Tuesday, March 5, 2013

Transform the way health care is delivered

Mar 02, 2013

Focus funds on preventive health, primary and extended care: Expert

HEALTH-CARE expert Jeremy Lim, 40, used to work on health-care policy and financing when he was executive director of the SingHealth Centre for Health Services Research.

Now principal consultant of Insights Health Associates, Dr Lim is writing a book on Singapore's health-care system and teaching a course on health-care management at the National University of Singapore.

He talks to The Straits Times about the review of health-care financing raised in Deputy Prime Minister Tharman Shanmugaratnam's Budget speech this week, which includes reducing out-of- pocket payments and broadening insurance coverage.

  • What ails Singapore's health-care financing?

Singapore's model attracts attention as total health-care spending - less than 4 per cent of gross domestic product - is very low compared to most developed countries and outcomes such as life expectancy and infant mortality rate are pretty impressive.

That said, the underpinning philosophy of individual responsibility and family as the basic social support unit is increasingly challenging for three reasons:

Change from acute illnesses to chronic diseases with much higher lifetime spending, largely outpatient punctuated by short inpatient admissions for acute complications.

Health-care inflation has far outstripped wages, especially for the lower-income groups, and it is no longer realistic to expect citizens to have sufficient savings.

Families are smaller and "risk-pooling" within families is in the main no longer possible.

The emphasis on hospitals and government intervention to keep hospitalisation affordable, with citizens bearing outpatient costs, needs to evolve.

  • What do you think of the broad strokes that DPM Tharman sketched for the review?

I was hoping he would highlight how government funds would be more strategically managed to enable a fundamental transformation of the way we deliver health care and promote health.

It's time more attention and funds were focused on preventive health, primary care and extended care, meaning rehabilitation, nursing homes and the like.

As long as hospitals are more heavily subsidised than primary or long-term careand it makes perfect economic sense to patients and their families, they will make societally sub-optimal decisions like staying hospitalised in a restructured hospital longer than needed, spurning home care for nursing homes.

Most hospitals and doctors are paid when patients are unhealthy. The unsung heroes who work to keep the population healthy are not well-paid. One could question whether the social good that plastic surgery, orthopaedics and ophthalmology create is so much higher than what a geriatrician or a palliative care physician would offer. The Government, as the largest health-care provider, should be more active in determining market salaries for certain specialities. Its policy intent is to have a healthy population. But the finances are not congruent with the policy intent. A lot of primary care, where preventive health is largely delivered, is out of pocket.

We are so wedded to the idea of co-payment, we insist on it for mammograms. This is unenlightened because women don't want to go for mammograms.

And it's hard to get patients to adhere to screening schedules or chronic medicines when they feel well. More strategic subsidies with lower co-payments or doing away with co-payments would be very helpful. It may even be less expensive in the long run.

The state is not enthusiastic about paying for your care until you've got a heart attack, go to the hospital, and the Government gives you an 80 per cent subsidy. Why don't they take some of the billions of dollars they put into hospitals to strengthen primary care, so that citizens feel that it is affordable and accessible?

Living in Britain, we had one child. Britain is strong in community services. Nurses call us up: "Has the baby gone for vaccination? How is the appetite?" They make home visits to make sure the home is safe.

We don't have these measures by and large because we don't pay for them. The willingness of patients and citizens to pay is not high, but that's why Government (has to) step in.

  • How may the out-of-pocket share of costs be reduced?

First, redistribute the costs of health care and financial risks arising from a major illness. Second, lower the unit cost of health care... through more efficient use of resources and minimising unnecessary health care.

It is clear we have taken the notion of "individual responsibility" to extremes without providing a sufficient safety net for catastrophic health-care costs.

Co-payments are the correct policy tool to mitigate over-consumption, but not having caps on individual spending means that in the event of ballooning bills, patients have to worry about payment as they strive to recover.

Medifund can help, but it is approved post hoc and does not reassure. Our schemes place excessive risks, that should be borne by the state, on individuals and families.

Most European countries have co-payments capped at a percentage of the individual's income. They say: "We want you to feel the pinch, but you won't go bankrupt if you need health care."

When I was in the public hospitals, some elderly patients would decline curative treatments. They are worried about money, but have too much pride to say: "I can't afford it. I'll wipe out the inheritance I've spent 40 years (building up) to give to my children."

In our system, we are asking parents for a trade-off: Do I want to give my children a better life, or do I want to selfishly think of my own health as a 75-year-old?

No one can assure them the Government or someone will help bear the cost without touching something personal like the family home or nest egg they are leaving for the next generation. They go home and we never hear from them again.

We have a hospital-centric, doctor-heavy health-care model. We need to explore greater use of technology: tele-health to support self-care and home-based care, and physician substitutions for routine and less complex care.

In many countries, individuals self-medicate independently or do so with the help of a national telephone or Internet helpline.

For well-controlled chronic diseases such as high cholesterol and blood pressure, must the consultations be in person with a doctor?

A significant amount of health-care spending is from employer benefits, which hurts the elderly and unemployed most. For them, the individual share can be more than half: They have no employer benefits, Medisave dollars may be meagre and they may be struggling with other expenses.

  • How may you broaden insurance cover but not adversely raise premiums?

A World Health Organisation report makes a strong point that efficient health insurance has to be mandated, because of all the problems as healthy people opt out and unhealthy people opt in.

It's worthwhile for the Government to think about a more inclusive MediShield. We've started to include children with congenital illness. Every newborn is included in MediShield unless parents opt out. The logical next step is to nationalise and bring everyone in, because if you fall on hard times, don't pay premiums and drop out, it means we're leaving segments of the population vulnerable.

In Singapore, we've prided ourselves on individual responsibility and now the Government is calling for a total review, so how sustainable does that suggest our health-care system is? It's not just financial sustainability. It has to be politically resilient also.

For all the faults of Britain's National Health Service, Taiwan's National Health Insurance, the Germans' social insurance, (they've) been remarkably resilient from a political point of view.

They may have to cut back on benefits so that it's a sliding scale based on how much money the government has, but nobody has deviated away from the principle that health is a human right, that the state should do what it can to offer everyone fair innings.

I don't think it's a bad thing if premiums go up, or if the Government pays the premium for a segment of the population that cannot afford to. That's what places such as Thailand, Taiwan and South Korea did when they implemented universal health care.

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