. Let the private sector do the job, having a bit of a tax on it might not really make them so unhappy frankly.

    2) Money from the tax can be used to subsidize the public hospitals with a single class across the board. Having a single class also removes the suspicion and paranoia of patients thinking there are others treated better, given better drugs etc in THE SAME HOSPITAL I am staying in because they pay more and I pay less. It's not a very nice thought I understand. So why have it?

    3) Salaries and loss of talent. As it is, even today, don't the best senior consultants leave the public sector for the private sector? You mean they tend to stay in the public sector? If I am not wrong, we allow the specialists to practice in BOTH the public and private sectors today. Is that not correct? So just keep this system. This whole business about losing the "best doctors, nurses and advanced diagnostics" is something that we use to scare people. Every senior surgeon starts somewhere as an MO and then a registrar and then C then SC then leaves for the private sector. It's ALREADY HAPPENING. Don't tell me by asking pte patients to go to the pte hospitals instead of A class in restructured hospitals then we all the training doctors become screwed up and third world standard? Come on.

    4) My point is more that the public sector and private sector should work TOGETHER instead of against one another for the benefit of the healthcare scene. At the moment it seems like the public sector is "subsidizing" pte health care by offering "competitive" rates thus keeping the private sector on their toes. Whatever for? Promote Singapore as a medical hub with world class service like those in Thailand and around the region. Personally if I have patients who are willing to pay, I would send them to MT E or Gleneagles or other true private hospitals. Might as well go for the real thing if you are paying the full rates right? At the same time, in return the pte hospitals can accept a tax to give back to the public hospitals and let the public hospitals work on providing a reasonable standard of healthcare for the people. Let the money making be handled by the fellas trying to make money and the public hospitals work on providing. Simple as that.

    By Blogger Dr Oz bloke, At May 24, 2007 5:47 pm  

  • Hi anon,

    just to add a bit more on the losing the "best doctors, nurses and advanced diagnostics".... ( cos it always seems to form the most passionate objection)

    I am not sure if you are a doctor or not. But if you privvy to how the restructured hospitals work, much of the work done there regardless of whether patients are A class, B class or C class is borne by the junior staff. The senior consultants are there to supervise and for the junior staff to consult, but more often than not the junior staff eg registrars and young consultants handle the cases themselves. The senior consultant has a whole team working for him in the public hospital. Whereas in the private hospitals he has to asnwer and see the patients himself no matter how small the problem (of course he charges accordingly)

    From what I know some senior consultants like staying in the institutions because of this team he heads. Helps relieve his duties.

    So if you analyze it that way, most of the "world class" work in the public hospitals is done by the junior consultants and the rest of the team (non-specialists). Does that surprise you?

    Also if you know how consultants train especially surgeons, no young consultant in his right mind would leave for the private sector immediately after passing his exit exams. They usually apply for a consultant post in the public hospitals chalk up even more experience, build a clientele or a name for himself/herself, get promoted to senior consultant BEFORE leaving for the private sector.

    So be assured many of the "world class" doctors will still be in the public sector for a reasonable period of time.

    The only issue is that of training our young doctors. As it is this is already an ongoing problem despite the current schemes and MOH has allowed pte specialists to practice in pte hospitals despite them rejoining the public hospitals as mentors and teaching staff. So I see no difference. Just allow them to work in both the public and private hospitals.

    There are benefits in seeing patients in both sectors. Senior consultants will know that.

    By Blogger Dr Oz bloke, At May 24, 2007 6:00 pm  

  • "Yes, hospital bed shortage is across the classes, and patients in subsidised classes are lodged in beds of higher classes.

    And just to add another point: C-class wards are probably more cost-efficient to the hospital, since they have a higher patient to staff ratio."

    Hi angrydoc,

    Yes you and I know the system. All the B2 clas lodgers and C class lodgers enjoying the aircon in the A class wards etc! LOL!

    Yes the shortage is across the hospital.

    Looking at how the hospital is bursting at its seams and how many empty A class and B1 class beds are opened up for B2 and C class lodgers.....don't you think it's already all the same that we might as well just convert all beds into a single class?

