Who Shall Live?

Who should be subsidised?

04:45 AM Jan 14, 2013, Today newspaper

by Jeremy Lim

“Who shall live?” is the dramatic title of Victor Fuchs’ classic text on health economics. The melodrama is unfortunately not over-stated. Healthcare is marked by finite resources and infinite demand. There can never be enough doctors, nurses, hospital beds and medicine to fulfil the wants and needsof society. Even the richest country in the world, America, struggles with burgeoning healthcare costs which, at 17 per cent of gross domestic product, is four times what Singapore spends. Incredibly emotive and wrenching decisions have to be made, not only in clinics and at bedsides, but also in government offices.

Why government offices? Because governments decide which services and drugs should and should not be subsidised. And like it or not, health officials play god.

How does Singapore do it?

Former Health Minister Khaw Boon Wan had explained previously that the Singapore government subsidises drugs based on three principles: Used in the treatment of medical conditions that are important causes of morbidity and mortality, more efficacious and effective when compared to existing standard drugs, and sufficient evidence of long-term safety and cost-benefit.

These positions are not controversial, but it is unfortunate that there is little public information about the mechanisms used to determine what constitutes “cost-benefit”, “important causes of morbidity and mortality” or “long-term safety”.

In fact, what is subsidised was, until recently, not even known by the public as the Health Ministry was reluctant to make the list of drugs included in the Standard Drug Lists public for fear of lobbying by pharmaceutical companies.

INVOLVE THE PUBLIC

There are a number of issues to contemplate.

First, let’s look at the very process of decision-making. In Singapore, bureaucrats determine subsidy decisions in a largely top-down, opaque fashion, adopting a “Trust us, we know best” approach. This is in stark contrast to the approach taken by other countries.

Take Australia and Canada for example. Both countries devote entire websites to informing the public of the process of decision-making, the composition of the committees that advises on reimbursement decisions and even the rationale for decisions. And the Canadians, in not recommending listing Gefitinib (Iressa),provided a two-page report concluding that “it was the Committee’s opinion that although Gefitinib holds promise, its degree of effectiveness is not known in patients with locally advanced or metastatic non-small cell lung cancer”.

There are even layman descriptions of the coverage decisions to supplement the often technical judgments to enhance public understanding. Transparency is so valued that the manufacturer’s comments are often reflected verbatim in the final publicly released report.

The Australian decision to recommend against listing Cervarix in July 2007 also captured the manufacturer’s comments in its report: “GSK (GlaxoSmithKline) is extremely disappointed by the PBAC’s (Pharmaceutical Benefits Advisory Committee) decision. We believe the PBAC has significantly undervalued the evidence of some cross-protection by Cervarix against infection caused by HPV-31 and HPV-4 …”

Public involvement is also increasingly important internationally. Sixty-seven per cent of countries surveyed by HTAi – the international society for health technology assessment – reported that citizen participation was built into their processes, with an additional 21 per cent stating they already had plans to engage their citizens.

THE LUCKLESS MINORITY

Secondly, defining the scope of “important causes of morbidity and mortality” should be a matter of public dialogue. While the “greatest good for the greatest number” is the often pragmatic articulated position of the Government, should Singaporeans with rare diseases be disadvantaged?

Multiple sclerosis affects an estimated 100 Singaporeans. Should drugs needed in their care such as beta interferons be subsidised? Do Singaporeans want public monies to be used to subsidise these 100 citizens? And is this consistent with what President Tony Tan called for when he wrote: “As a society, we must judge ourselves by how we care for those in need … Together, we should ensure that the last are not left behind, the lost have a guiding hand?”

The decision to emphasise long-term safety is controversial. If we were to wait until procedures or drugs are “proven”, it means that in the interim, subsidised patients will be deprived of the latest and potentially hugely beneficial therapies. Of course, waiting allows better control of healthcare costs as prices typically plummet after patent expiry or introduction of rival devices or drugs, but Singapore needs to balance between cost control and access to innovative treatments.

This dilemma is starkest with the new and very expensive biologics. Gleevac (imatinib), approved by the FDA in May 2001, has revolutionised care and survival in Chronic Myelogenous Leukemia but is still not on the Ministry of Health’s list of drugs “subsidised at our public healthcare institutions for eligible patients”.

‘Who shall live?’ is a difficult question under any circumstances. It is timely to engage society in an informed, mature debate and find common ground between State and citizens on what to subsidise, who to subsidise and how much to subsidise.

Economics and rationality help in the decision-making around optimising “value” but cannot decide. This is a question as much of “values” as it is of “value”. It is something Singaporeans collectively as a society should decide.

