Friday 7 September 2012

An 'ethical limit' to doctors' fees?

By Salma Khalik, The Straits Times, 6 Sep 2012

DR SUSAN Lim's court case next January will be followed with keen interest for a variety of reasons - there is the celebrity halo from the involvement of royalty, a well-known surgeon and multimillion-dollar bills.

The most far-reaching ripples from the case, however, will go beyond the personalities involved and test a key question: Is there a limit on what a doctor can charge his or her patient?

The Singapore Medical Council (SMC) says there is a limit, and in the opinion of three of her peers, Dr Lim overstepped it when she charged a fee of $26 million to treat the sister of Brunei's Queen for seven months before the patient died in August 2007.

Following a complaint from the Health Ministry, the SMC stepped in with an inquiry. Its disciplinary committee fined Dr Lim $10,000 and suspended her for three years - the maximum penalty, short of stopping her from practising altogether.

Dr Lim is launching a legal challenge to the SMC's decision, including, among other things, the SMC's evocation of an "ethical limit" to fees doctors may charge.

The SMC has not elaborated on what the limit might be, or how it arrived at this concept. The phrase itself is little-used in Singapore.

The notion of a limit on fees is not new. In 1987, the Singapore Medical Association produced a set of guidelines on charges. These were in the form of advisories: For example, certain fees were stipulated for "long consultations" or for "short consultations". While these served as a guide for both doctors and patients, they are far from the detailed fee guidelines that can run into a couple of hundred pages, found in jurisdictions like Canada.

But even these non-binding guidelines were scrapped in 2007, when they were found to contravene the Competition Act.

An appeal to have them reinstated on the grounds that the medical profession was of a "unique nature" was rejected in 2010. Explaining that decision, Mr Teo Eng Cheong, the then chief executive of the Competition Commission of Singapore, said it was difficult to set a price that could be considered a "right or reasonable" level.

Since this episode, doctors in the private sector have been practising on the assumption that market forces apply - in other words, that fees are an arrangement between doctor and patient, on a "willing buyer, willing seller" basis.

That assumption is now set to be tested. No matter whether the appeals court upholds the SMC's premise of an ethical limit or disallows it, it will have a spill-over effect on how medicine in the private sector is practised. There may be a fallout in other professions too.

The SMC disciplinary committee's statement contends that all professionals, not just doctors, are bound by ethical limits on what they can charge. To quote from its written decision on Dr Lim's case: "It is one of the essential hallmarks of a profession that a member of a profession who sells her professional services to the public accepts an ethical obligation to limit what she can charge for those services to what is a fair and reasonable fee for those services."

Should the court disagree that there is an "ethical limit" on what doctors can charge, its decision will implicitly endorse the current scenario, where one doctor is well within his rights to charge 10 times more than another for the same procedure, so long as the patient is willing to pay for it.

Doctors have their own reasons to charge for what they do. Fees can reflect their expertise, their brand name, even their bedside manner. Some feel justified in charging a high fee to wealthier patients to offset the pro-bono services they render to poor patients. For others, a high fee rations demand, preventing long queues.

Without a limit on fees, it becomes extremely difficult for patients to make a case that they have been overcharged.

Of the 10 complaints to the SMC about overcharging by doctors between 2001 and 2010, no inquiry or action was taken in eight cases. In one case, a letter of advice was given to one doctor, with no formal inquiry into the case.

The fact that only 10 complaints arose in the last decade might also be taken to suggest that the laissez-faire system works, and that patients are prepared to pay what doctors ask.

On the other hand, should the court agree that doctors should abide by an "ethical limit", patients could have greater recourse to make complaints of overcharging.

But for doctors, setting the right fee will then be a veritable minefield. Discussing it with their peers would breach the Competition Act, as it suggests price fixing.

For a limited indication as to what they can charge, they can turn to the Ministry of Health's website, which publishes actual bill sizes at different hospitals.

But it lists only about 70 procedures, in a profession with hundreds of them. And to compound the difficulties, these bills already differ from hospital to hospital.

How much of a premium can a nicer ambience, shorter waiting time, modern equipment and a "brand-name" doctor command?

Twice the norm? Five times? Or even more than 10 times, as is sometimes the case now?

The question will remain hard to settle. The SMC does say that a doctor with greater expertise and seniority can charge more, but it does not indicate how much more.

Even informing the patient of the higher fees charged at a particular clinic or by a particular doctor will offer little protection against an accusation of professional misconduct if the concept of an ethical limit applies.

After all, the SMC committee holds that this "ethical limit" supersedes any contract between the doctor and the patient.

Theoretically, this could open the door to a flood of complaints from patients who knowingly choose an expensive "top" doctor, only to turn around and accuse him of overcharging after undergoing the procedure.

And on the flip side, any doctor can mark up fees using the "ethical limit" as a signal that it is not only safe to do so, but also "ethical". That would certainly push up health-care costs.

Whatever the outcome of the case, it may be worthwhile for Singapore's medical fraternity and policymakers to examine whether more information can help level the doctor-patient equation.

The Health Ministry, for example, could expand its portal on actual bill sizes, to include itemised costs. Doctors would no longer need a "spy network" to figure out what others are charging.

Such information would empower patients to make choices befitting their situation and expectations.

And with ready information on what the norm is - which was not the case with the Brunei patient - both doctor and patient have the requisite information to agree on a higher fee if they wish. There would then be no need for the SMC to step in to monitor their fee agreement.

In such a set-up, doctors set fees with good knowledge of the competitive market. Patients make decisions knowing what alternatives they have if they reject one doctor's fee proposal.

This way, patients themselves can rein in overcharging better than ethical limits to fees.

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