    And indeed the cost efficiency ratio is best for the C class wards and B2 class wards. So why not?

    Again my personal feeling is that the restructured hospitals are trying to think of how to increase occupancy of the A class and B1 class beds by REAL A Class and B1 Class patients instead of lodgers!

    Hence means testing. With means testing we will STILL have bed shortages and EVEN MORE COMPLAINTS to deal with

    By Blogger Dr Oz bloke, At May 24, 2007 6:32 pm  

  • Dr Oz,
    First, if public hospital patients get the same quality of service as those in private hospitals, why should anyone opt for private treatment? There must be a significant difference. Are you are advocating a two-tier service, where breast cancer patients in private hospitals get the full works including Herceptin, whilst those in the public hospitals get basic surgery and local radiotherapy.

    As I said, if the quality of medical treatment is similar between private and public, with the same senior doctors directing treatment (even if some of them may be carried out by junior staff), it will be daft to go private. Without means testing, there is no incentive for wealthier patients to seek private medical help. If you are going to impose a tax on top of that and make private healthcare even more expensive, you can be sure patients will not willingly go to the private sector.

    Third, private patients in public hospitals are actually subsidizing the paying patients. We are robbing Peter to pay Paul. If we get rid of all the private patients and take on more subsidized patients, the hospital will not be able to balance its books. Where's the money coming from?

    The problem we face in public hospitals does not come from the private patients. They are paying the full cost of their own treatment. It is the subsidized patients who consume more of the public healthcare dollar. Means testing will make those who can afford more pay more for their medical treatment.

    You want to raise the money for subsidized patients by taxing private hospitals more. That will not work. Our fees are already much higher than those of private hospitals in Bangkok and Malaysia. We will lose out in the competition for private patients. If you tax them heavily, they will pass on the costs to their patients and eventually, we lose the private patients to JB and bangkok. It's a lose-lose situation.

    It is no secret that surgeons (in NCC for example) earn far more than their basic salaries by doing procedures on paying patients (in the PFS scheme). Without the private patients, these surgeons will leave for the private sector. In fact, without the private patients, public hospitals will be greater in the red and in that situation, will there be money for pay rise? All the staff will consider moving to the private sector if their skills are wanted. Certainly the best and the good will move to the private sector, leaving public hospitals as just a training ground for junior doctors. That is happening to some extent now, your proposal will drive it to the extreme.

    If the most senior and experienced doctors leave, the best mentors are gone as well. If you are training to be a specialist, will you rather train with the world authority or the junior consultant? If we lose more senior doctors in the public hospitals, we will see standards in the private hospitals get better and those in public hospitals getting worse.

    By Anonymous Anonymous, At May 24, 2007 9:17 pm  

  • Hi anon,

    Are you a doctor?

    Anyway of course pte sector will not give the same quality of care as public sector!

    I'm suggesting allowing the specialists to work both in pte and public sector.

    Anyway I guess the government has all the answers so just let it be. Are you happy with what they have come up with so far and what they want to implement?

    Otherwise any suggestions yourself?

    By Blogger Dr Oz bloke, At May 24, 2007 9:28 pm  

  • Angry doc has made clear his position on 'needs' and 'means', but without the means, no medical need will ever be satisfied. The child in Uganda with Burkitt lymphoma needs intensive chemotherapy as much as the banker or the PM of Singapore if they have the same disease. The treatment they get is obviously going to be very different, since one has limited means and the other has the means to access cutting-edge technology and the highest quality medicine money can buy.

    Subsidized healthcare is paid for by taxpayers. If those have the means not to utilize subsidized healthcare pay the full costs or receive a lower subsidy, the savings can be better directed at those who really need it.

    Being human, we are naturally selfish and everyone would use subsidized healthcare if we can. That is why means testing is necessary.

    By Anonymous Anonymous, At May 24, 2007 9:32 pm  

  • Dr Oz,

    Yes, I am a senior doctor, but working in the UK now.

