Tuesday, January 29, 2013

Revisiting co-payments

Co-payments are sacrosanct in Singapore healthcare. Since the debut of co-payments in government polyclinics in 1960, the application of co-payment has been extended to virtually all healthcare services.

28 Jan 2012, Today

Co-payments are sacrosanct in Singapore healthcare. Since the debut of co-payments in government polyclinics in 1960, the application of co-payment has been extended to virtually all healthcare services.

Why co-payments? The economic literature is rich with insights on the utility of co-payments and there are very good reasons for co-payments, but not in every healthcare setting and definitely not as an unthinking blanket policy.

In the Singapore setting, the most important objectives are probably mitigating moral hazard and optimising limited government monies. Let us examine them and explore whether and how co-payments can be re-looked.


Moral hazard is the phenomenon where patients consume more than they should because someone else is paying. The 1993 White Paper on Affordable Health Care states emphatically: “To avoid the pitfall of ‘free’ medical services stimulating insatiable demand, patients pay directly for part of the cost of medical services which they use.”

As for targeting scarce subsidies, even the richest governments have finite resources, and Singapore is no different. Imposing co-payments enables some degree of cost recovery.

In Singapore, cost recovery has been substantial with government spending on healthcare today making up roughly a third of total system spending, and private monies comprising the other two-thirds.

This is the reverse of many developed countries, which, while critics decry as economically regressive, likely in no small measure contributes to the Singapore Government’s healthy finances — especially when contrasted with many European countries struggling to meet pension and other public service obligations.

Are there downsides to co-payments? Ultimately, co-payments are a tool, a means to an end. The “end” here would be appropriate, financially responsible health service utilisation.

Co-payments should dissuade over-consumption, burdening of the state and extending waiting times for everyone else, but should not discourage medically necessary care and definitely not cause patients to fall into the crevice of medical bankruptcy.

Easier said than done. Co-payment application must evolve as society evolves and as policy makers understand better behavioural sciences and their applications in public policy.


One way to conceptualise health services is to categorise them in five areas: Preventive care, acute ambulatory care, hospital services, long-term care and palliative care. Are co-payments as a policy instrument equally relevant in all five areas?

In acute care and hospital services where patients are in pain, co-payments make sense for the reasons cited above, and genuine patients generally would not defer care for financial reasons.

Co-payments also help to discourage over-consulting which can be seen in comprehensive insurance schemes. In countries with very low co-payments, physician consultations per citizen are significantly higher than in countries with higher user fees.

In preventive services such as cancer screening and regular diabetic follow-ups, co-payments are less useful and perhaps even detrimental. Citizens are already reluctant to seek healthcare due to the “silent” nature of their conditions and in screening, we are trying to motivate perfectly asymptomatic people to subject themselves to uncomfortable measures such as mammograms and Pap smears.

In Singapore, only 40 per cent of women undergo regular mammograms, a far cry from the 70 to 80 per cent needed for effective national screening. Co-payments are arguably not needed here as the inherent behaviour is already avoidance, and the financial outlay just adds one more “reason” to defer care.

Is it then to conserve subsidies? That would be penny-wise and pound-foolish. Screenings and good control of chronic conditions are meant respectively to detect disease early and prevent complications, which save individuals and society money in the long term.

What about long-term care? Poorly utilised and delivered long-term care services simply drive patients into hospitals with complications such as bed sores and lung infections. Again, blunt imposition of co-payments is being penny-wise and pound-foolish.

Some degree of co-payments is useful to reinforce responsible service utilisation and appreciation of the true costs of services, but co-payments cannot be so high as to deter appropriate care and encourage cutting corners.


Finally, let us look at palliative care. Often patients would have spent much of their life savings by the time they reach this stage, and co-payments may impede acceptance of such services.

In palliative care which emphasises so much holistic care and dignity, conserving subsidies through an intrusive means test involving siblings and children and detailed inspection of family incomes is simply bad practice.

As for moral hazard, can a dying man over-consume palliative care services? St Christopher’s Hospice in England, the birthplace of modern palliative care, has not imposed co-payments. Why not? Surely it would make the service more efficient and help the staff spend less time fundraising?

Founder Dame Cicely Saunders, spiritual leader of the palliative care world until her death in 2005, said: “You matter because you are you, and you matter to the end of your life. We will do all we can not only to help you die peacefully, but also to live until you die.”

Co-payments in healthcare are a powerful policy tool. Applied appropriately, they drive economic and operational efficiency, enabling services to function well with reduced wastage and over-consumption. Applied blindly as a matter of ideology, they can be ruinous to the humane functioning of our healthcare system.

Dr Jeremy Lim has held senior executive positions in both public and private healthcare sectors. He is currently writing a book on the Singapore health system. This is the third in a series on health policies in Singapore.

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