Wednesday, 22 January 2014

Gan spells out ways to ease hospital bed crunch

One is to reduce reliance on hospitals and another is to increase capacity
By Linette Lai And Goh Chin Lian, the Straits Times, 21 Jan 2014

THE way to ease the shortage of beds at public hospitals is to improve facilities for community care and home care so that there is "less reliance" on hospitals, said Health Minister Gan Kim Yong yesterday.

One such move is to "enhance and strengthen" primary healthcare providers such as polyclinics and general practitioners (GPs).

Patients with chronic conditions, for example, can seek treatment from them instead of having to return to hospital frequently.

Similarly, if those who need medical help for non-emergency conditions visit night clinics, the strain on hospitals' emergency departments will ease up, he said.

Yet another way, he added, is to get people to turn to community care and home care options, such as nursing homes or daycare centres for the elderly.

"If we continue to rely on hospital beds, and the home care sector is unable to develop or families are unwilling to take care of their family members at home... I think it will be more difficult," he said at the topping out ceremony for Ng Teng Fong General Hospital in Jurong to mark the completion of its structure.

Mr Gan made the point in a speech in which he spelt out the two long-term solutions to the shortage of hospital beds.

The other is to increase hospital capacity.

Meanwhile, hospital bed occupancy rates have "more or less stabilised". It stood at 87.6 per cent at the beginning of this year.

"But the bed situation will remain tight because given our ageing population, the demand for hospital beds will always be there," he said.

"Senior citizens generally take longer to recover to be ready for discharge. Coupled with a smaller family size... some family members may need to take a little longer to make preparations for the care arrangements, and these factors will affect the length of stay."

Later in Parliament, Mr Gan gave an update to Dr Lam Pin Min (Sengkang West) on the short- and medium-term measures to tackle the bed shortage. These include partnering private hospitals to supply about 50 beds.

Non-Constituency MP Gerald Giam asked if public hospitals had considered converting the A and B1 class wards to C class, and if they were still marketing their services to foreigners.

Mr Gan said some hospitals move C class patients up to B2 or B1 wards, while foreigners occupy less than 2 per cent of hospital beds, including emergency cases.

For the medium-term, a minimum of six new hospitals are scheduled to open by 2020.

Ng Teng Fong General Hospital will start with 500 beds by December. Another 200 will be available in its community hospital section.

A window by each bed in every ward at the general hospital improves privacy and ventilation. An outdoor terrace connects to the intensive care unit.

Said Jurong Health Services chief executive officer Foo Hee Jug: "For patients in a critical condition and who have been lying in bed for some time, sunshine makes a world of difference."

Home nursing care, however, was a concern for Mr Liang Eng Hwa (Holland-Bukit Timah GRC), who asked that the 3Ms - MediShield, Medisave and Medifund - be allowed to be used for it.

Mr Gan said his ministry is reviewing its financing, especially for needy patients.

Sengkang hospitals 'cannot be rushed'
By Goh Chin Lian, the Straits Times, 21 Jan 2014

THE building of Sengkang General and Sengkang Community hospitals is a complex undertaking and it would be risky to hasten their completion, said Health Minister Gan Kim Yong yesterday.

Besides the physical infrastructure, a team of people to run the hospital also has to be built up, he said in his reply to Dr Lam Pin Min (Sengkang West). Citing Ng Teng Fong General Hospital, which is due to open by the end of the year, Mr Gan said it is already training and building up a team by putting staff through their paces at Alexandra Hospital.

"Manpower development cannot be accelerated at will because we need time for people to be trained, to acquire the necessary skills and experience," he said.

The Sengkang hospitals are due to be ready in 2018.

Immediate measures:
- Adding more than 300 beds in the past six months
- Partnering private hospitals to supply about 50 beds
Medium-term measures:
- Public hospitals and nursing homes to add 1,200 beds by the end of the year; 10,000 beds by 2020
- Six new hospitals by 2020; 12 new and replacement nursing homes by 2016

How to keep patients healthy and hospital-free

By Jeremy Lim, Published The Straits Times, 25 Jan 2014
THE biggest challenge facing Singapore's health-care system, and most health systems around the world, is coping with ageing patients and the rising prevalence of chronic diseases.

At a ceremony marking the near-completion of the Ng Teng Fong General Hospital on Jan 20, Health Minister Gan Kim Yong revealed that a third of hospital beds were taken up by elderly patients despite the fact that the elderly only constituted a tenth of the total population. By 2030 - that's just 16 years away - the number of elderly people will triple to over 900,000. The Singapore population is growing older. Ominously it is also sicker. One study projects Singapore's diabetic population will number one million by 2050, a more than threefold increase from today.