Dr Jeremy Lim has held senior executive positions in the public and private healthcare sectors. He is writing a book on the Singapore health system, the second in a series on health policies in Singapore.

URL http://www.todayonline.com/CommentaryandAnalysis/Commentary/EDC130114-0000031/Who-should-be-subsidised

===================================================

I wrote this to share the mechanisms in the Singapore system and to encourage greater citizen participation in decision-making. Personally, I doubt the model of top-down decision making by a select elite on behalf of the entire nation is sustainable and greater transparency and engagement of the public will be necessary. Whether in health policy or in any other facet of government, the public is hungry for information and the ‘right’ to understand the basis of decisions before it will be satisfied of the ‘correctness’. ‘Playing God’ is hard, and ‘Playing God’ alone is even harder.

Advertisements

5 comments

  1. Yeoh Lian Chuan · · Reply

    Hi Dr Lim:

    The standard drug list is already published so your comment about transparency boils down to (a) who makes the decision, and (b) whether the reasons for decision are published?

    I would agree that a *some* process for internal debate and discussion makes sense, but from an outsider’s perspective, am less immediately convinced that publishing all the decisions is necessary or wise ( of course I am open to be convinced – but merely citing other country’s practices is not proof ). Take the example you cited where a drug company responded to the request by saying “… We believe the PBAC has significantly undervalued the evidence of some cross-protection by Cervarix against infection caused by HPV-31 and HPV-4 …”

    As a lay person, I wouldn’t know how to make head or tail of this – and this is probably true of most lay persons.

    So it seems to me that the debate is one amongst medical professionals. And if that’ the case, is public debate the best model?

    I think there is some force in the Government’s argument about regulatory capture or lobbying …

    There will also be risk of capture by over-emotional interests. Life and death decisions give rise to such emotions, its only natural. I think you once noted that Prof Tambyah had once suggested (at an election speech) it was better to die than fall sick in Singapore – and you labelled this as “extreme emotional theatre” – so I think my concern is not altogether unfounded.

    Are life and death decisions best debated in public, where such strong emotions may become involved?

    With respect to cost-benefit of the latest and best treatments, I agree that this is a question of “values” in part, although it remains a question of “value”. Personally, I start from the premise that the Standard Drugs List should generally NOT include highly expensive and new drugs on the grounds that they are normally unlikely to be COST-effective. To use a lay analogy, albeit an imperfect one, its like not wanting to buy the latest and most high performing graphics card.

    I agree this question needs to be debated by the public. My own view is stated above. What’s yours? 🙂

    Finally, while I agree that the decision making process counts, how do you think we should deal with the concerns about regulatory capture, lobbying and “emotional theatre” that may attend the question of who lives?

  2. Thanks for the comments. I don’t think there are ‘right’ or ‘wrong’ answers and so discussion and debate can only help bring us closer to what society wants and is prepared to pay for. This is something that I feel pretty strongly about and so will be devoting a whole chapter in the upcoming book on Singapore’s health system to this. Please see my responses to your specific questions and comments in [..] below. Thought I’d use this format to make it easier for others to follow the train of thought.

    The standard drug list is already published so your comment about transparency boils down to (a) who makes the decision, and (b) whether the reasons for decision are published? [Actually, the list of subsidized drugs is available but not the Standard Drug Lists. MOH publishes on its website in a complete list all the drugs that are ‘subsidized’ (whether this is a subsidy off the government purchase price or a ‘market subsidy’ is a topic I will cover in more detail at a later stage) without differentiating whether the specific drug falls into SDL I (which means it is priced at S$1.40 per week) or SDL II (which means it is priced at 50%o discount from the retail price) or even the Medication Assistance Fund (which means it can be subsidized up to 75% from the retail price depending on the outcomes of the means testing.]

    I would agree that a *some* process for internal debate and discussion makes sense, but from an outsider’s perspective, am less immediately convinced that publishing all the decisions is necessary or wise ( of course I am open to be convinced – but merely citing other country’s practices is not proof ). Take the example you cited where a drug company responded to the request by saying “… We believe the PBAC has significantly undervalued the evidence of some cross-protection by Cervarix against infection caused by HPV-31 and HPV-4 …”
    As a lay person, I wouldn’t know how to make head or tail of this – and this is probably true of most lay persons.
    So it seems to me that the debate is one amongst medical professionals. And if that’ the case, is public debate the best model? [I agree with you but the issue is not just whether the public can understand or appreciate the nuances, but also about transparency and providing the information necessary for interested parties to contribute more effectively to the discussion. I am doubtful too many Singaporeans would understand the economic data put out regularly by the economic agencies but this should not deter the government from putting the data out as those with the expertise can debate and interpret the data in different ways and collectively add to the quality of the discussion and future decisions. An imperfect biiological analogy would be a child growing up into the teenage and then the adult years and how the relationship with her parents changes. Part of the ‘messiness’ we are seeing now is probably because Singaporeans have become ‘teenagers’/ ‘young adults’ who no longer unquestioningly put their complete faith in the government. In the same way, the amount of information about drug subsidies made public needs to be calibrated and reviewed frequently as Singapore evolves as a society.]

