Saturday, 23 August 2014

Reasons for soaring private health-care costs

Docs divided on reason for rise in costs
Some feel new procedures come at a price; others blame overcharging peers
By Linette Lai, The Straits Times, 22 Aug 2014

WHEN it comes to rising medical costs in private practice, doctors fall into two camps.

Some say medical progress comes at a price. Others believe their peers are taking advantage of the lack of price guidelines to overcharge patients.

The long-running debate has been reignited in The Straits Times Forum pages over the past week, sparked by a letter from neurologist Tang Kok Foo who wrote that the "fee-for-service" model gives doctors the incentive to provide more treatments than are strictly necessary.

In an interview with The Straits Times, Dr Tang, who is in the private sector, claimed that patients are "at a big disadvantage".

"You are in a very poor bargaining position," Dr Tang said. "You are sick; you just want to get better. It's not like shopping."

For example, a hysterectomy - or womb removal surgery - can be carried out for about $3,000.

But Dr Tang said some private sector doctors charge as much as $20,000. "A lot of patients don't know any better," he added. "They think the higher the price, the better the doctor."

In 1987, the Singapore Medical Association (SMA) drew up fee guidelines for GPs and specialists to inject transparency into private medical charges. These gave a range of charges for various services - such as a fee of between $10 and $20 for a 10-minute GP consultation.

But other doctors say that with rapid advances in technology, the costs of certain procedures is bound to rise.

Robotic surgery, for instance, is increasingly popular with doctors in both the public and private sectors. Patients who undergo this tend to recover faster and suffer less scarring. But it can also cost thousands more than traditional surgery.

"The important thing is how cost-effective a new advance is," said retired plastic surgeon George Wong, who spent 40 years in private practice. "Is it worthwhile? Is it necessary? Patients are not in a position to know this. They want the latest and the best."

The onus is thus on doctors to be "judicious" in what they recommend to patients, he said.

But medical costs are not just driven up by patients' lack of knowledge, putting doctors in a position where they can charge what they like. Spiralling rental fees are a burden on GPs, said Dr Leong Choon Kit, who has colleagues that pay between $20,000 and $30,000 a month for an HDB unit which houses their practice.

Some doctors also practise "defensive medicine" - such as ordering a test in case they have missed something serious.

Dr Leong said: "It is the fear of the unknown - of the public and the practising doctor - that is the problem."

Reasons for soaring private health-care costs

DOCTORS' bills are arguably the most rapidly escalating component of private health-care costs.

I am amazed at how expensive it has become to be treated by doctors in private practice over the past five years. The surgical fee for simple lumbar disc surgery has shot up from $5,000 to as high as $25,000, even when performed by junior doctors.

The free market in health care is among the reasons for the astronomical rise in fees.

An ear, nose and throat surgeon once told me that since the Government abolished guidelines on professional fees, he has been competing actively with his colleagues to see how high his fees can go.

The professional fee system in public hospitals, where foreign patients can be surcharged up to 400 per cent, is a good "training ground" for doctors charging higher fees when the market can bear it.

Then, there is the vicious circle of rising clinic costs and overheads.

Doctors who face escalating rents for clinic space have no choice but to charge more, which in turn attracts more doctors, mostly from public hospitals, to go private. With greater demand for clinic space, rents continue going up.

Another factor is the fee-for-service model, which incentivises doctors to provide more treatments.

I have been in private practice for 24 years and have not encountered any local surgeon operating on a closed collarbone fracture until the past year, when there were three cases. Last year was also the first time I saw a patient undergo an operation for plantar fasciitis, or jogger's heel.

On the other side of the equation are frightened patients who are eager to undergo treatment even if it is not necessary.

For instance, many patients with bulging spinal discs that do not cause any health issues have agreed to surgery after being warned they could become paralysed if they have a fall.

"Pay as charged" insurance policies also encourage doctors to charge higher fees, since these will be covered by insurance. A patient once said that a surgeon told her not to worry about her $55,000 cervical spine surgery as it would be paid by the insurance company.

Singapore patients have good reasons to be afraid.

Tang Kok Foo (Dr)
ST Forum, 14 Aug 2014

Fee guidelines are like speed limits

THERE has been considerable interest in the recommendation by a Singapore Medical Council review committee to amend the law to "re-allow" some form of fee guidelines.

Recent letters to the Forum page have also dealt with this issue ("Reasons for soaring private health-care costs" by Dr Tang Kok Foo, last Thursday; and "Consider fee guidelines, medical oversight" by Dr Ong Siew Chey, last Friday).

The relevant authorities can consider re-implementing some form of fee guidelines. The problem lies in revising them later as costs go up over time.

If fee limits are increased by too much or too quickly, the public may ask why the authorities are allowing doctors to earn more. If the fee limits are revised too slowly or modestly, a grey market or dubious practices may ensue.

Hence, the most elegant solution is to have the authorities outsource this responsibility to a professional body, and to step in only when needed. This was what had been in place from 1987 to 2007 without any fuss.

I was the president of the Singapore Medical Association (SMA) when its fee guidelines were withdrawn in 2007. It was the saddest decision I had to make as president, because the guidelines had served patients and the medical profession well for 20 years.

My colleagues and I in the SMA foresaw the grave consequences, and we did our best to engage and warn the relevant parties. Those parties that could have helped to keep the guidelines alive did not do so, and the SMA was compelled to withdraw the guidelines because they contravened the Competition Act.

The sum of almost all our fears has now indeed come to pass.

An oncologist related this metaphor about withdrawing the guidelines: On a highway with a 90kmh speed limit, there are three kinds of drivers - the first group travels well below the limit (the drivers actually do not need it); there will also be a few who go well above the limit and they may be caught and punished; the last (and largest) group will travel at or near the limit, but if it is removed, the drivers will probably travel much faster than 90kmh, and the second group may now go even faster.

This was what happened when the fee guidelines were removed.

Wong Chiang Yin (Dr)
ST Forum, 21 Aug 2014

Consider fee guidelines, medical oversight

DR TANG Kok Foo has rightly pointed out some factors behind the rise in private health-care costs ("Reasons for soaring private health-care costs"; yesterday).