It's clear that we are on an unsustainable trajectory. Soldiering on with "more of the same" will fail. Singapore needs to find a better way.

Fortunately, there is a better way. America, with its bloated health system consuming almost a fifth of its GDP, ironically shows that better way.

The crippling growth in health-care spending in the United States has forced innovation. And it is from these "forced innovations" that we can draw important lessons for Singapore.

Take for example CareMore, a Californian group which focuses on the most expensive patients, the elderly with chronic diseases such as heart failure and diabetes. These patients, whom providers traditionally shun, have proven a boon to CareMore. How? By changing the care and the payment model.

Instead of waiting until heart failure patients deteriorate to the point when urgent hospitalisations are needed, CareMore arms patients with weighing scales that wirelessly transmit weight measurements to the care team.

If a patient starts to gain weight, the earliest sign of impending acute heart failure, the care team is alerted and takes urgent action in the patient's home, providing oral medicines and other measures to prevent further deterioration.

Instead of waiting for a small cut in a diabetic to deteriorate into a festering wound needing amputation, CareMore has wound nurses whose primary job is to care for patients with small cuts and make sure they get better. Instead of grumbling about "no-shows" and non-compliant patients, CareMore provides transport to take patients to clinics for appointments.

The net result? A fall in admissions for heart failure of 56 per cent and a decline in diabetic amputations to more than 60 per cent below the average. Importantly, CareMore patients' costs are 18 per cent below the industry average.

How do the economics work? Incentives drive behaviour. System planners need to ensure doctors, hospitals and patients all win in providing the "better way". CareMore eschewed the traditional fee-for-service model, in which hospitals and doctors are paid only when patients use their services.

Instead, it enrolled into Medicare Advantage, which pays it an annual per patient fee, adjusted for risk profile. In such payment models, the health systems that keep patients out of hospitals are the ones that are the most financially successful.

In public health care, more revenues for Singapore's restructured hospitals mean taking more money from the public purse. This is money that could have been spent on better public transport, schools or social services. Hence, we must focus on the cost side of the equation.

There are three crucial lessons for Singapore.

First, a dollar spent today can save a thousand tomorrow through avoided hospitalisations and obviating the need for expensive treatments.

Second, CareMore-type models only work if health systems invest upfront. CareMore incurred losses of about US$12 million (S$15.3 million) in its first four years while it built up the infrastructure needed to provide a different care model. However, it turned the corner in Year 7, reporting a profit of US$24 million.

Third, the CareMore experience highlights an invaluable lesson. Targeted system changes are all that are needed. Former CareMore CEO Alan Hoops told The Atlantic magazine: "We talk as if we need to overhaul the entire health-care system. But that's not quite correct. "The biggest problem - and opportunity - lies with the part of the system that serves our high-risk populations. That's the part of the system that's unsustainable."

To avoid a bottomless pit of health-care spending to the detriment of other essential public services, Singapore needs to change the way health care is provided to the elderly and those with chronic conditions.

Stop paying restructured hospitals and their doctors based on the number of patients, the number of surgical operations and tests. Throw out the current Medisave and MediShield claim amounts, which are based on the number of days in hospital or surgery performed.

Instead, assign restructured hospitals populations of patients with chronic conditions in their respective locations. Then pay them an annual amount from subsidies, Medisave and MediShield based on patients' clinical complexity. Actuarial analyses have been done in many other countries to determine how much health systems should be paid for what types of patients. Singapore can do likewise.

Singapore can reform Medisave, MediShield and government subsidies to promote better health care. New payment schemes could cover tele-health, care by non-physicians and even services like transport.

Whatever works!

The worst thing the government could do is to be overly prescriptive and issue "edicts" as to what can and cannot be paid for. And please don't subject hospitals to painful bureaucratic rules such as "This is 'social' and falls under a different ministry; we can't pay for this".

Then, challenge the doctors and health-care leaders to keep these patients healthy, happy and hospital-free. The dollars saved equate to lower patient bills and more money to improve public service - and bigger bonuses for health-care staff.

Singapore has waited too long to take decisive action. Let's not dither any further. Our children deserve a future better than one blighted by worrying about how to pay for the medical needs of their parents.

The writer, a doctor, is partner and head of the health and life sciences practice at Oliver Wyman, a global consulting firm.


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