It was hard to offer excerpts from my upcoming book ‘Myth or Magic: The Singapore Healthcare System’ within the word limit constraints of a newspaper. The Straits Times editors chose the chapter ‘How should Singapore change?’ and asked initially for the over 10,000 words to be condensed into 1,500 words.
I tried but could not do so and instead settled for excerpting 2 of the dozen or so recommendations. Even then, the text was shortened due to space constraints. To me, not ideal as the healthcare is an integrated eco-system and one change ripples throughout the entire system. Furthermore, the first half of the book dives deep into the questions of ‘how’ and ‘why’ Singapore has the health system it has and these answers provide to me a vital context to understanding the need for change and the challenges reformers will encounter. Still, I appreciate the challenges of brevity that any newspaper editor faces. And the publicity hopefully helps generate more awareness about the book and the ongoing healthcare debates.
I hope the excerpts offer a glimpse into the book. Below is what was submitted to the Straits Times.
How should Singapore’s Healthcare System Change (Straits Times 7 Sept 2013)
In this edited excerpt from Myth or Magic: The Singapore Healthcare System, author Jeremy Lim discusses reform of co-payments and how primary care should be restored to its foundational role in healthcare.
As Singapore relooks its healthcare model, a few key priorities merit re-stating.
First, the need for a healthcare financing system that provides “peace of mind” but that is, at the same time, efficient, sustainable and congruent with the dominant political philosophy which is deeply concerned with possible abuse of the system.
Second, healthcare financing needs to support and be aligned to the way healthcare is practiced and not the other way around. Hence, the financing orientation may need to move away from the false dichotomies of “inpatient versus outpatient” and “specialists versus GPs” to look instead at episodes of care, regardless of the “where” and “who”.
Third, we need a health system that actually promotes health rather than disease treatment, and rewards quality over quantity.
I have chosen two recommendations out of the many in my book to be included in this excerpt.
- Re-thinking the application of co-payments to achieve maximal societal utility
- Restoring primary care to its foundational role in the health system
The Co-Payment principle
Co-payments are sacrosanct in the Singapore health system. Just last month, the Ministry of Health emphasised that even as healthcare policies evolve to prepare for the future and face new challenges, “what will not change is the emphasis on individual responsibility for one’s own health and the principle of co-payment”.
What do we want from co-payments? There are three considerations. First, we want to recover some of the cost of providing the service. Second, the Government is determined to avoid a situation in which patients take unfair advantage of the system. But this needs to square with a third consideration, which is to not deter medically necessary care.
In acute care and hospital services, where patients are in pain or distress, genuine patients generally would not defer care for financial reasons. Advocates of co-payment often forget that in economist Mark Pauly’s seminal 1968 paper introducing moral hazard in health insurance, he was careful to limit the concept to elective physician visits.
Mr Pauly also qualified that with catastrophic illnesses, the elasticity of demand is likely “not very great” as there would likely be just one appropriate treatment.
In preventive services such as cancer screening and regular diabetic follow-ups, co-payments are less useful and perhaps even detrimental. In Singapore, less than 50 per cent of women undergo regular Pap smears and less than 40 per cent regular mammograms. This is a far cry from the 70 per cent to 80 per cent needed for effective national screening.
Co-payments are arguably not needed in these cases as the inherent behaviour is already avoidance, and the financial outlay just adds one more “reason” to defer care.
Screenings and good control of chronic conditions are intended to detect disease early and prevent complications respectively. These measures save both individuals and society money in the long term.
Long-term and palliative care
What about long-term care? Poorly utilised and poorly delivered long-term care services simply drive patients into hospitals with complications such as bed sores, lung infections and the like. Blunt imposition of co-payments is penny wise and pound foolish.
Finally, let us look at palliative care. Often, patients would have expended much of their life savings by the time they reach this stage and have little monies left. Co-payments may thus impede acceptance of palliative care services. Can a dying man over-consume palliative care services? Perhaps, but is it really so important to guard against moral hazard here, especially when the psycho-social aspects of end-of-life care are just as important as the medical elements?
Co-payments in healthcare are a powerful policy tool which Singapore has wielded extensively. Applied appropriately, they drive economic and operational efficiency, enabling services to function well with reduced wastage and over-consumption. However, when applied blindly as a matter of ideology, they can be ruinous to the humane functioning of the health system.
Transforming primary care
The Primary Care Master Plan was unveiled by the Ministry of Health in 2011. Although still evolving, it already entails creating new models of care with community partners. These include the Family Medicine Clinic (FMC), which would bring GPs together under one roof as group practices in close affiliation with the Restructured Hospital in its locale; the Community Health Centre, which would provide support services to GPs; and finally, the “Medical Centre”, which offers ambulatory specialist services in the community.
In primary care, I personally feel that Health Minister Gan and his team are on the right track. The “solo” GP model is entirely inappropriate for the challenges we face in coping with today’s diseases. On the other hand, the solo GP, augmented with a CHC which provides patients with access to allied health professionals and laboratory support, and a national electronic health records system, is viable. It will be part of a larger network that benefits clinical care and hence patients. With a sturdy foundation in primary care, hospitals and patients can truly feel confident about community care and hospitals can be reserved for only the most acute conditions.
Singapore healthcare is at the crossroads. Like many countries, it is facing the need for healthcare reform to meet the changing needs and demands of an aging, vocal public. Unlike many other countries, however, it is reforming from a position of strength.
Singapore’s system is fundamentally sound and is versatile enough to reform and transform as necessary. Sure, there are challenges and there have been noticeable policy missteps, but on balance, there is more right than wrong.
In this latest reform effort, Singapore just needs to be wary of mistakes of dogma and ideology.
The writer, a medical doctor, is Principal Consultant of Insights Health Associates, a specialty health and life sciences advisory firm.
The book, published by Select Publishing, will be on sale at major bookstores at $34.24 including GST from Sept 18.