In 2010, the Competition Commission of Singapore ruled against fee guidelines set by the Singapore Medical Association (SMA), because they breached Section 34 of the Competition Act and interfered with free market competition.

The SMA is not vested with any official authority, and observance of the guidelines by doctors was not compulsory. The guidelines were just for reference - they provided variations within a range, and the fee set for a particular service was not absolute. Nevertheless, the guidelines were useful to both doctors and patients, and were largely workable.

It is a pity no substitute has been put forth, and abolishing the guidelines has partly fuelled today's runaway medical charges.

In this respect, the Government has overlooked basic human nature - self-restraint is rare when there are no restrictions - and it is time to review the need for fee guidelines.

Dr Tang also pointed out the trend of patients undergoing surgery that is not indicated.

An operation should not be done when conservative treatment yields equally good or better results. Even if a condition can be treated effectively only by surgery, the operation should not be done when pre-operative evidence overwhelmingly points to its futility.

And even when an operation is pre-operatively indicated, it should be aborted during the operation when new, unexpected intra-operative findings contradict the pre-operative judgment.

These surgical criteria are sometimes ignored by surgeons for monetary reasons. The complex nature of surgical decision-making is not easily appreciated by laymen.

In countries such as the United States, the hospital providing facilities to the doctors assumes certain responsibilities in oversight. Peer review and proliferating malpractice suits tend to keep doctors in line.

Peer review has limited effectiveness in Singapore because of the small medical community, where few people want to be the "bad guys".

The Singapore Medical Council (SMC) is a body with official authority but is passive in its functions. It does not actively initiate investigation of medical irregularities unless a whistle-blower comes forward with an affidavit.

The Government should either change the nature of the SMC or form a separate body similar to the Commercial Affairs Department for medical matters.

Ong Siew Chey (Dr)
ST Forum, 15 Aug 2014

Emphasise ethics in health care

I COMMEND Dr Tang Kok Foo for highlighting the reasons for soaring private health-care costs ("Reasons for soaring private health-care costs"; yesterday).

He cited the free market in health care as one of the factors. This is certainly a cause for concern. Although such a system has its merits, it can be abused.

I am appalled to learn from patients that some doctors and dentists are still charging hefty fees under the Community Health Assist Scheme (Chas). From the patients' point of view, their treatments are not being "subsidised", and they are in no position to know whether the medication and treatment they receive are really necessary.

Doctors leaving the public sector for the seemingly "greener pastures" of private practice are creating a vacuum in public hospitals.

Although Chas allows for subsidised rates for patients referred to specialists in public hospitals, the lack of specialists and the heavy patient load mean patients can be seen only after several months. Those in urgent need of treatment have no choice but to turn to private specialists.

There is a need to emphasise to health-care practitioners that compassion and integrity are essential in the practice of medicine and dentistry.

If they are in it just for the money, then there is always the risk of breaching ethical standards. Any system can be compromised if the motivation is not altruistic.

Quek Koh Choon (Dr)
ST Forum, 15 Aug 2014

Medical advances come at a cost

DR TANG Kok Foo highlighted some reasons behind the rising cost of private health care ("Reasons for soaring private health-care costs"; Thursday).

A large part of the increase is due to advances in medical technology and appliances, and not just doctors' fees.

Nowadays, medicine can cost from $10 to $100 per tablet, and injections of substances like monoclonal antibodies can cost between $500 and $1,000 per jab.

In vascular surgery, where stents are used, each stent can cost from $5,000 to more than $10,000.

Those who opt for robotic surgery will have to pay $5,000 more for the same type of operation. And the latest machines for MRI and PET scans can raise the cost of these tests to thousands of dollars.

This is the way medical science is going; progress comes at a cost.

It is imperative for doctors and patients to be aware of this and keep costs down by using the services judiciously.

The most expensive test or appliance should be used only when it is absolutely necessary.

Unfortunately, emotions come into play in matters of health. All patients want the "best", whether they need it or not. Very often, the patient does not have the knowledge to make the choice, and it is natural for the doctor to recommend the "best" treatment. We cannot blame him for that.

I can only point out the facts, and hope society can find the solution.

George Wong Seow Choon (Dr)
ST Forum, 16 Aug 2014

Free market unhealthy for health-care sector

I FULLY agree with Dr Tang Kok Foo ("Reasons for soaring private health-care costs"; Thursday) that the free market for private health care has to be reined in, and the unhealthy practice of doctors competing against one another to charge higher fees should be stopped.

Medical care cannot be subjected to market forces.

When you are sick, you do not have the luxury of time to "shop around" for the lowest prices. Patients are at the mercy of doctors and will pay whatever fee the doctor charges.

Insurance policies that pay medical bills as they are charged worsen the problem. Where does that leave those who cannot afford such policies?

Public health care is not the solution as public hospitals are already bursting at the seams.

Dr Tang also does not see much sense in paying ever increasing rentals.

Who benefits from that, apart from the landlord? What has changed to the piece of land on which the hospital sits, or the building itself, that justifies such rental increases? And who bears the brunt of such increases, apart from the patients?

It is high time the authorities looked into rising costs and their knock-on effects. Affordable medical care should be available to everyone.

David Lim Yoke Peng
ST Forum, 16 Aug 2014

Rising costs: Private hospitals no less culpable

I THANK Dr Tang Kok Foo for exposing the mercenary practices of doctors and hospitals ("Reasons for soaring private health-care costs"; Thursday).

As he rightly pointed out, doctors' bills contribute most to the rising cost of private health care.

Private hospitals are no less culpable. They charge high rents for clinics, operating theatres and laboratories, which encourages doctors to carry out unnecessary tests to generate income.

The fee-for-service model offers unbundled services that are paid for separately, encouraging specialists to offer more treatments because payment is dependent on the quantity of care given.

In short, private hospitals, faced with high financial targets set by the management, work hand in glove with doctors to encourage over-utilisation of services.

