Sunday 3 March 2013

Transform the way health care is delivered

Focus funds on preventive health, primary and extended care: Expert
By Goh Chin Lian, The Straits Tmes, 2 Mar 2013

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.





Health sector needs to radically innovate, now
Healthcare infrastructure is so lagging, there may be opportunities for radical innovation
By Jeremy Lim, Published TODAY, 1 Mar 2013

Singapore is short of healthcare resources. We need 32,000 additional healthcare professionals by the year 2030 to care for our rapidly ageing society, a 70 per cent increase over today’s workforce. We currently have about two hospital beds (both acute and extended care) per 1,000 population, which pales in comparison to the Organisation for Economic Cooperation and Development average of five beds per 1,000 population.

What can we do then? We cannot lower our standards or compromise the health of our citizens, and must raise our productivity.

We know we face, and will continue to face, severe manpower and infrastructure shortages. If we do not radically innovate and enable Singapore healthcare providers to do more with less people, fewer beds and so on, we will pay a price in human life.

To avert this, the generous monies provided for the Ministry of Health in this year’s Budget, to the tune of S$5.7 billion (an 18-per-cent increase from last year), must be well spent.

The often-quoted labour saving efforts, such as mechanical patient lifters in nursing homes reducing the number of attendants needed, or a pharmacy packing robot, are really only incremental innovations. Can we do better?

MORE HEALTH, LESS HEALTHCARE

A pivotal insight is that healthcare providers offer “healthcare” but what patients really want is “health”. How can we have more “health” even if this actually means less “healthcare”?

Productivity cast in this perspective cannot be about squeezing more patients into an already overbooked clinic session, or pharmacists being able to dispense medicines to 25 patients when they were previously able to only do 15. It has to be about achieving the same objective, “health”, and being agnostic about the means.

Here are some examples from around the world to stimulate our imagination:

• Chronic Disease Management

Does a stable and well-controlled hypertensive patient need to physically consult her doctor every two or three months? Would a virtual consult or even a computer-augmented self-management regime suffice in between annual visits to her physician?

Years ago, I had the privilege to visit Kaiser Permanente, a world-renowned Californian integrated care provider.

I asked my host: “How often does a well-controlled hypertensive patient need to physically consult?” His response: “Never, we can do everything remotely through the Internet or over the phone”.

He added that during the annual in-person general preventive health screening consultation, high blood pressure control could be discussed. Almost a quarter of the Singapore adult population has high blood pressure. Imagine how many physician visits could be obviated.

• Minor Ailments

The average person is afflicted with “flu-like” symptoms maybe four to six times a year with the vast majority being minor and self-limiting. How do we know which ones are “minor”?

England has a remote care service called NHS Direct where members of the public can consult over the telephone or online and as necessary, decide whether an in-person consultation is warranted. Do patients want “impersonal” remote care? Well, yes, four million calls and 10 million online consults a year are made for all kinds of symptoms.

The ecosystem has to exist to support this, and by ecosystem, I mean pharmacies where members of the public can purchase medicines for treatment of common ailments without a prescription, and a societal model where workers can call in sick without the need for medical certification at least some of the time.

Singapore has more than 3.36 million persons in the workforce; multiply this by, say, five minor illnesses a year, and that is almost 17 million consultations per year. Can patients self-manage select conditions with some help and minimise the strain on our healthcare system?

• Specialist Referrals

Certain specialties such as dermatology are highly visual. Can a dermatologist provide advice remotely to a family physician instead of having the patient moving back and forth, creating additional visits? Sure. In the University of California Davis, dermatologists treat patients from 32 remote sites in California via “live interactive” teledermatology.

In Singapore, 5 per cent of all GP visits are for skin-related ailments. How many progress to specialist referrals, and of these, how many could have been avoided by enlisting teledermatology?

A NATIONAL TELE-HEALTH STRATEGY?

Technology adoption does not occur in a vacuum. Premium cars will struggle if roads are rudimentary and signage is absent. In the same way, while technology (and especially tele-health) has tremendous potential to revolutionise the way we deliver healthcare and enable Singapore to mitigate our infrastructure shortfalls, the Government has a key role in building the roads and organising street signs.

What is needed, and quickly, is a national tele-health strategy that establishes standards for appropriate remote practice; enables viable business models so that private enterprise can bring its creative energy into the fray; and empowers patients and healthcare professionals to do the right thing for themselves, and for the country.

The Government has announced it will “build infrastructure well ahead of demand”. Infrastructure is not just beds or buildings; it also includes the policy and legal frameworks necessary to realise productivity and innovation. Let us start doing things differently — we have to.

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 part of a series on health policies in Singapore.

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