Doctors v doctors: What’s ailing them

By Han Fook Kwang, Editor at Large, Straits Times

When doctors complain that their own profession is responsible for the escalating cost of health care, it is time to take notice.

We have heard these stories before, of physicians charging excessive fees or ordering tests that seem unnecessary.

They were mainly anecdotal, from unhappy patients who did not know better, and usually spoken about in hushed tones.

But when it is doctors themselves telling on their own kind, and doing it so visibly in The Straits Times Forum pages, you know there must be more to it.

Almost 40 letters were received on this issue, of which 13 were published.

It looked like open heart surgery of the medical profession was taking place in public, and the patient has not recovered yet.

The first incision was made by Dr Tang Kok Foo in a letter published last month, and his words were so cutting that his instrument of choice appeared more chopper than surgeon’s scalpel.

He wrote: “I am amazed at how expensive it has become to be treated by doctors in private practice over the past five years. The surgical fee for simple lumbar disc surgery has shot up from $5,000 to as high as $25,000, even when performed by junior doctors.

“An ear, nose and throat surgeon once told me that since the Government abolished guidelines on professional fees, he has been competing actively with his colleagues to see how high his fees can go.

“The professional fee system in public hospitals, where foreign patients can be surcharged up to 400 per cent, is a good ‘training ground’ for doctors charging higher fees when the market can bear it.”

Ouch! You could almost smell the blood on the floor.

Another doctor offered this anecdote: “A patient I referred for specialist medical treatment was hospitalised and operated on almost immediately. He consented to surgery because the surgeon warned him of the dire consequences if he did not undergo the procedure. The patient ended up $25,000 poorer and complained that he was not given time to consider the options. A quick check with another surgeon showed that the same surgery would have cost only half as much.”

But not all pointed their knives at unscrupulous doctors. Several said it was unfair to blame the profession and cited other reasons: Advances in expensive medical technology, demanding patients who insist on specialists’ care and the removal of medical fee guidelines.

Still others blamed ever rising hospital charges.

So, what to make of this very public spectacle of doctors washing their dirty instruments in public?

There are several issues of public interest.

First, there will always be black sheep in any profession.

If the examples cited were merely the result of some mis- guided doctors, the problem would be of limited concern.

But if there are features in the health-care system that encourage this type of behaviour, and the tendency is likely to increase in the future, remedial action is called for.

Are there?

I can think of at least two recent developments that have aggravated the problem.

First, medical insurance, which is now being extended to everyone, can lead to escalating costs.

When doctors know that the patient’s bill will be covered, fully or partly by insurance, there will be a tendency to do more – more tests, and more expensive treatment.

Why worry when it is paid for by a third party?

A friend told me this story he heard of a doctor, who was being treated for a medical condition, telling the attending surgeon to charge a bill of $100,000 as he was fully covered by insurance.

I don’t know if the story is true, but I can see how having insurance coverage can alter behaviour and distort costs.

Measures should be put in place to ensure that it does not lead to these undesirable effects.

Second, and this is peculiar to Singapore, the promotion of the country as a medical centre for wealthy foreigners can have se-rious repercussions for health-care costs.

There is a huge demand among the well-to-do in South-east Asia for first-class medical treatment, and Singapore’s health-care system fits the bill because of its high and proven standards.

But medical resources are limi-ted, especially the number of specialised doctors, and a steady inflow of rich foreign patients can not just overload the system, but also lead to a culture of overcharging.

In his letter, Dr Tang cited the professional fee system in public hospitals which allows doctors to impose a surcharge of 400 per cent on foreign patients.

That is an incredibly attractive financial incentive, and I would not be surprised if these hospitals try to get as many of these foreigners as possible.

Could the health-care system here be experiencing the same problem the property sector faced before the Government acted with its cooling measures to dampen the demand from foreign buyers?

I hope this isn’t the case, but the fact is that medical tourism was promoted very strongly at one time as one of Singapore’s econo-mic strategies.

What can be done to prevent doctors from overcharging?

Some of the interesting suggestions I have heard include making it compulsory for specialists and hospitals to send to the Health Ministry the total bill of every patient.

The possibility that the authorities may investigate unusually large bills should act as a deterrent.

Another sensible idea: Institute a whistle-blower system, much like what is now commonplace in many commercial and public organisations.

Some people might believe that rising costs in the private health-care system isn’t really a public issue.

It is a free market, and people have a choice between going private or choosing a government restructured hospital where costs are controlled by the authorities.

This is a mistaken view because what happens in the private sector will affect the public health-care system.

The most serious effect is when doctors in public hospitals leave for private practice because of its financial attraction.

Recently, the spine unit at a public hospital here had to close because its entire team of doctors left for private practice.

If it wants to continue operating this branch of medicine, it will need to attract these or other specialists back, thus raising the cost of the public health-care system.

The incident shows how di-rectly public hospitals are affected by what takes place elsewhere.

I believe the majority of doctors are motivated not by money, but by a higher calling that made them want to practise medicine in the first place.

But the environment they operate in and the prevailing culture can significantly affect their behaviour.

These are issues that the professional bodies responsible for their code of conduct, the Singapore Medical Council and the Singapore Medical Association, ought to look into.

Ultimately, doctors themselves have to ensure they meet the highest ethical and professional stan-dards expected of them.

The rest of us can only hope they do not fall short.

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