Some hospitals use terms such as "ward fees", "nursing fees" and "miscellaneous fees" for the same service rendered. That is why patients must insist on a detailed bill upon discharge, and scrutinise it carefully.

The mark-up on inpatient medication, blood tests and everyday items such as tissue paper and diapers can be as much as 200 per cent.

When queried about items in the bill, cashiers can give excuses that the layman is in no position to verify.

Edmund Khoo Kim Hock
ST Forum, 16 Aug 2014

Introduce checks to ensure affordable, sustainable system

SOME doctors have written on the subject of high health-care charges ("Reasons for soaring private health-care costs" by Dr Tang Kok Foo, last Thursday; "Consider fee guidelines, medical oversight" by Dr Ong Siew Chey, last Friday; and "Medical advances come at a cost" by Dr George Wong Seow Choon, last Saturday).

The key is "value for money".

Because of information asymmetry, patients often do not have enough understanding to evaluate the treatments they are receiving.

Also, certain aspects of financial aid schemes need to be reviewed.

For the Community Health Assist Scheme to be really useful, users should co-pay a fixed amount rather than get a fixed subsidy. This is done in some countries.

The Government has the expertise to better evaluate the reimbursement to be made to health practitioners. Perhaps this could be determined by a tripartite body comprising representatives from the Government, private sector and independent consumer organisations.

For MediShield Life, the need to minimise moral hazard is very real, to keep utilisation to justifiable limits.

The provision of "as charged" benefits (in private plans) may be comforting in the short run, but will hit us in the form of higher premiums subsequently.

Let us discuss this matter openly.

I also urge the the relevant bodies to put in place vital checks and balances to ensure a more affordable, sustainable system that will truly bring peace of mind to all.

Lee Hin Peng
ST Forum, 19 Aug 2014

Unfair to blame doctors' fees

I AM an anaesthesiologist who has been in private practice for 14 years.

The letters by Dr Tang Kok Foo ("Reasons for soaring private health-care costs"; last Thursday) and Dr Ong Siew Chey ("Consider fee guidelines, medical oversight"; last Friday) gave the impression that ethical standards of our doctors have fallen drastically.

Their assertions must be challenged.

It is unfair for Dr Tang to blame medical professional fees for high health-care costs.

Advances in implant and surgical techniques have resulted in better outcomes for patients and should not be construed as malpractice.

The use of high-tech equipment also comes with extra costs.

Another factor is the higher expectations of patients.

My son is a polyclinic doctor. Every day, he has requests from patients for referrals to specialists for conditions that family doctors can manage.

Some of his colleagues practise defensive medicine and will make the referrals for fear of missing something serious or receiving complaint letters.

If patients do not insist on private specialist treatment, fees would not be so high.

In fact, if one compares the specialists' fees here with those in the United States and Hong Kong, one will find that our doctors are not overcharging.

If medical professional fees are to remain affordable, then we have to tackle issues like the high expectations of patients, increased property costs of clinics and rising medical indemnity costs.

Patients should demand to know the cost of professional fees before consenting to procedures. If they feel it is too high, they can seek another opinion as the fees charged by private medical specialists can vary quite a bit.

All the specialists I know do not perform unnecessary procedures for generating income. Granted, there may be the rare case of unwarranted operations but this is very hard to prove when we do not know the specifics of the case.

As for fee guidelines, a patient may value a certain doctor's skills and is willing to pay much more. Where there is freedom of choice, equality of professional charges is unrealistic.

Dr Tang is free to make a complaint to the Singapore Medical Council if he has proof of specialists overcharging or performing unwarranted procedures.

Chong Jin Long (Dr)
ST Forum, 19 Aug 2014

Hard financial realities cut across society

THE recent exchanges on doctors' charges are timely and highlight one segment of society that perceives prices to have gone through the roof.

This may have given the wrong impression that overcharging is rampant. However, the majority of doctors charge reasonably. Those who do not will be found out eventually by patients and insurance companies, and their business will suffer.

"Overcharging" cannot be easily defined when financial counselling is mandatory and all patients know the estimated bill size before admission for procedures. There are also multiple avenues for patients to seek redress, for example the Singapore Medical Council or Ministry of Health, if they feel they have been "cheated".

Where do we expect health-care costs to go if we allow hospitals to be run by publicly listed companies that have to answer to shareholders?

There are hard financial realities, individual materialistic dreams and pursuits driven by society and personal values. These trends cut across society and can be seen in high clinic rentals, lawyers' fees, certificate of entitlement prices and property prices.

Singaporeans really have to be afraid - of our society and not just of doctors' fees.

Yap Chin Kong (Dr)
ST Forum, 19 Aug 2014

Fee guidelines act as 'restraint'

I AGREE with Dr Ong Siew Chey that in a free market economy, self-restraint is rare ("Consider fee guidelines, medical oversight"; last Friday).

Private medical practices are profit-oriented businesses. Without fee guidelines from the Singapore Medical Association (SMA), there is nothing to stop medical practitioners from testing the limits of what the market can bear.

I do not agree that fee recommendations are a guise for price-fixing among competitors. Rather, they serve as a "restraint", discouraging the medical fraternity from raising prices indiscriminately.

Another factor fuelling runaway medical charges is the liberal payouts by the insurance industry, which has seldom challenged overly high medical bills in court. Perhaps this is because it can easily recoup losses by raising premiums.

The Life Insurance Association should study the issue, while the SMA should issue new fee guidelines to prevent overcharging.

Paul Chan Poh Hoi
ST Forum, 19 Aug 2014

Health-care costs can't keep rising

MY LETTER ("Reasons for soaring private health-care costs"; last Thursday) has stirred a hornet's nest. The most vocal critics are doctors who think the party can go on indefinitely - that patients would choose to pay more every year, or insurers would take ever rising claims in their stride.

They should be thankful I have warned of the impending train crash for privately funded health care. Foreign patients have already started to vote with their feet.

Yet other doctors have called me to tell me about even worse abuses of the free market system for doctors' fees.

Dr George Wong Seow Choon ("Medical advances come at a cost"; last Saturday) is correct in many aspects, and it also illustrates how easy it is to be seduced by those who claim that technological advances have changed the practice of medicine.

