Angry Doctor

Friday, May 25, 2007

Subsidy and Other Preoccupations 15

Great. angry doc devoted so many posts on means testing, and now they tell him it's bed availability he should be worried about.


Khaw: Treat hospital bed shortage with care
A bed for acute illness costs Govt $1,000 a day; heavy usage ups costs
Tan Hui Leng


The current high occupancy rate at some public hospitals is stressing doctors to discharge their patients, admitted Health Minister Khaw Boon Wan yesterday.

Occupancy has hit highs of more than 90 per cent for some hospitals recently, above Mr Khaw's ideal of 85 per cent. "When you run at over 90 per cent, it's very stressful," said the Health Minister, who was the chief executive of several hospitals from 1985 to 1992.

"Stressful in the sense that, every day, our doctors have to go down to beg the patients (to be discharged)."

Occupying a hospital bed for acute illness costs the Government an average of $1,000 a day, compared to "a few hundred dollars" for a community hospital bed.

This is "the cost to society", said Mr Khaw at the sidelines of an event yesterday. "If I don't actively shift patients down, our total cost will just be heavy."

Urging patients to cooperate with doctors to be relocated to suitable care institutes when they are fit enough to be discharged, he said: "Hopefully, people will be more circumspect."

"When we say we need to discharge you to a nursing home, it's not for frivolous reasons, we really need to free up those beds."

High occupancy rates do not allow for a sudden surge in patient numbers, he explained.

Last week, Today reported that some hospitals were facing a surge in occupancy, hovering at a 88-to-97-per-cent occupancy rate recently, a problem compounded by seasonal diseases such as the flu and dengue.

To tackle the problem, the Health Ministry will add a total of 67 new beds to the National University and Changi General hospitals over the next few months.

Earlier this week, Mr Khaw told Parliament that there will be a new hospital in the west in the "next few years".

This is in addition to the new Khoo Teck Puat Hospital in Yishun, which is being built.

Even with the current squeeze, the Health Minister said he is in no rush to implement means-testing in subsidised hospital wards.

Although earlier reports had quoted him as saying means-testing could start in 12 months, Mr Khaw said this may not be the case. His current priorities are the ElderShield review and another round of MediShield review to revise patient co-payment from the current 40 per cent down to 20 per cent.

Details about the revamped ElderShield scheme would be available by the end of June or early July.

Possible changes to Medisave may be introduced in the revamp as the ministry mulls a staggered withdrawal rate for those with bigger balances, he added.


Now there is already a ruling in place at the hospitals which allows for patients to be charged at the full (unsubsidised) rate if they choose to remain in the hospital even after they are deemed "fit for discharge" (usually after a grace period of a week or so). That being the case, angry doc wonders why doctors need to beg patients to leave. Are the patients staying on despite the withdrawal of subsidy (in which case the expectation that means testing will ease bed shortage will be proven wrong), or is it a case of the the ruling not being enforced?

The decision for fitness for discharge is a medical decision; the decision on what happens after that decision is made is an administrative one, and angry doc feels that doctors should not be made to beg patients to comply with an administrative decision.

But this situation raises another question: is the bed shortage due to an absolute shortage of beds with respect to real medical needs, over-subsidy, or just an ineffectual execution of a system which we already have in place to reduce over-staying? And is means testing a solution to our 'bed shortage', or do we just need a healthy dose of moral courage in deciding who gets a bed?

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17 Comments:

  • Seems like a bit of everything except acknowledgment of the last point about the admin.

    I have always felt it frustrating having to be on the frontline explaining to patients about unpopular policies made by the administrators and having to answer all the angry objections and protests from the patients only to later be told by the administrators that we should not have said this or that and that we miscommunicated this and that points about the policy to the patients.

    Frankly, we're doctors. All this policies and MOH or hospital rules created by the admin guys....why don't they come down to the frontline and explain it to the patients themselves?

    By Blogger Dr Oz bloke, At May 25, 2007 7:45 pm  

  • They should just issue us all with "Fit For Discharge" chops in bright permanent indelible red ink, font size 60 (and also blue "Not Fit For Discharge regardless of not-so-subtle hints from BMU" chops).

    And you job ENDS after you make your bright red chop mark. None of this "begging" patient crap.

    The admin can damn well get someone else to carry out this non-medical task of making them go home. If they can afford to get green-suited doormen to open taxi doors at you-know-which-hospital, they can damn well get these same guys to call a cab and send these patients home.

    By Anonymous Anonymous, At May 25, 2007 9:08 pm  

  • Doctors should just make the clinical decision as to whether a patient is fit for discharge and as anon 9:08 said, stamp on the notes 'Fit for discharge'. The patients should be told he is fit to go home or to a nursing home.

    Whether or not the patient will be charged more if he insists on staying or if the police will be called in to evict the patient is the job of the CEO and administration, not doctors.

    By Anonymous Anonymous, At May 26, 2007 3:00 am  

  • I think the problem is also that the patients do not trust the doctor's medical decisions.

    And when these admin/non-medical people try to tell the patients to leave, the patients will question teh medical decisions, thus bringing the questions back to the doctor again.

    In effect the admin people might also not believe the doctor's decisions and find it difficult to convey this to the patients also.

    So it all boils back down to the doctors again.

    By Blogger Dr Oz bloke, At May 26, 2007 10:47 am  

  • Heheh. Maybe we should stamp the "Fit for Discharge" on the patient's forehead, so the other patients will know who is occupying a bed unnecessarily.

    Oz Bloke,

    I believe the overstayers we are concerned with here are not those whose medical conditions are in doubt, but those whose medical conditions are stable but whose families refuse to bring them home for social reasons.

    By Blogger angry doc, At May 26, 2007 1:12 pm  

  • From my personal experience, here's what the relatives tend to say

    "Look at my mother. She still cannot walk. She cannot feed herself. I have to go to work. My wife has to go to work. We have no maid. (or maid only coming X date) You want her go home how? You all never CURE her. She still cannot walk properly!"

    This is with regards to stroke patients. Or even old patients who already came in with trouble walking due to being frail.

    To some people the doctors job is not just to restore the patient back to their pre-morbid status, but to actually improve her to be better than pre-morbid status!

    I know there are many hospital administrators out there who are ALSO doctors with MBBS. Maybe they would be the best guys to do this "discharging" communication business to difficult patients after the clinical team has made the clinical decision for fitness for discharge home.

    By Blogger Dr Oz bloke, At May 27, 2007 9:08 am  

  • Provided you can even get the relatives to come down and meet you or the case manager...

    And when the maid arrives, she must be trained first.

    And when the maid is trained, they need to install grab bars in the bathroom and ramps.

    By the time all that is done, grandma has caught another nosocomial infection...

    By Blogger angry doc, At May 27, 2007 11:04 am  

  • Exactly! You know the problems and excuses angry doc!

    Frankly I myself don't know how to answer those "problems" the family brings up.

    Cos they are real problems that prevent us from just "sending grandma home to nobody to look after her"

    We need a stronger "step down care" setup.

    But the problem is that the community hospitals are also frequently full. It also takes time to get the bed and then arrange the transfer etc. And then grandma gets another nosocomial infection and we're back to square one again.

    The reality is that in Singapore everyone is too busy working to take care of their family when they are healthy much less when they are sick.

    I know these are real problems. But that's where the administrators come in.

    Why talk about means testing and all that when you have such serious problems that have been around for many many years!!!!

    Means testing is about the money I guess and that's very important to MOH.

    By Blogger Dr Oz bloke, At May 27, 2007 7:14 pm  

  • I think a lot of this problem has to do with relative costs.

    If we make inpatient care too expensive, many people will be affected.

    Private nursing homes are expensive.

    If we make subsidised nursing homes too cheap, people will lack the incentive to bring their parents home.

    We can try home nursing, but at the present the coverage is not sufficient (infrequent), and if it were more frequent the cost will go up.

    Interestingly, a maid is the cheapest option!

    Actually, I see this as an area where the nursing community can take the lead in; afterall, the main reason why a patient needs to stay in a hospital or nursing home is nursing care.

    Certainly the Singapore Nurses Association seems up to this kind of challenge:

    "Nurses form the largest component of health care providers. They play an essential role in the continuum of care at all levels and in al sectors of the health care delivery system.As the bedrock of the entire gamut of health care services, nurse are in a strategic position to make critical decisions about the management and the practice of health care. Supported by expert knowledge, nursing skills and influencing power, nurses should be given the opportunity to be actively involved in the policy making and planning of health care services both locally and nationally".

    http://www.sna.org.sg/cms/publish/article_16.shtml

    By Blogger angry doc, At May 27, 2007 8:53 pm  

  • angry doc & dr oz bloke, I think u have hit the nail of the head! Yes, I believe the main problem lies in the step down care. I can understand how intimidating it would be to bring home a hemiplegic, dysphasic, incontinent patient. Can we expect the caregiver to be able to give the appropriate care to the patient? Even if they have maids, these maids are not nursing trained.
    So what's the solution?

    By Blogger aliendoc, At May 27, 2007 9:47 pm  

  • Unlike maid, trained nurses are not cheap. Nursing homes have to watch their bottom lines as well. However, given that it costs the government more to keep a stroke patient in hospital, the minister may want to give more subsidies to nursing home and increase step-down facilities. Where's that money coming from? By means testing and charging patients in hospitals more, especially when they are fit to go.

    At the end of the day, Singaporeans are selfish. They would rather keep the patient in hospital if that's the cheaper option compared to nursing home.

    By Anonymous Anonymous, At May 27, 2007 11:14 pm  

  • If you look at the discussions both here as well as outside the blogosphere....the problem all boils down to this.

    NO ONE WANTS TO PAY FOR SICK CARE.
    NOT THE GOVERNMENT. NOT THE PEOPLE. NO ONE WANTS TO PAY ANYTHING. NOT JUST IN $$$ BUT ALSO TIME EFFORT AND ENERGY.

    Makes me wonder sometimes. If the relative just passed away wouldn't it solve everything?

    I get tired of listening to all this debate about how "expensive" this and that is when it comes to health care/sick care and then the newspapers are full of articles about how people take up 2nd loans to buy their 2nd condo investment and can still sleep soundly etc etc.

    Can buy all these million dollar homes, investments, stocks, cars but then when it comes to health care $1 is too much!

    !@#$@$@##@#!!!!

    By Blogger Dr Oz bloke, At May 28, 2007 10:17 am  

  • Dr Oz, so true. How many times does a patient say "I cant afford my prescription" or a lousy 5 dollar copay or a taxi home. But they ALL have freaking CELL PHONES!

    What a load of crap! Kick em to the curb I say. Call the cops. Its a hsoptial, NOT A HOTEL!!!

    By Blogger Mike, At May 29, 2007 12:49 am  

  • We can't win...Singaporeans think that medical care is a right. They honestly think that they have the right to the best medical treatment for next to nothing, by virtue of their citizenship.

    They will say doctors' salaries are too high and ministers are earning too much. How can they be expected to look after an elderly parent who is incontinent? They have to work, you know? And not everyone can afford a maid.

    You point out that it costs more to keep the patient in hospital. He replies, "C class ward is cheaper than nursing home. You trying to cheat me huh?"

    You say that he/she is depriving someone else a bed. "That's not my problem! Go ask the million-dollar ministers la.." he replies.

    By Anonymous Anonymous, At May 29, 2007 2:39 am  

  • Sidetracking a bit from the commentary thread so far, this is a letter I sent to the ST forum last week (regarding the orginal article), which doesn't look like it's getting published.

    Cheers.

    ----------------------------
    I refer to Ms Khalik's article "Means Test the Solution to ease
    hospital bed crunch" on 25 May 2007. I agree with the Health Minister
    that public hospitals are designed for the acute care of patients, and
    that patients who are fit for discharge may be better served by
    step-down facilities such as community hospitals.

    However I disagree that means testing is the solution to ease the
    hospital bed crunch. As currently envisaged, it will apply to everyone
    staying longer than 5 days, regardless of whether they are fit for
    discharge or not [1]. As the Minister himself brought up, an elderly
    patient may need weeks to recover. Is it fair to penalise a patient
    who needs the bed, but takes longer to recover?

    Furthermore, means testing applies only to a subset of patients,
    namely those who can afford to stay in private wards but choose to
    stay in subsidised wards. It will not apply, for example, to the
    destitute old man who qualifies for C class and is fit for discharge,
    but whose family refuses to bring him home. Means testing will not
    help free up beds occupied in such a way.

    Lastly, inpatient means testing has yet to be implemented, and
    difficulties are already anticipated. We should concentrate on
    fulfilling its basic objective (namely to ensure that subsidies go to
    those who need them), rather than tack on additional goals.

    Therefore I would like to bring to your attention a policy that
    directly addresses the problem of social overstayers and is already in
    place in our public hospitals. It is available on the
    he.citizen.gov.sg website, and can be found (aptly) under the "Social
    Overstayers" heading at
    http://he.ecitizen.gov.sg/health_dollar_charge_sgh.htm - I quote
    "Patients who are fit for discharge but insisted on staying on will be
    charged the full cost of the period of their overstay, from the 7th
    working day after the hospital has assisted in finding a placement in
    a step-down care facility."

    Rather than use the bed shortage to justify the introduction of
    means testing, the Health Minister should instead familiarise himself
    with methods that are simple and already available, and ensure that
    they are carried out smoothly.
    ----------------------------

    By Anonymous Gerald, At May 31, 2007 12:01 pm  

  • And just to play devil's advocate... would implementing inpatient means testing really solve the problem of patients refusing to go to the nursing homes? i.e. by making acute care beds expensive relative to the step down care ones?

    And I so totally agree it should not be the doctors who have to beg the patients to go home. Totally warped implementation.

    By Anonymous Gerald, At May 31, 2007 12:05 pm  

  • "would implementing inpatient means testing really solve the problem of patients refusing to go to the nursing homes?"

    I believe it will, but the quantum of difference between an unsubsidised C-class bed and a subsidised (or otherwise) nursing home bed must be significant.

    There are a few things which we can do to 'sweeten the deal' too, like building nursing homes close to housing estates (but of course there will be those who will argue that it lowers their property value...), and letting families know that the nursing home is better-organised to do rehab and carer training, and also tag on other services like home environment assessment and continued daycare.

    I'll see if I can dig up some papers...

    By Blogger angry doc, At May 31, 2007 2:37 pm  

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