Need for Guideline on Medical Fees : Aftermath of Dr Susan Lim case

Dear Friends
The letter below was published in the Straits Times Forum page (4th July 2013).

Revisit need for Fee Guideline

THE verdict of the Court of Three Judges, in dismissing an appeal by Dr Susan Lim against her professional misconduct conviction by the Singapore Medical Council (SMC), brings about a welcome closure to a contentious issue that had split the medical fraternity into two opposing factions (“Surgeon Susan Lim loses appeal”; Tuesday). Click here for background.

(Until the verdict was finally made known, no one had any inkling on which side of the fence the ruling would fall. Anyone who said “ I told you so” either had inside information or is a liar.)

 The “free market” proponents have no qualms about charging what they think is the “market rate” as, to them, medicine is just another means of making a living, and as patients come to them of their own volition.

“Caveat emptor” (let the buyer beware) being a dictum that is repeated ad nauseum, they think it must be permissible to charge what the market can bear. After all, in materialistic Singapore, is not wealth the main measure of a doctor’s true worth?

 The opposing faction is made up of the “traditionalists” whose most conservative members frown upon all forms of advertising. To them, medicine is a noble calling that is different from other professions, and it is crass to even promote one’s practice.

 Patients will find them by word of mouth, hence advertising is superfluous at best and a tool for false representation at worst.

 The appellate court has decided that “a doctor cannot rely solely on the morals of the marketplace” and that there is “an objective ethical limit” on medical fees, in both private and public health care, that operates outside of contractual and market forces.

 Doctors, especially in private practice, now face a very real problem. What is this proverbial “ethical limit” that has been bandied about? What may seem like a reasonable fee to one might appear to be “fleecing” to another, thereby leading to unnecessary complaints to the SMC.

There used to be a fee guideline published by the Singapore Medical Association (SMA), but this was scrapped in 2007 as it was deemed anti-competitive by the Competition Commission of Singapore.

(The GOF was mooted in the early 1980s when the Ministry of Health, the SMA and the Association of Private Medical Practitioners of Singapore felt a need to publish a fee schedule to provide greater transparency for patients. )

 It is surely timely to revisit the need for such a guideline.

 The Academy of Medicine, SMA and the Health Ministry should also come together to provide answers to the perplexing question of what the “ethical limit” is.

Huang Shoou Chyuan (Dr)

PS: Edited out parts in (brackets)
I had blogged on this issue several times and had some letters published in both Straits Times and Today
1.Click here
and
2. Here

How to shorten long A & E queues? - Patients referred from GP/Polyclinic should get 50% discount

 Dear Friends,

This is a suggestion to shorten the never-ending queues at the public hospital’s Accident and Emergency Departments that may be worth considering. Sometimes the queues can be longer than 4-5 hours ( not exactly a first world standard?).

I want to emphasise that obvious serious emergencies such as symptoms of heart attacks and major trauma ( eg broken bones)- of course should go straight to the A & E and I trust that the staff who do the triaging ( filtering) at the reception will get the doctors to treat these immediately. It is the rest ie not obvious emergencies- eg giddiness, fevers, pain here or there etc that I think may consider seeing the GP or Polyclinic. If the doctors at the GP/Polyclinic then direct them to A&E as they are deemed emergencies needing urgent and early intervention, then these should get a 50% ( or whatever sum) discount. Hence the total sum of someone who sees a GP + A&E ( referred) should be less than the flat fee of A & E ( direct self-referral). Eg Flat fee of A & E now ( approx $95), new amended sum ( if accepted) should be ( $43 + $25-30 ( GP’s fees)).

I did not add, that referred patients should join a fast-track queue also…

Addendum (19.1.13- same day)
Another non-emergency source of A & E attendance are the patients who go there to get referral to specialist clinics at the public hospitals.  Referrals to specialist clinics from A & E and polyclinics are considered subsidised and enjoy discounts whereas patients referred by GP's are automatically considered as non-subsidised and pay ( often substantial) full rates even if the patients are obviously poor. Those who are referred by GP's , and who then try to appeal to be downgraded to subsidised rates have to go through a sometimes demeaning process where they are interviewed by Medical Social Workers who pry into household incomes etc to see if there are any rich members in the family etc and hence do not deserve subsidies ie the Means test. This is the subject of another letter to the press...
 

Click here for the published letter ( which was edited slightly). Here

Below is my original letter.

Cheers,

Dr Huang Shoou Chyuan

Unabridged Letter

Dear Editor,

I wish to lend my support to 2 recent letters writers (Lower A&E fees for referred patients: Ms Soh Ah Yuen ) and (Why non-emergency cases throng A&E departments:Ms Wong Jee Kiat ) who suggested that patients referred to the Accident and Emergency Departments ( A&E) of public hospitals ( by GP’s and polyclinics respectively) should get a discount from the flat fee charged to patients who “referred” themselves there directly.

This is a sound proposition as one of the major reasons why patients (even emergency cases) need to wait for several hours before being seen by attending doctors is that despite best efforts at triaging patients at the reception area to identify patients who have life or organ-threatening conditions (eg heart attacks; airway obstruction) , many others with less dire emergencies but still require timely intervention nonetheless ( eg semi-acute bleeding from internal organs) are left to wait in the queue together with many who obviously do not have urgent conditions (eg patients whose companies do not recognize GP’s Medical Certificates (MC); mild diarrhoeas).