New and expensive technology still has to be carefully selected for the appropriate clinical circumstance. Video laparoscopic surgery and robotic surgery, including the da Vinci system, have improved outcomes in some instances. Yet unscrupulous doctors can use technology to their advantage.

Several years ago, a very rich patient had a small breast lump removed by the da Vinci robotic system and was billed $70,000 for the surgeon's fee alone. Conventional open surgery would have taken one-third the time at less than one-fourteenth of the price.

Some doctors have claimed I have not kept up with advances in medicine, and that up to 5 per cent of patients with plantar fasciitis will require surgery. The patient I described had open surgery after three days of heel pain and was never offered any alternative treatment.

Honest and ethical medical practice and putting the patient's interest first have not gone out of fashion. These remain elements of an equitable civic society.

It is time for the Health Ministry to seriously monitor and control rapidly rising health-care costs.

The Monetary Authority of Singapore has far greater powers than the Singapore Medical Council, while transport providers are overseen by the Public Transport Council. The Ministry of National Development has even decided that housing should not be left to the free market.

Last year, a visiting Health Manpower Development Programme expert from the United States warned that health-care costs in America could not possibly continue on their present trajectory. Isn't this also true for Singapore?

Tang Kok Foo (Dr)
ST Forum, 19 Aug 2014

Rein in medicine charges at private hospitals

I AM glad Dr Tang Kok Foo ("Reasons for soaring private health-care costs"; last Thursday) and Dr Ong Siew Chey ("Consider fee guidelines, medical oversight"; last Friday) have highlighted some causes of rising private health-care costs.

Another factor is the cost of medicine at private hospitals.

My mother was admitted to Mount Elizabeth Hospital last month with a lung infection.

She stayed in a two-bed ward that cost $326 per night. When she was discharged after 15 days, the bill came up to more than $30,000, excluding doctors' fees and goods and services tax. The "pharmacy" category alone made up 41 per cent of the total bill.

The charges for medicine were extremely high. For example, 20 tablets of Panadol cost $8.80 and two pieces of Mepilex sacrum dressing cost $113.30 - about three times the cost at other pharmacies. A 100ml albumin infusion alone cost $364.21.

We could not verify the amount of medicine administered and had to rely on the nurses' record.

The staff said these charges had been reviewed by the hospital's management committee and were supported by the Ministry of Health.

If private hospitals are given a free hand to determine medicine charges, patients indeed have good reasons to worry.

Can the ministry explain why it allows private hospitals to levy such high charges for medicine? What procedures are in place to monitor charges?

Tan Jiak Hong
ST Forum, 21 Aug 2014

Hospital charges a major factor as well

DR TANG Kok Foo ("Reasons for soaring private health-care costs", last Thursday; and "Health-care costs can't keep rising", Tuesday) attributed escalating health-care costs in private hospitals to doctors' exorbitant charges and unnecessary procedures being performed.

Like Dr Tang, I have been in private practice for some 20 years. And like many of my colleagues, I feel that these are not the main reasons.

As in any other profession, there will be a minority who levy unreasonable charges or perform unethical or unnecessary procedures.

The patient's word of mouth is the doctor's best advertisement, and any doctor foolish enough to rip off his patients will not be able to sustain his practice.

It is also extremely short-sighted for doctors to carry out unnecessary procedures as patients will also find this out in due time.

As Dr Tang has rightly pointed out, patients will vote with their feet, and there is a huge supply of private specialists for them to choose from.

Singapore, however, is an expensive city, and in accordance with the rising cost of running a private practice, it is only correct that doctors' charges be reasonably increased.

One of the main reasons for rapidly rising private health-care costs is the hospital charges. This component of the patient's bill has at least doubled over the past 10 to 20 years. There are hidden charges in the hospital bill that are not obvious to patients.

The fact that the three main private hospitals in the city are owned by one publicly listed organisation is not exactly a healthy situation.

Doctors are able to reduce or waive their charges whereas the hospital management is often very reluctant to give a discount to assist with a patient's enormous bill.

Doctors are also subtly encouraged to discharge their patients or transfer them to another hospital if there is any sign that family members may have a problem paying the bill.

Rising health-care cost is an unavoidable issue but it is not just doctors who are responsible for it. The whole health-care business is involved.

Lye Wai Choong (Dr)
ST Forum, 21 Aug 2014

Huge mark-ups for basic medication and supplies

THE experience from my two stays in a private hospital earlier this year does not bear out the assumption by many Forum writers that doctors' bills contribute most to the rising cost of private health care.

In my case, the hospital's charges amounted to almost 80 per cent of the total bill, while the fees for the surgeon and anaesthesiologist made up around 20 per cent.

One major cause of high medical costs is the mark-up for basic medication and supplies. Examples of what I paid for (before goods and services tax) include:
- $10.61 for a tablet of augmentin (compared with $2.20 at my surgeon's clinic);
- $18.93 for a sodium chloride infusion and $13.63 for hepsal (both used for flushing intravenous devices);
- $4.54 for a safety pin;
- $4.51 for a small foam cup;
- $74.69 for a small abdominal binder;
- $5.12 for six pieces of gauze; and
- More than $50 for using an infusion pump for one day.
The charges levied would not have included any service element as there was already a daily treatment fee of around $150, on top of the charges for room and board (the same amount is charged even when no food is provided).

Moreover, the unit cost for operating theatre/laboratory/radiology charges can vary even though they bear the same service code and description. There is no way to verify any differences in the charges because of the arbitrary manner in which they are levied.

Patients also need to scrutinise their bills and ask for supporting records, to check for any errors.

When I asked for my records, I noticed several errors, including records of medication having been given to me intravenously at times when there was no intravenous line.

Charis Mun (Mrs)
ST Forum, 21 Aug 2014

Doctors capable of self-regulation

IT IS clear that in today's highly complex medical landscape, better guidelines and regulations are required ("Health-care costs can't keep rising" by Dr Tang Kok Foo; Tuesday).

