Monday 10 June 2013

Why Singapore's health-care system works

By Gillian Tett, Published The Sunday Times, 9 Jun 2013

A decade ago, I had an experience that left me profoundly grateful to Singapore's health-care system. During a work trip to the island state, I was suddenly taken ill and succumbed to a rare variety of meningitis.

In many countries, I would have died, but two extraordinary things occurred.

First, a colleague had a strange premonition that something was wrong and came to my hotel room, where she found me sliding into a coma.

Second, the colleague then had me rushed to a local hospital, where Singaporean doctors identified the problem with astonishing efficiency and then took a bold medical gamble to save my life. (Essentially, they injected every type of antibiotic they possessed directly into my heart because they did not have any tailored way of treating the rare strain of meningitis I had.)

When that gamble pulled me out of the coma, the staff set me on the path to rehabilitation, with further efficiency and grace.

A few months later, I stumbled on some paperwork between the hospital and my insurance group and noticed that the bill for the intervention was not that large.

"If this had happened in America, it would be many times that size," a colleague later grimly remarked in New York. To which I retorted that if the incident had happened in America, I might not have survived at all since litigation risk might have deterred the doctors from engaging in that antibiotic gamble.

Was this just a piece of random good luck? Yes, in part. But that may not tell the whole tale. Recently I have been flicking through a fascinating e-book, Affordable Excellence, that a scientist friend, Professor William Haseltine, has written about Singaporean medicine for the Brookings Institution. And this leaves me convinced that I have even more reasons to say "thank you" to Singapore than I realised at the time.

Professor Haseltine believes that Singapore's health-care system is not just low-cost but also very effective in terms of saving lives; so much so, in fact, that this might offer lessons to the US, which is embarking on health reform.

The statistics are striking. At present, the US spends about 18 per cent of its gross domestic product on health care, more than any other Western nation. But while this produces fantastic results in some niches (such as cancer treatment), the metrics for infant mortality, adult deaths, life expectancy and other health issues are worse.

Singapore's health-care costs, by contrast, are just about 4 per cent of its GDP; and while the system is based on insurance programmes, premiums per capita are just 2 per cent of those paid by Americans. But on issues such as life expectancy, infant mortality, premature adult death and emergency care, Singapore produces much better outcomes than the US.

Why? One reason, Prof Haseltine suggests, is that Singapore created a health-care system from scratch a few decades ago and was able to adopt a rational plan that focuses on the total health experience of the population. America, by contrast, is marred by competing, wasteful silos.

But another weapon for lowering costs in Singapore is consumer pressure: Hospitals are forced to publish prices for medical procedures and outcomes so that consumers can compare them. Patients are also forced to co-pay for treatment, alongside insurance groups, to create incentives to scrutinise their bill.

Now, it would be impossible to replicate some of this in a vast, fragmented system such as the US'. After all, most Americans hate the idea of state meddling, but there is one aspect of Prof Haseltine's report that is relevant: accountability. If Americans could compare the price of treatments as easily as they can in Singapore, that might lower treatment prices - doubly so if the use of co-payments was as widespread among the rich as among the poor.

The good news is that the US is moving that way since there is growing support within the medical world for co-payments and price transparency. But the bad news is that any changes are slow and patchy because the system is so fragmented. For the foreseeable future, in other words, those statistics from Singapore are likely to keep putting the US and other nations to shame.

It is a sobering thought, given that behind those statistics stand millions of human stories, many of which were not as blessed with as much good fortune as mine.

Ill effects of raising health spending

MR HENG Aik Jin calls for society to step in when personal efforts fail, by increasing the Government's share of health-care spending to 6 per cent to 8 per cent of gross domestic product ("Society must step in when personal efforts fail"; Thursday).

Singapore's health-care system is one of the best in the world. In 2000, the last time the World Health Organisation (WHO) ranked health-care systems, our system was deemed sixth-best in the world.

Recent WHO figures also reveal that we have the fourth-best life expectancy rate in the world ("S'pore ranks world No. 4 in longevity"; May 27).

Spending more money does not necessarily improve health care; it is more crucial to spend wisely.

Take Britain for example. It provides free health care through the National Health System, and its health spending accounts for 9.3 per cent of its gross domestic product. The corresponding figure for Singapore is about 4 per cent. Yet, the WHO ranked Britain's health-care system No. 18 in the world.

This may come as a surprise to someone struggling with high medical bills. But things look different when one sees the big picture.

If our Government were to raise its health-care expenditure, where would it get the money?

It could reduce spending elsewhere or raise taxes, but the latter means we will end up paying higher goods and services, income, property and corporate taxes.

For comparison, Britain's version of our goods and services tax - called the Value Added Tax - is 20 per cent.

