Bilateral Cochlear Implants- A heartless, bureaucratic MOH? Not quite…

The 24th May 2013 letter in the Straits Times Forum pages appealing for the government to “Allow Medisave use for daughter’s ear implant” has elicited severe criticisms of the authorities for being unsympathetic, bureaucratic and the like.

Some comments from the Real Singapore website which publicized the letter:

  • A very cold and uncompassionate govt & MOH, medical save is your citizen money and yet we citizen are unable to use it for our own family member. No logic, get locked up like CPF (sic)
  • Typical of this in Singapore. At least they can offer for installments. As the popular sayings in Spore ‘Better to die than to be sick’.

However, many netizens also asked whether there was more than meets the eye and indeed, there is likely to be. Let’s see what we can tease out from the information available coupled with some medical knowledge and awareness of how the Ministry of Health operates.

The author writes

“While I am happy to know that she would be able to hear much better after getting the implants, the bill would come up to $39,000. The maximum government subsidy was allowed for the first implant. However, the second implant, which therapists said would enable my daughter to hear more effectively in school, had to be paid in full.”

Some salient points:

I. Science of Bilateral Cochlear Implantations

Cochlear implants are now recognized treatment for deafness. Traditionally, only one cochlear implant was placed. The science is rapidly evolving though and some centers today recommend for certain cases to place two or bilateral cochlear implants. In 2006, the Swedish reviewed the data and concluded “Scientific documentation on the benefits of bilateral cochlear implantation in children is insufficient”. The meaning of ‘insufficient’? “No conclusions can be drawn when there are not any studies that meet the criteria for quality and internal validity.”

The Scots in 2009 approved bilateral cochlear implants for children after intense lobbying by parents. Scottish Health Secretary Nicola Sturgeon was quoted in the Daily Record as saying then: “Being able to offer hearing implants in both ears from now on will make an enormous difference to the lives of severely deaf people in Scotland.”. It was not without controversy as the ruling confirmation was delayed because 2 healthcare providers had actually argued against bilateral cochlear implants and appealed against the ruling.

The latest and most comprehensive evaluation is probably the one released by the Washington State Health Authority. It is 127 pages long (!) and worth reading if one is in the business. Otherwise, the conclusions are sufficient (I have translated into plain English after the ‘medico-speak’):

“A large quantity of very small studies, generally using patients as their own controls, has shown that bilateral CI improves scores on auditory tests measuring speech perception, especially speech perception in noise, and sound localization in children with severe to profound bilateral sensorineural hearing loss (SNHL). Available studies include very few children with postlingual deafness. It should be noted that benefits to spatial hearing (localization) were especially dramatic. A small quantity of research suggests that measures of more complex language skills, hearing function in real-life situations, and disease-specific quality of life (QOL) are also improved by bilateral as opposed to unilateral CI, but this body of evidence is of low quality. The long-term impact of bilateral CI on educational achievement or employment has not been studied. The magnitude of gains in auditory testing measures that can be expected to lead to more patient-important outcomes is unknown. Thus, an inference of health, functional, and QOL benefits based on the evidence showing improved test scores is not well supported.

Serious adverse effects are possible with bilateral CI, including the need for ex-plantation. Precise estimates of risk were not possible from the evidence available for this report, but major complications may be as high as 10% or more over the long term. The evidence does not allow conclusions about differential effectiveness or differential safety according to patient, device, or provider factors except for moderate-quality evidence suggesting no difference in effectiveness between simultaneous or  short delay sequential bilateral CI and long-delay bilateral CI. The cost-effectiveness of bilateral CI in children and adolescents is unknown because no cost-effectiveness studies using a reliable estimate of utility or another effectiveness measure have been published. Published studies to date have included at most small minorities of individuals who received a second implant as an adolescent.”

In simple English stripped of the jargon?

It’s hard to tell at this point as the studies conducted so far have only very small numbers of patients (Statistical validity issue). There are benefits documented especially in localization of sound but also additional risks, e.g. infection, implant failure etc. since not one but two implants are being surgically placed. There is no way to tell whether placing two (instead of one) implants is cost-effective since there are no adequate studies available.

II. Use of Medisave

It seems from the author’s letter that there are no issues on the part of MOH with subsidizing the first implant. Not surprising since the science is robust. The problem arises with the second implant which I note was advised by the ‘therapists’ whoever they are. It is worth noting that the author does not highlight the advice given by his doctors, the ENT specialists in KKH.