But who should draw up and administer these? I would argue that doctors are capable of self-regulation, both in drawing up guidelines as well as implementing them fairly.

First, doctors clearly care about the reputation of their profession, as shown in the heated discussion of the issue in the Forum pages.

The majority of doctors are proud to be trusted by their patients and know they will lose their efficacy if they lose this trust.

Second, only those in the profession have intimate insights into health-care delivery and its complicated ramifications, given new technology and rising patient expectations.

While non-medical input would help, depriving the profession of the final say would be disastrous in the long term.

If guidelines or rules were imposed by external parties, doctors would not have the sense of responsibility to improve their professional practices and control costs. In fact, they could find ways to circumvent the guidelines.

The problems raised on medical costs came about largely because the medical profession had insufficient say in the matter.

I, therefore, recommend that we take a good look at this thorny problem and that health practitioners, together with representatives from the Government and private sector, be extensively consulted.

Let us not allow a few black sheep to tar the entire profession.

Geh Min (Dr)
ST Forum, 22 Aug 2014

Relaxed advertising rules another reason for rising costs

BESIDES the removal of medical fee guidelines a few years ago, the easing of advertising rules for the medical profession is another reason for the increase in health-care costs.

Until a few years ago, doctors were not allowed to advertise their services on television, in newspapers and magazines, or on the Internet.

Doctors, especially specialists, obtained their patients mainly through fellow doctors' referrals or recommendations from patients. What this meant was that for any doctor's practice to survive, he had to be ethical and competent. If his charges were too high, or if he was known to subject patients to unnecessary tests or surgery, then it was unlikely he would get many referrals.

Now, any unethical or less-than-competent practitioner can still have a thriving practice as long as he advertises heavily.

Thus, easing advertising rules destroyed the built-in mechanism of checks and balances that stopped doctors from overcharging and prescribing unnecessary treatments.

Rising health-care cost is inevitable because of factors like higher rentals, licensing fees, malpractice insurance fees, manpower costs and so on.

However, indiscriminately raising health-care facility charges and doctors' bills as a result of over-servicing, unnecessary investigations or procedures and "abuse" of technology is unacceptable.

The relevant authorities and professional bodies should look into any systemic or regulatory changes that have inadvertently contributed to this trend.

If not, the ultimate losers are not just the patients but also all other stakeholders.

Hospital operators and doctors would lose market share to facilities in neighbouring countries; medical professionals would face rising malpractice insurance premiums; and the public can expect higher medical insurance premiums and health-care costs.

Ultimately, Singapore's reputation as a regional medical hub would be threatened.

Lim Chong Sian (Dr)
ST Forum, 26 Aug 2014

Basic tenet in patient care

DR TANG Kok Foo's comments on the escalation of doctors' professional fees ("Reasons for soaring private health-care costs"; Aug 14) have sparked much debate.

The questions we need to ask are: Is self-restraint really a rare virtue among doctors and dentists? Have they thrown ethics out of the window?

The fact that many doctors supported Dr Tang's cause tells me there is hope among our medical fraternity and self-restraint is still being practised, albeit not across the whole spectrum of medical professionals.

Through the Hippocratic Oath, physicians promise to prescribe regimens for the good of their patients according to their abilities and judgment, and to never do harm to anyone.

We in the medical and dental profession should always fall back on this basic tenet.

Treating our patients well means treating them as if they were our family. We need to ask ourselves: Would we prescribe this same treatment to our parents, brothers and sisters?

Doing no harm means we will not cause physical and emotional damage to our patients by prescribing unnecessary operations and treatments for the sake of lining our pockets.

In a materialistic society, the thirst for more material possessions drives selfish motives that may override our basic desire to do good.

For example, a patient I referred for specialist medical treatment was hospitalised and operated on almost immediately. He consented to surgery because the surgeon warned him of the dire consequences if he did not undergo the procedure.

The patient ended up $25,000 poorer and complained that he was not given time to consider the options. A quick check with another surgeon showed that the same surgery would have cost only half as much.

As physicians, we have to strive to uphold the noble qualities of the great healers we were commissioned to be. Above all, we should never justify our professional fees based on high property prices and labour costs, which form only part of our operating costs.

Dr Wong Chiang Yin wrote in support of re-introducing some form of fee guidelines ("Fee guidelines are like speed limits"; last Thursday). To me, being humane supersedes any fee guidelines. Showing respect to our patients instead of weighing the size of their wallets is the best form of self-regulation.

Eugene Tang Kok Weng (Dr)
ST Forum, 26 Aug 2014

Private hospital charges not under MOH's purview

MR TAN Jiak Hong ("Rein in medicine charges at private hospitals"; Forum Online, last Thursday) quoted staff at a private hospital as saying that the charges at the private hospital "had been reviewed by the hospital's management committee and were supported by the Ministry of Health".

Private hospital charges do not fall under the Ministry of Health's (MOH) purview; private hospitals set their fees independently.

According to the Singapore Medical Council's Ethical Code and Ethical Guidelines, a doctor cannot abuse the doctor-patient relationship for personal gain. This means a doctor shall not let financial considerations imposed by his own practice, investments or financial arrangements influence the objectivity of his clinical judgment in the treatment of his patients.

A doctor shall refrain from improperly obtaining fees from patients, improperly prescribing drugs or appliances in which he has a financial interest, and fee-sharing or obtaining commissions from referral of patients.

To increase transparency and enable patients to make more informed choices, the total hospital bill sizes of 80 procedures in public and private hospitals are published on MOH's website. This will help Singaporeans make more informed choices.

From next month, MOH will also publish the "total operation fees", which is a component of the total hospital bill comprising the "surgeon fee", "anaesthetist fee" and "facility fee" in our public hospitals.

Publishing such data for both unsubsidised and subsidised patients in our public hospitals will serve as a useful point of reference on procedure-related professional fees, which are applicable to both public and private sector health-care providers.

MOH will continue to work to extend transparency of health-care charges to facilitate informed decision-making by patients.

Lim Bee Khim (Ms)
Director, Corporate Communications
Ministry of Health
ST Forum, 26 Aug 2014

Ministry should do more to regulate drug prices

THE Ministry of Health's reply ("Private hospital charges not under MOH's purview"; Tuesday) seemed to miss the points raised in my letter ("Rein in medicine charges at private hospitals"; Forum Online, last Thursday), which highlighted the extremely high cost of medication at a private hospital.

In my case, the price was about three times that charged by other pharmacies.

As a result, medication made up about 41 per cent of my total hospital bill, excluding doctors' fees and goods and services tax.

Hence, I asked why private hospitals are allowed to levy high medication charges, and what measures are in place to monitor such prices.

Another letter ("Huge mark-ups for basic medication and supplies" by Mrs Charis Mun; last Thursday) also raised concerns about the high mark-up for basic medication.

In Mrs Mun's case, the hospital charges amounted to almost 80 per cent of the total bill.

Over the past two weeks, there have been several letters raising concern over high charges by doctors and hospitals.

If medication charges at private hospitals are not under the MOH's purview, then it is time for the ministry to be more pro-active to ensure that basic medication and supplies are not priced excessively.

Otherwise, health-care costs will continue to rise, which in turn affects health insurance premiums.

Ultimately, consumers will have to bear the additional costs.

Tan Jiak Hong
ST Forum, 28 Aug 2014

Pricing: Medication no different from other goods

I EMPATHISE with Mr Tan Jiak Hong's call for the Health Ministry to regulate medicine costs in private hospitals ("Ministry should do more to regulate drug prices"; last Thursday), yet I feel he does not fully understand the nature of medical practice.

Once professional and ethical obligations are fulfilled, medication and medical services proffered are no different from other commodities. They are subjected to market forces and will rise to as high a level as the consumer can tolerate.

One knows the cost of a soft drink or a plate of peanuts at the supermarket, but is willing to pay multiples of these costs in a restaurant. Paying for overpriced medication in a private hospital is similar, distasteful as the comparison between pills and peanuts is.

Private hospitals are capitalistic ventures, and making handsome profits is as much their raison d'etre as healing the sick. They cannot be mistaken for altruistic institutions where profits are secondary.

On another note, purchasing costs of medication for doctors practising individually are far higher than those for pharmacy chains, hospitals or polyclinic pharmacies. These buy in bulk and are offered enormous discounts and bonuses, so that the unit cost is a small fraction of the list price even though the holding cost is high.

Depending on the time of purchase and the varying bonuses and discounts given by drug manufacturers, no two doctors or institutions pay the same price for the medicine stocked.

Whether to pass savings to patients is the vendors' prerogative. But constantly adjusting pricing to reflect the unit cost of different batches of medication is time-consuming and not their top priority.

Yik Keng Yeong (Dr)
ST Forum, 3 Sep 2014

Keeping doctors' high fees in check
There are ways to moderate doctors' high fees in private practice. These include setting fee guidelines and letting private-sector doctors 'give back' their time to the public sector at set public-sector rates.
By Jeremy Lim, Published The Straits Times, 22 Aug 2014

PRIVATE specialist Tang Kok Foo commented in this newspaper that he was "amazed at how expensive it has become to be treated by doctors in private practice over the past five years". He also lamented the practice in the public sector where, allegedly, foreign patients can be surcharged up to 400 per cent standard fees.

Earlier this year, the MediShield Life Review Committee in its report identified "high professional fees" as a key driver of private insurance premium increases.

Are Singapore's doctors charging too much? And if so, what should be done about it?

To begin, I would say that Singapore doctors deserve to be well compensated.

There is a strong public interest in ensuring that enough of Singapore's talented young take up medicine and remain in medicine their entire careers, and compensation is an important enabler for this.

Paying doctors incomes comparable to the average Singaporean's would be insufficient. Doctors inevitably compare their earning potential with those of top performers in other sectors and cannot or will not see themselves falling too far short.

That said, doctors are professionals and a key tenet of professionalism is to put society's interest first.

Spiralling health-care costs driven by high professional fees are patently not in society's interest. There is thus a tension between individual and societal good which needs to be managed.

Costs aside, there is another societal dimension: Fees cannot be so high that the public views doctors as people out to fleece patients. The Singapore courts in Lim MLS vs. Singapore Medical Council (SMC) frames this issue as one where "a doctor is subject to an ethical limit on the level of fees".

So how does one draw the line?

There are lessons from other countries that Singapore can draw from. In the United States, Medicare payments are made to doctors based on Relative Value Units (RVUs). RVUs are computed by taking into account three factors: the physician's work defined based on "time, technical skill and effort, mental effort and judgment, and stress", the expenses of the physician's practice, and professional liability insurance.

This is very similar to how other professions price their services. For example, lawyers typically bill on a per-hour basis and the more senior or the more specialised the expertise, the higher the billing rate.

But use of RVUs and other similar schemes is usually confined to state-funded health care. In the private sector, is it fair and reasonable to price based on the patient's ability to pay? Should health care be a market and services allocated based on ability to pay?

In my mind, the answer is both "Yes" and "No".

"Yes", because a doctor's only "product" for sale in a sense is her time. In the private sector, this finite time going to the highest bidder is not unreasonable. "No", because medicine is a profession and citizens with complex medical needs but without sufficient monies should not be deprived of appropriate care.

Singapore cannot afford to have policies which condone such exclusionary practices by medical professionals on the basis of wealth. This is bad policy and even worse politics.

In concrete terms, what then should be done? Three areas merit further consideration.

Fee guidelines

THE first is to bring back guidelines on doctors' fees.

The Competition Commission subsequently advised the guideline would contravene the Section 34 prohibition of the Competition Act. It further noted that the guideline sought to address information asymmetry but considered that there were "other more effective measures" such as pricing benchmarking and transparency.

While data on hospital charges is now published, in accordance with what the Commission envisaged, for various reasons, data on doctors' fees is not put in the public domain in a way that patients as consumers can find meaningful and use in decision-making.

Meanwhile, health-care costs have increased 10 per cent every year, over the last five years.

The SMC is currently reviewing guidelines for "determining ethical and reasonable medical fees" and recently suggested: "Perhaps the Medical Registration Act should be amended to include a provision to override any competition commission concerns on setting of fees and to allow SMC (or another body) to set fees".

It may be time to bring back fee guidelines.

To keep fees reasonable, a good course of action is to publish doctors' fees data. A compromise is to return to having guidelines on fees.

Fee guidelines can help rein in high fees as the guidelines typically set an upper limit to what is considered reasonable. Doctors who exceed this limit will naturally ask themselves whether this can be justified.

Make medical outcomes transparent

THE second way to rein in professional fees is to make medical outcomes public and transparent.

The science of performance measurement in health care has progressed by leaps and bounds in the last decade. This can enable price-setting based on medical performance or outcomes.

For example, the price of a knee replacement operation at a facility with a high success rate might be higher than that at a facility with a lower success rate.

The world-renowned Cleveland Clinic reports its outcomes data, which is benchmarked against itself and other health-care institutions. In benchmarking against itself, the Cleveland Clinic compares its actual outcomes against what they were expected to be, based on calculation of the complexity of the treatments and the patients' medical conditions.

Hopefully with both policy initiatives and public pressure, doctors and hospitals will start publishing such data. This will help patients make much better decisions, at least in the specialities where such benchmarking is possible.

And if patients are paying more, my guess is they would be prepared to, if they feel they are getting more bang for their buck, in terms of better outcomes.

Let private sector give back to public sector

THE third thing that can be done is for private-sector doctors to "give back" to society by treating patients in the public sector.

What happens if a Singaporean in a public hospital has a complex disease, but the best physicians for that disease reside in the private sector? Rather than have the public sector soldier on and risk poor outcomes, or have the unfortunate Singaporean sell everything he or she has to access the needed expertise in the private sector, it would be better to organise a system in which private specialists contribute back a certain proportion of their time at standard public-sector rates.

I'd like to believe the vast majority of my fellow doctors are honest, decent professionals seeking fair remuneration for their skills and expertise painstakingly built up over the years.

I would venture that most would not be averse to giving back their time to the public sector to take care of complex cases at set rates.

Yes, there are and there will always be a few black sheep. But with fee guidelines and robust outcomes measurement, the medical profession and society at large can take these deviants to task.

Finally, with schemes akin to the legal aid schemes organised by the Law Society of Singapore, we can collectively ensure all Singaporeans can avail themselves of the appropriate expertise when needed.

The writer is a partner in the global consulting firm Oliver Wyman.

Operation fees and doctors' salaries: 'No direct link'
By Linette Lai, The Straits Times, 23 Aug 2014

THERE is "no direct link" between total operation fees and doctors' salaries at public hospitals, Minister of State for Health Lam Pin Min said yesterday.

He explained that this is why the Ministry of Health (MOH) will not be providing a breakdown of total operation fees when it starts publishing them on its website next month.

"In public hospitals, as most doctors are paid a salary by the hospitals, there is no direct link between the total operation fee and doctors' salaries," Dr Lam said.

"Therefore, the data will not be further broken down into the various components, including what would have been called 'doctors' fees' in the private sector."

He was speaking at the Asia Pacific Congress in Maternal Fetal Medicine, held at the Suntec City Convention Centre.

Total operation fees - which make up part of the total hospital bill - sum up how much the surgeon, anaesthetist and the facilities cost.

The MOH announced plans to publish the figures for public hospitals last Saturday.

Currently, it provides only total hospital bills for 80 common conditions in both public and private hospitals.

However, an MOH spokesman said that it will work with private hospitals "to ensure accuracy and completeness of their data... and will publish that data when it is ready".

Dr Lam also highlighted how some doctors had raised concerns over how their peers might be contributing to medical inflation because of "the way (they) practise and charge for their services".

In the light of this, a working committee from the Singapore Medical Council (SMC) is preparing a consultation paper to review the ethical and professional conduct framework for doctors, to reflect the changes in technology, practice patterns, societal norms and expectations.

The SMC said in a statement released yesterday: "The draft guidelines are being finalised and we anticipate that they will be sent to all SMC-registered medical practitioners shortly for their inputs as part of a consultation exercise."

Dr Lam also said the Health Ministry is working with public hospitals to set up medical-device committees.

These will help "ensure rational selection and utilisation of new medical devices".

Similar committees to ascertain the cost-effectiveness of drugs already exist.

"The value of health technology is maximised when it is used for the right patient in the right way in clinical practice," he said.

When doctors' charges cause heartburn
Editorial, The Straits Times, 2 Sep 2014

ONE comment heard in the energetic debate over doctors' excessive charges was that only a small number indulged in the objectionable habit. Whatever the true scale, such conduct contributes to medical fee inflation, as fair-minded doctors have pointed out, to the credit of their profession. Rising health-care costs are common in all of the developed world - the United States is the outlier. Rents, malpractice insurance, diagnostic equipment and improvements in surgery and drug therapy are driving up costs everywhere. Also complicit are the demands of patients, especially those who are endowed with generous medical benefits.

Health-care providers may place a premium on skill but should not gouge. It is unethical if fees are based not on intrinsic worth of the service provided but on what the market can bear. The Singapore regulatory authorities' function is to not only police professional ethics but also help the public make cost-benefit evaluations so medical technology is not used as an excuse to scalp patients.

If overcharging is anywhere near rampant in private hospitals and among specialists in hot disciplines, the Health Ministry would be expected to intervene as a prerogative in promoting patient welfare and to ensure Singapore does not price itself out in the competitive field of medical tourism. Europeans are seeking elective treatments and health screening in India, Thailand and South Korea. Why not Singapore? Wealthy Persian Gulf countries that pay fully or partially for citizens' cancer treatment abroad have a choice of countries now.

It is important to ensure the free-market ethos in health care is not manipulated such that the Government's compact with the people on affordable health care is betrayed. Holes will otherwise be blown in the national health insurance scheme and system of subsidies in public hospitals and private clinics.

Two acts should be undertaken without delay. The more urgent is a review of the use of doctors' fee guidelines to act as a regulatory brake on arbitrary charging. These had once been ruled in breach of the competition code but circumstances have changed. Doctors who weighed in on the matter are in favour of fresh guidelines as a reference point, like the published price comparisons on surgical procedures performed in hospitals.

Next, hospitals' charging protocols for facilities, medicines and consumables should be made more transparent to prevent ruinous runaway inflation. The Health Ministry's move yesterday to publish data on how much operations cost in public hospitals is another welcome step in this direction. Free enterprise in health services differs from goods commerce in that patients leave matters of efficacy and fair recompense to the judgment of the service provider. The implied trust should not be abused.

Doctors v doctors: What's ailing them
Action must be taken to curb overcharging and ensure industry is in the pink of health
By Han Fook Kwang, Editor At Large, The Sunday Times, 14 Sep 2014

When doctors complain that their own profession is responsible for the escalating cost of health care, it is time to take notice.

We have heard these stories before, of physicians charging excessive fees or ordering tests that seem unnecessary.

They were mainly anecdotal, from unhappy patients who did not know better, and usually spoken about in hushed tones.

But when it is doctors themselves telling on their own kind, and doing it so visibly in The Straits Times Forum pages, you know there must be more to it.

Almost 40 letters were received on this issue, of which 13 were published.

It looked like open heart surgery of the medical profession was taking place in public, and the patient has not recovered yet.

The first incision was made by Dr Tang Kok Foo in a letter published last month, and his words were so cutting that his instrument of choice appeared more chopper than surgeon's scalpel.

He wrote: "I am amazed at how expensive it has become to be treated by doctors in private practice over the past five years. The surgical fee for simple lumbar disc surgery has shot up from $5,000 to as high as $25,000, even when performed by junior doctors.

"An ear, nose and throat surgeon once told me that since the Government abolished guidelines on professional fees, he has been competing actively with his colleagues to see how high his fees can go.

"The professional fee system in public hospitals, where foreign patients can be surcharged up to 400 per cent, is a good 'training ground' for doctors charging higher fees when the market can bear it."

Ouch! You could almost smell the blood on the floor.

Another doctor offered this anecdote: "A patient I referred for specialist medical treatment was hospitalised and operated on almost immediately. He consented to surgery because the surgeon warned him of the dire consequences if he did not undergo the procedure. The patient ended up $25,000 poorer and complained that he was not given time to consider the options. A quick check with another surgeon showed that the same surgery would have cost only half as much."

But not all pointed their knives at unscrupulous doctors. Several said it was unfair to blame the profession and cited other reasons: Advances in expensive medical technology, demanding patients who insist on specialists' care and the removal of medical fee guidelines.

Still others blamed ever rising hospital charges.

So, what to make of this very public spectacle of doctors washing their dirty instruments in public?

There are several issues of public interest.

First, there will always be black sheep in any profession.

If the examples cited were merely the result of some mis- guided doctors, the problem would be of limited concern.

But if there are features in the health-care system that encourage this type of behaviour, and the tendency is likely to increase in the future, remedial action is called for.

Are there?

I can think of at least two recent developments that have aggravated the problem.

First, medical insurance, which is now being extended to everyone, can lead to escalating costs.

When doctors know that the patient's bill will be covered, fully or partly by insurance, there will be a tendency to do more - more tests, and more expensive treatment.

Why worry when it is paid for by a third party?

A friend told me this story he heard of a doctor, who was being treated for a medical condition, telling the attending surgeon to charge a bill of $100,000 as he was fully covered by insurance.

I don't know if the story is true, but I can see how having insurance coverage can alter behaviour and distort costs.

Measures should be put in place to ensure that it does not lead to these undesirable effects.

Second, and this is peculiar to Singapore, the promotion of the country as a medical centre for wealthy foreigners can have se-rious repercussions for health-care costs.

There is a huge demand among the well-to-do in South-east Asia for first-class medical treatment, and Singapore's health-care system fits the bill because of its high and proven standards.

But medical resources are limi-ted, especially the number of specialised doctors, and a steady inflow of rich foreign patients can not just overload the system, but also lead to a culture of overcharging.

In his letter, Dr Tang cited the professional fee system in public hospitals which allows doctors to impose a surcharge of 400 per cent on foreign patients.

That is an incredibly attractive financial incentive, and I would not be surprised if these hospitals try to get as many of these foreigners as possible.

Could the health-care system here be experiencing the same problem the property sector faced before the Government acted with its cooling measures to dampen the demand from foreign buyers?

I hope this isn't the case, but the fact is that medical tourism was promoted very strongly at one time as one of Singapore's econo-mic strategies.

What can be done to prevent doctors from overcharging?

Some of the interesting suggestions I have heard include making it compulsory for specialists and hospitals to send to the Health Ministry the total bill of every patient.

The possibility that the authorities may investigate unusually large bills should act as a deterrent.

Another sensible idea: Institute a whistle-blower system, much like what is now commonplace in many commercial and public organisations.

Some people might believe that rising costs in the private health-care system isn't really a public issue.

It is a free market, and people have a choice between going private or choosing a government restructured hospital where costs are controlled by the authorities.

This is a mistaken view because what happens in the private sector will affect the public health-care system.

The most serious effect is when doctors in public hospitals leave for private practice because of its financial attraction.

Recently, the spine unit at a public hospital here had to close because its entire team of doctors left for private practice.

If it wants to continue operating this branch of medicine, it will need to attract these or other specialists back, thus raising the cost of the public health-care system.

The incident shows how di-rectly public hospitals are affected by what takes place elsewhere.

I believe the majority of doctors are motivated not by money, but by a higher calling that made them want to practise medicine in the first place.

But the environment they operate in and the prevailing culture can significantly affect their behaviour.

These are issues that the professional bodies responsible for their code of conduct, the Singapore Medical Council and the Singapore Medical Association, ought to look into.

Ultimately, doctors themselves have to ensure they meet the highest ethical and professional stan-dards expected of them.

The rest of us can only hope they do not fall short.

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