 

To incentivize patients to see GP’s and Polyclinics first , patients who have been screened by doctors at family clinics and polyclinics and deemed as emergencies that require urgent intervention at public hospitals through admissions at A & E, should get substantial discount from the said flat fee. This sum must be significant enough or else the thought of paying at the GP’s followed by paying almost the same A & E flat fee again if referred to A&E will not be any incentive. I suggest 50% discount so that together with fee from the GP or polyclinic ( if referred back) – will still be lower than the original flat fee.

 

The advantage in this system is that :

1.     Many who would have otherwise joined the throng at the A & E , would have been treated and followed up at the GP’s / polyclinics with no untoward effects to themselves

2.     Less non-urgent cases in the A & E queue would allow more accurate triaging ( which is still needed) and more expeditious treatment of whole range of dire to semi-urgent emergencies.

3.     This also has added advantage of increasing the work load at the GP’s ( which is good and may dissuade some from embarking on non-conventional branches of medicines e.g. Aesthetics)

 Other measures that MOH/MOM can consider include not allowing companies to only recognize MC's from A & E and not those from GP’s as the latter are bona fide SMC-qualified doctors.

A further disincentive ( but may not be politically-palatable) may be to surcharge those who ( even by any stretch of imagination) can consider themselves as having an emergency ( eg mild rashes with no associated organ symptoms etc) .

 

Unfortunately, there will be an increase in attendence at polyclinics who may need to beef up their staff numbers but their consolation would be that they have contributed to emergency cases being better treated at the A & E’s!

 

Dr Huang Shoou Chyuan

Punggol East elections- reprise of Romance of 3 Kingdoms?

 

Dear Friends,

Events at Punggol East a reprise of Romance of the Three Kingdoms?

The events at Punggol East in the past days fascinates a neutral like me as they remind me of a period in Ancient China (first and second century AD) when the great Han dynasty was crumbling due to various reasons including palace intrigues by shadowy eunuchs and inept emperors. The ensuing civil war threw out legendary figures that remain forever etched in common folklore.

This period is characterized best by Luo Guanzhong’s classic novel “Romance of the Three Kingdoms” . Click here , here and here.  In attempts to resurrect the Han dynasty, 3 main protagonists from the 3 rival states of Wei (North) , Shu-Han (West) and Wu ( South) played key roles in this troubled time:

1. Wei state’s Cao Cao, the Prime Minister who usurped the authority of the Han by using the young Emperor Xian as a puppet as he is kept like a bird in a “gilded cage” in his capital Xu Chang

2.Shu-Han ’s Liu Bei , who though only a shoe maker ,was popularly acknowledged as “royal uncle” as he had royal blood and could trace his lineage to the Han emperor and hence had legitimate claim to the throne and

3.Wu’s Sun Qian , who though barely a teenager, was of great intelligence, foresight and rectitude.

All of us of course know the complementary roles played by other legendary figures like Guan Yu (dietified as a god), Zhuge Liang and Zhou Yu etc.

The horse trading reported in the media of the present pre-election period at Punggol East brings to mind what happened after the monumental battle at Chi Bi ( Red Cliff) when Cao Cao’s 800,000 troops were unexpectedly decimated by the numerically inferior troops of the Sun-Liu Alliance. Even when Cao Cao and his troops were beating a chaotic retreat back north, the alliance missed an opportunity to eliminate Cao Cao decisively as Wu’s and Shu-Han’s strategists were already acting in self-centered ways to prevent their fellow ally from becoming too powerful in the face of a weakened Wei state. Each ally wanted to prevent one tyrant ( Cao Cao) being replaced by another (their erstwhile ally) in the future.

Scholars opined that Shu-Han ‘s strategist ,Zhuge Liang’s, assigning general Guan Yu to HuaRong Pass knowing that the latter would let Cao Cao escape as a favour for past kindness and Wu’s commander ,Zhou Yu’s, strategy of pushing the retreating Wei troops towards Shu-Han forces are examples that none wanted to be the “bad guy” who kills Cao Cao and then risk becoming the target for Cao’s successors’ revenge. Not surprisingly, Cao escaped to fight another day.

Whether Worker’s Party (WP) or Singapore Democratic Party (SDP) has greater right to the vacant seat will be left to the ward’s electorate to decide. Most pundits feel that if both contest, none will win (ie PAP wins). If WP alone contests ( I am disregarding other parties who only play bit-parts), the chance is best but SDP would then be faced with another rival party that will totally eclipse them in time to come. If SDP alone contests, WP’s plan of domination in the East, which is but another brick in their scheme to build up a truly alternative party, would be delayed or even off-railed in the off-chance that SDP actually wins. SDP may then start to jostle with WP to be the main alternative party. If both contest, none wins but WP prevents the emergence of a upstart and SDP will attract scorn as being the spoiler …

Game theorists and other watchers have opinions about which is the dominant strategy and hence the most prudent step for each of the 2 alternative parties, but I am content to watch and see if my theory about what each party will do comes to fruition…

Akan Datang , folks….

Dr Huang Shoou Chyuan

 

Links to Romance of 3 Kingdoms:

1. ROTK
2, Summary of ROTK
3. Commentary on Cao Cao