    I agree there must be a two-tier healthcare service. There should be a basic standard of treatment for subsidized patients whilst private patients can get the best money will buy. The minister hinted as much when he was acting minister for health, saying that he 'had to modify the expectations of Singaporeans'. But he has failed to do so and I don't think anyone can do that.

    Singaporeans want the best treatment but at the lowest price. I remember when we first started laparoscopic cholecystectomy in SGH many years ago. When one 'A' class patient has it, all the 'C' class patients want it as well, but they won't pay the full costs of the procedure.

    It will be easier administratively if we get rid of all private patients in public hospitals. To do that, we have to downscale the services currently available in public hospitals. Which hospitals have the gamma knife? Which hospital has PET scans, which hospitals have CAP accredited labs? Which hospitals have JCI accreditation? The fact is, the premier hospitals in Singapore, the ones with most experience, expertise and the best technology are public hospitals.

    Are we going to transfer all these expensive technology out to the private sector? If not, the subsidized patient will always clamour for the same treatment as the private patients. If we keep all the infrastructure and expertise in the public sector, without the private patients as the cash cows, where is the money to pay for all that?

    Sure, faculty practice will let me earn the money in the private sector and have a position of some sort in the public hospitals. A senior doctor in the private sector may well do some teaching and demonstrate a case or two once a week, but public hospitals cannot afford to pay for many sessions. How many subsidized patients will actually benefit?

    What would I want to see? I want public hospitals to be less attractive to those who can afford private healthcare. I want to reserve public funds for those who really cannot access private healthcare. Those who can afford it should be made to buy private medical insurance and seek treatment in the private sector as much as possible. Those who cannot afford it will be treated in public hospitals where the waiting times (for non-emergency cases) must be longer, their attending doctors will be more junior with a large proportion of foreign doctors from Indian, Paskistan and China, where manpowers costs are cheaper. They will be given generic drugs and not have access to the latest treatment like Herceptin and Velcade, unless they are part of a clinical trial, when the drug companies will fund the treatment.

    We have already seen funding for research in the public sector and very little from the private sector. So I will expect new therapeutics and diagnostics being developed in public hospitals and research institutes, but not offered to their own patients. They will develop the technology and sell their assays and services to private hospitals and drug companies. But they will run clinical trials in public hospitals and those who are enrolled into these studies get treated for nothing. Research and development will be the only reason for keeping senior doctors to at least have a foothold in the public sector. Most of the senior surgeons will go to the private sector and on average, the doctors in the public hospitals will be more junior. But that's the price to be paid for subsidized treatment.

    The question is: will Singaporeans accept that? If we do not have a big different in standards between public and private hospitals, then only means testing will force those who can afford it to go out.

    By Anonymous Anonymous, At May 24, 2007 10:05 pm  

  • "The child in Uganda with Burkitt lymphoma needs intensive chemotherapy as much as the banker or the PM of Singapore if they have the same disease."

    The child in Uganda is as much a red herring as the lawyer living in a District 10 bungalow.

    We are not talking about sharing our healthcare resources with Uganda.

    The question I am asking is: is it fair that the "$9,300 man" receives less subsidy for a $300,000 bill (of which he must pay 35%) than the "$1,180" man who decides to dump his mother in the hospital for a bill of $2,000 (of which he must pay 20%) while he and his family goes off on a holiday?

    By Blogger angry doc, At May 24, 2007 10:17 pm  

  • The question I am asking is: is it fair that the "$9,300 man" receives less subsidy for a $300,000 bill (of which he must pay 35%) than the "$1,180" man who decides to dump his mother in the hospital for a bill of $2,000 (of which he must pay 20%) while he and his family goes off on a holiday?

    Whether it is socially or morally acceptable for the $1,180 man to dump his mother in the hospital is not relevant to the issue of healthcare financing. If his mother needs to be treated in the hospital, we still have to treat her and someone will still have to foot the bill. You can hardly force him to pay 35% of the bill when he can ill afford it.

    The point is that the $9,300 man can afford the medical insurance to pay 35% of a $300k bill and so he can afford to pay a greater proportion of the healthcare bill for the treatment he has received. By receiving less subsidies, he makes it possible for the $1,180 man or his mother to have higher quality healthcare without busting the budget.