    I think there is some force in the Government’s argument about regulatory capture or lobbying …
    There will also be risk of capture by over-emotional interests. Life and death decisions give rise to such emotions, its only natural. I think you once noted that Prof Tambyah had once suggested (at an election speech) it was better to die than fall sick in Singapore – and you labelled this as “extreme emotional theatre” – so I think my concern is not altogether unfounded.

    Are life and death decisions best debated in public, where such strong emotions may become involved? [I am with you in general but in this particular instance, I am doubtful we are anyway close to a government that is excessively swayed by lobbying Being ‘populist’ is still a bad thing in Singapore (!). In fact, the greater danger here may be policy blind spots which are not checked because there is insufficient information in the public domain to have independent voices constantly clarifying the data and verifying the basis for decisions]

    With respect to cost-benefit of the latest and best treatments, I agree that this is a question of “values” in part, although it remains a question of “value”. Personally, I start from the premise that the Standard Drugs List should generally NOT include highly expensive and new drugs on the grounds that they are normally unlikely to be COST-effective. To use a lay analogy, albeit an imperfect one, its like not wanting to buy the latest and most high performing graphics card. [Again I am with you; the issue is one of degrees. I could list a handful of drugs that are recommended as first line treatments in oncology, hematology which are not subsidized. Between old and cheap AND new and expensive, there is a huge swathe of grey that merit debate and dialogue. The bigger societal debates are around how much of a country’s resources should go into social services, healthcare, education etc. and the size of the pie will determine what is cost-effective and what is not. Cost-effectiveness is a relative concept in a certain sense as the definition depends heavily on what a country is able and willing to pay.]

    I agree this question needs to be debated by the public. My own view is stated above. What’s yours? 🙂 [As above. I’m not too fussed up over what is subsidized as long as the decision is made well and the process is well-accepted by the public and the professionals.]

    Finally, while I agree that the decision making process counts, how do you think we should deal with the concerns about regulatory capture, lobbying and “emotional theatre” that may attend the question of who lives? [Good government brave enough to do what is right, trustworthy enough that the people will give the benefit of the doubt most times, and transparent enough to win the people’s trust from generation to generation…]

    1. Yeoh Lian Chuan · · Reply

      Many thanks for your sharing, which have helped me to understand your arguments better.

      I agree with your last paragraph.

      Definitely looking forward to reading your book when published.

  3. Thanks. Hope we can keep the discussion flowing for future posts. Good learning for me.

  4. I’m glad citizens are getting involved and taking stands. The discussions will be good for Singapore in the longer term. A little messy but necessary.

    Involve public in healthcare financing decisions (Jan 18, 2013)
    by Chua Boon Ling
    I refer to Dr Jeremy Lim’s commentary on government subsidies for new treatments and the decision on “Who should be subsidised?” (Jan 14), which highlighted an issue in our healthcare financing.
    Many patients and healthcare providers are in the dark as to why some treatments are not subsidised.
    I speak as a patient with multiple sclerosis (MS), which affects adults in their 20s and 30s, the prime of their lives. It is a devastating disease because it can incapacitate the sufferer physically and mentally.
    Interferon has been the first-line treatment for MS for over a decade. It has proven to be both safe and effective. In many developed countries, interferon is the standard treatment for MS and receives government subsidy.
    While the treatment is expensive, costing about S$2,500 a month here, one should look at the other side of the equation: Treating these patients reduces hospitalisation and sick leave as well as delays disability, which all cost society financially. As a patient and citizen, I cannot understand the rationale of not recognising this treatment, which reduces the relapse rate by about 30 per cent compared to those not on it. That information alone should justify support for interferon.
    As Dr Lim mentioned, the public is not involved in deciding what should be subsidised; only a few decide the fate of many.
    It is time for the Health Ministry to listen to patients and involve them as partners in promoting a healthier Singapore.
    URL http://www.todayonline.com/Voices/EDC130118-0000011/Involve-public-in-healthcare-financing-decisions

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: