Live Long and Prosper

An interesting article in Today today looks at the issue of healthcare spending.


let the community lend a helping hand
Community health promotion, rehabilitation is key to help stem rising healthcare costs
DR OW CHEE CHUNG

We have an efficient and effective healthcare system, especially in our acute hospitals. Improvements are also being made in primary healthcare. But healthcare provision will become more challenging and difficult.

Last year, healthcare costs have jumped 6.2 per cent over the previous year. Studies show there are two major limb amputations due to diabetes and six hip fractures per day. Earlier reports showed growing concerns about caring for those with heart problems and those recovering from stroke.

These facts present an urgent need to review the current approach of delivering healthcare to the community.

The current approach, including funding and payment, focuses on acute hospitals, community hospitals and polyclinics. As long as patients seek treatment at these places, support and funding will be available. They may also receive good treatment and face low risk of complications, good diagnosis, evidence-based treatment and prompt improvement.

However, from the point of view of the patient's total lifecycle and total healthcare expenditure, is the patient really getting good treatment and results? Is our healthcare system so efficient that we reduce or arrest a patient's follow-ups or lower death rates?

Cynics may advocate letting nature take its course, but that option is 20 years outdated — acute hospitals are so well equipped and structured these days.

To reduce the incidence and prevalence of conditions that diabetes amputees, stroke survivors with significant disabilities or post-heart attack patients all have, the key lies in community health promotion and rehabilitation.

We were able to maintain affordable healthcare for the last two decades with the current system. The assumption is that the overall outcome is acceptable as long as acute and community hospitals are able to run hyper-drive outpatient care and look after inpatients, while being backed by community-based organisations. But outcome studies — tracked beyond single episodes — published so far by respective specialists are not encouraging.

Unlike hospitals, community organisations can provide holistic care and get better outcomes for patients. They can look into the physical rehabilitation of the patient and his other needs through their host of programmes to help prevent the patient from going back into acute care.

A recent press report indicated that diabetes amputations have fallen 26 per cent in the National Healthcare Group and nine per cent in SingHealth hospitals from 2004 to 2006. This was attributed to close tabs being kept on patients — the number of foot screenings had gone up at community organisations, proving that professional intervention in a community setting brings better outcomes.

Key professionals in the community like general practitioners, community nurses, therapists, clinical case managers, dieticians/nutritionists and other support staff provide both preventive and treatment services and are familiar with the delivery of healthcare services at outpatient, home-based and community settings. What is important is their development.

Community health promotion and rehabilitation provision is, at present, fragmented and largely provided by non-profit organisations with limited infrastructure, manpower planning and funding support. The depth and breadth of good clinical information is also lacking.

Funding straddles the radar systems of the Ministry of Community Development, Youth & Sports, National Council of Social Service and Ministry of Health. With each department doing its own fiscal planning based on allocated resources and priorities, community health promotion and rehabilitation has been and will always be grossly neglected.

Thus, it will be difficult to look at a lifecycle approach to service planning and a true lifecycle outcome and cost-benefit studies will be forever lacking.

Judging by medical cost inflation of 6.2 per cent now, if we continue to have an unbalanced system with under-investment in the community system, we may even hit double-digit inflation by the end of the decade.

While it is important to continue maintaining and developing acute hospitals and it may cost the government more to build up the community health promotion and rehabilitation sector, the latter is the solution to having good outcomes and to arresting healthcare costs.

It will be harder and more expensive if we were to delay the development of this area till we hit double-digit inflation in healthcare. If we can step up the development of community health promotion and rehabilitation to the level close to that of acute hospitals, we will stand a good chance of keeping healthcare inflation to a single digit despite the ageing population.

We will then truly have affordable healthcare, delivered at the setting appropriate for the condition and the patient.

(The writer is the executive director of the Society for the Physically Disabled)


angry doc must admit to being one of those cynics Dr Ow wrote of. Sort of.

While angry doc agrees with Dr Ow that we can probably do a lot more to develop community health promotion and rehabilitation care, he is not so certain that doing so will in the long run reduce healthcare spending.

The fact is people in their last year of life consume a disproportionate percentage of a nation's healthcare spending, so regardless of the amount of step-down or community care resources available, every life eventually comes (or in this case ends) with a price-tag. In fact, there is also a case to be made that the older this 'last year of life' is, the greater the amount of spending in the last hospitalisation will be.

We may be able to prevent a number of complications from happening, but eventually everyone dies of *something*.

To use a rather blunt example, one might say that it may be cheaper for a 65 year-old man who is no longer working with poorly-controlled diabetes to die from complications of the disease than to let him have state-subsidised treatment so he will live to an age of 75, since the cost of the 'last admission' is likely to cost about the same.

And that is before we take into account all the food he would eat all those years without being economically-productive.

Or worse still: what if he gets cancer and needs expensive chemotherapy?

All that is not to say that angry doc opposes investing more in community health promotion and rehabilitation - he just doesn't think that the economic argument is particularly convincing, or that it should be the primary consideration. Investing more in community health promotion and rehabilitation may give us better outcomes, but will it really cost us less?

angry doc suspects that as long as a commodity is perceived as being desirable, people will be willing to spend money to obtain it; and as long as people are willing to spend money to obtain it, there will be people who will be willing to supply it to them, and to make a profit while doing so. It will cost ya.

As long as we see longevity and good health as desirable commodities, healthcare spending will continue to rise.

The question then is not perhaps on how much to spend, but when to stop spending.