    By Anonymous Anonymous, At May 24, 2007 11:11 pm  

  • "Whether it is socially or morally acceptable for the $1,180 man to dump his mother in the hospital is not relevant to the issue of healthcare financing."

    I think it is relevant, and I don't think it is wrong to take into account social and moral considerations when deciding healthcare financing.

    If the $1,180 man's mother does not need to stay in a hospital, then she should not be in a hospital at all.

    By Blogger angry doc, At May 25, 2007 10:14 am  

  • Hi anon,

    thanks for the reply. Looking at your proposals I would say our philosophies are actually quite similar.

    Public hospitals should focus on providing affordable and acceptable health care to the people.

    Private hospitals focus on delivering the best quality care that patients can buy.

    So we're actually more or less on the same page.

    By Blogger Dr Oz bloke, At May 25, 2007 11:36 am  

  • "The question I am asking is: is it fair that the "$9,300 man" receives less subsidy for a $300,000 bill (of which he must pay 35%) than the "$1,180" man who decides to dump his mother in the hospital for a bill of $2,000 (of which he must pay 20%) while he and his family goes off on a holiday? "

    Hi angrydoc and anon,

    I see your point angrydoc.I also see your point anon.

    To sum it up, anon's concerns are more along the lines of "someone has to pay, so who's going to pay? And the answer: the ones with money"

    As for angrydoc, he delves more into how we can control the expenditure by various means thus reducing the dilemma of "who's going to pay" if there is less to pay for anyway.

    Supply and demand.

    At the moment the supply at the public hospitals is INCREDIBLY GOOD. In fact I would say there is an oversupply of amazing world class level healthcare services for patient. (not that Singaporeans appreciate it)

    Why this over supply? I think that's a difficult question to answer. But part of it is that the public hospitals want a share of the private healthcare market and thus want these services. Another advantage is that this allows the poorer people to also have access to those high end services thus improving the healthcare service to that income group (again not that Singaporeans appreciate that)

    But the reality now is that this oversupply in the public hospitals is being paid for by the government and not generating enough profits. (lack of pte patients) At the same time, the consumption by the people who cannot afford it is increasing (and these people feel it is their RIGHT to have it)

    So problem arises. Who is going to pay for the deficit?

    One way is to reduce the supply in the public hospitals. I DON'T MEAN REDUCING BEDS OF COURSE! But reduce the high end drugs, and imaging etc etc. Cut costs. Of course politically there will be a backlash. The Singaporeans who all along think it is their RIGHT to have access to cutting edge healthcare would be angry.

    But frankly....are they really informed enough to know the difference?

    It is easy to compare now because you go to the same hospital eg SGH and at times different people get different treatments for the same condition. So they compare. But if it was at different hospitals eg SGH and Mt E. Maybe people wouldn't see it so straightfoward and would be thinking....yup that's the pte hospital so it is DIFFERENT.

    Another thing is to empower the doctors. If the mother of the $1,180 man who wants to dump his mother in the hospital does NOT need hospitalisation in the public hospital, then we should say no and let him know he can put her up at the private hospital if he wishes to do so. What's wrong with that? But the problem now is that if he were to tell SGH doctors, ok lah I admit her to A class you take? (And they will take her I assure you) Well you see where that makes people view doctors and hospitals as hypocrites?

    But different locations may help to draw clearer lines of what the public hospitals are there for.

    Can you guys see where I am going with this?

    By Blogger Dr Oz bloke, At May 25, 2007 11:58 am  

  • If the $1,180 man's mother does not need to stay in a hospital, then she should not be in a hospital at all.

    As I said, whilst health financing policies may emerge from the moral and social values of the land, it is not the job of the doctor to make judgment on whether a particular family's care arrangements is moral. We do not have the resources to investigate into the circumstances of the case.

    But I do agree that those who need not stay in hospital should vacate their beds. As the minister has said, currently it makes no economic sense to send the patient to a community hospital because the 'C' class bed is too cheap. Means testing will remove the anomaly. It must be cheaper for all patients (regardless of income) to move into a community hospital. Means testing and adjusting the amount of subsidy will ensure that.

    By Anonymous Anonymous, At May 25, 2007 2:43 pm  

  • One way is to reduce the supply in the public hospitals. I DON'T MEAN REDUCING BEDS OF COURSE! But reduce the high end drugs, and imaging etc etc. Cut costs. Of course politically there will be a backlash. The Singaporeans who all along think it is their RIGHT to have access to cutting edge healthcare would be angry.

    But frankly....are they really informed enough to know the difference?


    As I said, I do agree with you about a two-tier healthcare system and a clearer separation between public and private hospitals. In fact, this minister said the same when he first came on as acting minister of health. At the NHG Congress (in 2002 if I am not mistaken)he said he didn't want the public hospitals to compete with the private sector for patients. He saw the job of public hospitals as providing a basic level of healthcare.

    What has changed? First, he begins to realize that all the cutting-edge technology, most of the top surgeons, physicians and advanced diagnostics are in the public hospitals. If Singapore wants to attract foreign patients here and if public hospitals provide a basic level of healthcare, he'll have to migrate all that to the private sector. That can be done and many doctors would be happy to earn more in the private sector. The influx of more doctors into the private sector will also lower costs in private hospitals, thus keeping our competitiveness.

    The 6-million dollar question is, "Do you think Singaporeans will accept that?" No, I am afraid not. You suggest that patients may not know the difference. I am afraid the horse has bolted.

    With the internet, we now see patients coming in armed with stacks of printouts about new treatments and tests. The printed media contributes to that too. Not long ago, ST journalist Chua Mui Hoong wrote about her breast cancer treatment with Herceptin as part of a trial when she was in Harvard and lamented that doctors here don't even tell our patients about this drug. In fact, we do not even test for the gene amplification to determine suitability for this treatment, unless the patient can afford Herceptin. Of course not! It is more cruel to tell a patient about a drug that could improve her survival but sorry, she could not afford it.

    If all the expertise and advanced techonology move to the private sector, the difference in standards between the public and private hospitals will become increasingly glaring. Singaporeans will object and I dare say the majority of voters will fall into the ones who seek treatment at public hospitals.

    That is why we have a system that is not completely satisfactory. It's neither here nor there. It's the best we can do given the political realities.

    By Anonymous Anonymous, At May 25, 2007 3:02 pm  

  • There are actually two different anonymous posters on this thread, right? I get confused...

    "As I said, whilst health financing policies may emerge from the moral and social values of the land, it is not the job of the doctor to make judgment on whether a particular family's care arrangements is moral. We do not have the resources to investigate into the circumstances of the case."

    The decision as to whether someone needs to be in a hospitalis a medical one; what to do once you have decided that someone does not need to stay in a hospital one is an administrative decision.

    Currently the system allows for us to remove the subsidy from that someone, but it seems to me this is not being executed on the ground (as apparent from the news article today's post).

    By Blogger angry doc, At May 25, 2007 5:15 pm  

  • Currently the system allows for us to remove the subsidy from that someone, but it seems to me this is not being executed on the ground (as apparent from the news article today's post).

    I agree. It's down to politics. The administrators don't want angry NOK writing to the Forum page about the hospitals being uncaring etc. If you try to remove the subsidy, they will complain to the minister, MP etc that the hospital is out to make money and trying to evict the poor sick patient in order to admit rich paying class patients.

    Tell you what I used to do when I want to 'encourage' a patient to go home. I will whisper in his ear, "I am not supposed to tell you this but if I were you, I will leave the hospital as soon as I can. There is a bacteria spreading around the hospital that is resistant to all our drugs. If you catch it, you will die. Don't tell anyone, we don't want to spread panic. I am telling you only because I think you might not be able to handle it."

    It was very effective. Those were the bad old days when we could do such things, including telling white lies. You probably can't do that now.

    By Anonymous Anonymous, At May 26, 2007 3:12 am  

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