Medisave is indeed one’s own money but the government has conventionally behaved here like a protective parent. In fact, then-Health Minister Khaw had explained in Parliament before:

“With medical science, life expectancy is growing every decade by a year or two.  So, really, people should look at Medisave carefully and try to conserve, and that is the reason I have to be the very unpopular gatekeeper now and then when Members put up their hands and say, “Please, can I use Medisave for this and for that?”, I have to always bring them back to the original purpose of Medisave, which is for costly hospitalization.” 

The government has rightly or wrongly assumed the stewardship role to ensure firstly Medisave can be sufficient for one’s lifetime medical needs and secondly that Medisave dollars are used in only clinically appropriate ways. The science of bilateral cochlear implants including the cost-effectiveness is still not fully clarified and I personally am not too surprised MOH is unsure whether to approve in this particular instance.

The lack of subsidies explains why Medisave is insufficient. Medisave usage at this stage is likely confined just to the standard arrangements, i.e. S$450 per day of hospitalization, surgery coverage based on the level of complexity (The maximum for surgery is S$7,550) which is far short of the S$39,000 the author mentions is needed. This is because Medisave is computed for subsidized patients and a major cost in cochlear implant surgery is the charge for the implant. I guess at this point, the second implant is not being offered at subsidized rates.

One final point: If the author has been waiting for months for a reply that is a lapse. Whatever the policy position ambiguity or state of resolution, ongoing dialogue and communications remain vital.

 ****

So ‘yes’. The issue is not a simple one of the government being stingy or unreasonable. Medicine is complex and the policy dilemmas very real. I’m sympathetic to both parties and do wish they would talk to each other, and not through the Straits Times. Think it would be much more effective to resolve this aware from the media spotlight and public emotions.

Allow Medisave use for daughter’s ear implant – Straits Times Forum (24 May 2013)

MY DAUGHTER was diagnosed with profound hearing loss at birth and fitted with hearing aids when she was five months old.

Now, at 21 months, hearing aids do not help her anymore and doctors at KK Women’s and Children’s Hospital recommended that she get cochlear implants.

While I am happy to know that she would be able to hear much better after getting the implants, the bill would come up to $39,000.

The maximum government subsidy was allowed for the first implant. However, the second implant, which therapists said would enable my daughter to hear more effectively in school, had to be paid in full.

In January, I sent e-mail messages to the Health Ministry and Central Provident Fund Board to seek approval for the release of part of my Medisave funds to help pay for the procedure, but have yet to receive a response.

I cannot understand why my appeals have gone unanswered. Is it because my daughter was born before the MediShield scheme was extended to cover neonatal conditions?

Author CCK

Update (31 May 2013, 9.20 am)

Response from MOH on 31 May 2013

Help Available for Daughter’s Treatment

WE UNDERSTAND Mr Chan Chee Keong’s concerns over the cost of treatment for his daughter’s hearing condition (“Allow Medisave use for daughter’s ear implant”; last Friday).

In fact, both the KK Women’s and Children’s Hospital (KKH) and, later, the Ministry of Health have been in close contact with Mr Chan and his wife since January over their daughter’s impending surgery.

We understand parents’ desire to provide the best possible care for their children. However, we encourage Singaporeans to consider the cost-effectiveness and their financial means when deciding on suitable treatment options.

Based on the hospital’s clinical assessment, a basic cochlear implant in one ear would enable Mr Chan’s daughter to lead a normal life.

The estimated out-of-pocket payment for the hospital stay involving a basic implant for one ear is about $6,000 after the government subsidy and Medisave, compared to Mr Chan’s preference for middle-range implants for two ears, which would amount to about $39,000. This option would also allow the family to preserve their Medisave balances to pay for their future health-care needs, including the replacement of parts of his daughter’s cochlear implant, which would be necessary as she grows up.

While we turned down Mr Chan’s appeals for two middle-range implants, we are working closely with KKH to assist with the treatment cost for a single basic cochlear implant for his daughter, in line with her doctor’s recommendation. We remain committed to helping Mr Chan’s daughter lead a normal life.

Bey Mui Leng (Ms)

Director, Corporate Communications

Ministry of Health

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