Do we really want to pay more taxes? Don't forget that we are competing against Hong Kong, where tax rates are low.

Raising taxes discourages investments and talented individuals from coming here. This will result in higher unemployment and slower economic growth.

For example, the unemployment rate in the highly taxed euro zone is 12.2 per cent, compared with around 2 per cent in Singapore.

In the United States, states with low income taxes or none at all generally have lower unemployment rates than those with high taxes.

To sum up, there are trade-offs in getting the Government to increase health spending - in the form of slower growth, more taxes and higher unemployment rates. Do we want these when we already have one of the best health-care systems in the world? I think not.

Tan Keng Soon
ST Forum, 8 Jun 2013

Society must step in when personal efforts fail

DR PHUA Kai Hong ("Govt and patients should pay fair share for health care"; Monday) provided an informative, reasoned and - most importantly - local perspective in response to Dr William A. Haseltine's commentary ("Learning from S'pore: It pays to make patients pay"; May 23) on the virtues of Singapore's health-care funding model.

Both pieces flag the need to change the model in the face of our changing demographics. Dr Haseltine reminds us to consider the trade-offs, and Dr Phua articulates the conflicting considerations.

This is the heart of the matter - that the asymmetry of information characterising the demand, provision and consumption of health care and its economics prevents anything like the fair and equitable allocation of resources many wish to see.

We cannot resolve this asymmetry by practising rational economics.

There are real, negative externalities attached to uncertainty about one's future health status - we cannot know what may ail us tomorrow. And the underwriting that attends health insurance reminds us that this is an industry trading on that very uncertainty.

There is only one possible approach - reasoned, determined action to produce a caring and supportive system, where the mantra of "individual responsibility" and the focus on "cost recovery" are softened by the recognition that no individual can completely control his health status.

We need to depend on others to ameliorate our sufferings, should we have the misfortune to fall ill.

Beyond the effects of health uncertainty on the individual, there are also real, negative externalities faced by those of us daunted by our potential inability to fully care for our family, friends and fellow citizens.

This can be partially mitigated by, for example, the confidence that acute hospitals will properly care for fever cases in a dengue epidemic; or our own efforts to encourage healthy lifestyle choices in those around us.

But nothing reassures us like the knowledge that, should our own efforts fail, the society in which we have chosen to live, work and contribute will make every collective effort to catch us when we - inevitably - fall ill.

Let us find it in ourselves to increase the Government's share of health-care spending. The figure of 6 per cent to 8 per cent of gross domestic product has been proposed. A rational, pragmatic society should be able to see the stark realities facing us and make this necessary allocation.

Heng Aik Jin
ST Forum, 6 Jun 2013

Govt and patients should pay fair share for health care

I READ Dr William A. Haseltine's article ("Learning from S'pore: It pays to make patients pay"; May 23) with interest.

He compared Singapore's health-care system with the wasteful systems of the United States and other industrialised countries, which are fraught with both market and government failures.

While I agree that indemnity insurance models, whether private or public, with their third-party reimbursement act to create moral hazards and excessive consumption, I do not agree that the answer lies in high co-payments and individual responsibility.

Most insurance models end up fuelling consumption while trying to play "catch-up" to manage supply-side inducements, over which they may have little control, thus contributing to higher costs.

But to conclude that Singapore spends a low 4 per cent of gross domestic product on health care due to the principle of co-payment does not explain the effects of the total system and determinants of health.

In fact, the excessive levels of co-payment have led to a greater sense of insecurity and unfairness, contrary to the principle of shared responsibility on the part of Government vis-a-vis the people.

Moreover, it is unfair to compare a small city-state with large countries having older populations.

Based on our past research, we projected about 6 per cent to 8 per cent of GDP spending for health care after adjusting for age-specific consumption levels, which therefore approach levels closer to, but are still lower than, those of other industrialised countries.

The real question is whether we can continue to do cost-containment, with rising cost inflation and changing public expectations in future?

Dr Haseltine thinks that our debates about who pays and how much to be shared by the Government is a domestic matter.

Yet these are important from a policy and equity perspective for all governments.

Are the current levels of co-payment too much to bear and is private expenditure rising disproportionately higher than the public share?

What are the acceptable levels of cost-sharing and risk-pooling, if there is to be no reliance on transfers from progressive taxation or social insurance?

I am afraid that the past over-emphasis on individual responsibility and excessive cost-recovery would drive our health-care model towards a more uncaring and socially unacceptable system.

By default, perceived fears of unaffordable prices would be channelled towards greater reliance on private health insurance, leading to market failure like that in the US health system.

We will have to strike a judicious balance between creating wealth, while ensuring that scarce resources will be allocated not just efficiently but also equitably.

Phua Kai Hong (Dr)
ST Forum, 3 Jun 2013


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