Tactics for GPs in Singapore
I was reading a comment made by a 5th year medical student who says he is a future medical administrator over at angry doc's blog.
http://www.blogger.com/comment.g?
blogID=15575652&postID=114052645118601554
Ang Yee, Gary suggested "1. raise GP consultation fees to a suitable one and allow pharmacy to sell medicine instead."
You don't have to raise it. You only need most GPs to charge what the recommended consultation fee is.
The problem is that in Singapore the culture of the patients is that no medicine = no need to pay.
Go see doctor = go get medicine.
If we reverted to a consultation system, the GPs would be happy, but the people would be up in arms. People like Gary in the admin who came up with such unpopular policies would get fired because the Minister would also get fired.
That is the culture in Singapore. It is almost impossible to change now.
I was just thinking about the complaint case again in the ST forum page last night. The one about how this patient got very good medicines but felt she was paying too much. Seems to be that in Singapore, these are the options GPs take in their practices :
1) Give patients cheap generic medicines. Stay away from new drugs unless patients specifically request for them. They are expensive, and inflate the bill to look very scary.
Advantages : It is very cheap in terms of cost. Keeps the overall bill for the patient low and presentable also. Profit margins are higher because of the very very low cost of the drugs. So although you charge $2 for a course of generics, you make $1.90! Compared to say charging $20 for the non generic and making $3!
Disadvantage : patients would say your medicines are old and similar like what they get in SAF camps. Bad for clinic image.
2) Keep the newer non-generic drugs for "special" patients. Either those who are RICH or those who are the "Can give me more better medicine" types.
Advantages : The profit margin is actually lower, but it is good for the image of the clinic. "That clinic give 'special' new medicine you know!"
Disadvantages : Downside is that the cost of the medicine from the pharmas is very high. So profit margins are lower. Yet the bill is scary to the patients. You will get complaints letters like these in the Straits Times http://straitstimes.asia1.com.sg/forum/story/0,5562,372710,00.html?
3) Create a niche market for yourself. Go into some special area of interest which is as far removed from mainstream general medicine as possible. Eg Aesthetics, alternative medicine, nutrition, mesotherapy etc.
Advantages : Mainstream medicine is not lucrative because people will not pay GPs extra to manage what they can get for much cheaper at the polyclinics or the subsidized specialist clinics. But they would pay for what they cannot get there. Serve the rich and prosper.
Disadvantages : Be prepared to be ostracized by the morally righteous right wing groups. Medical malpractice insurance does not cover mesotherapy anymore.
4) Stay away from being a absolutely good practising doctor. Patients want to hear what they want to hear. Patients who have very minor trivial problems should be treated seriously and told they are very ill and need a lot of treatment. Especially the chronic clinic hoppers. This endorses their fears and addresses their concerns. They will like the doctor. Give conditions like tension headache a different sounding diagnosis like Migraine. Common colds should be called excessive heatiness in whichever dialect and treated with the most unusual concoctions.
Advantages : As most of these problems are self limiting they will get better anyway, but they will attribute it to the treatment the doctor gave! Patients will love you the knowledgable doctor who tells them they have a "serious" problem when other doctors dismiss them.
Disadvantages : The rest of the profession would call you a quack. Problem in staying sane treating all these neurotic hypochondriacs.
5) For patients with chronic problems eg Diabetes and Hypertension, just give them the token medication and if their condition is not severe just say it is well controlled even when it isn't. The patients will like you. For example for hypertension, if the BP is 160/90 tell them "For your age it is ok so don't worry"
Advantage : They will keep coming back because you are the only doctor who tells them what they want to hear, never increases their medicines unlike other doctors, especially the young guy across the road who says that above 140/90 means Grade I hypertension for patients 18 and above according to MOH clinical practice guidelines.
Disadvantage : none, is already widely practised.
Advantages : The aim is that you don't want to have a bad rep of treating gone case type patients who die on you. When the death comes, they will call you to sign the death cert and you can still make money for the visit.
Disadvantage : none
Yes market forces are at work. But it works both ways. For a GP to survive and prosper in Singapore, he has to know what the market wants and adapt accordingly. There is no place for the practise of good proper family medicine in Singapore. We are not Australia or Canada we have to accept that.
posted by Dr Oz bloke @ 5:59 PM
13 Comments:
OZ,
With deep respect, how in heaven's name can you pull this stunt off with a knowledge based population?
" 5) For patients with chronic problems eg Diabetes and Hypertension, just give them the token medication and if their condition is not severe just say it is well controlled even when it isn't. The patients will like you. For example for hypertension, if the BP is 160/90 tell them "For your age it is ok so don't worry"
Advantage : They will keep coming back because you are the only doctor who tells them what they want to hear, never increases their medicines unlike other doctors, especially the young guy across the road who says that above 140/90 means Grade I hypertension for patients 18 and above according to MOH clinical practice guidelines.
Disadvantage : none, is already widely practised."
Any GP who tells me this crap will be referred to the SMC and the SMA.
Well I hear that all the time.
I tell patients their blood pressure readings for the day are high. And then they say how much. And for example I say "150/100"
They will say "that is my usual and the doctor at the polyclinic/other clinic says it is ok for my age. I am not young man you know. Old people blood pressure is higher one lah"
So I print for them the page with the table from the Clinical Practice Guidelines published by MOH.
Then you know what the patient says?
"Aiyah, I know it is true lah, but cannot act so smart also. Wait show doctor all this prove him wrong then the doctor tell me you so clever then go see that doctor lah!"
So they continue to go to the polyclinic/other clinic. They just want to hear what they want to hear.
Eg Patient : "Doctor can check my Blood Pressure?" (Means I hope dr check is ok)
Doctor :"Your blood pressure is OK"
Patient : "Good! Thank you very much"
Whereas....
Patient : "Doctor can check my Blood Pressure?" (Means I hope dr check is ok)
Doctor : "Your BP is high today. 150/100. I suggest you come back on 3 other seperate visits when you are not ill to see if the mean BP is high or not"
Patient : "Cannot be leh. I already eat medicine from polyclinic, how can have high blood pressure still? Some more my doctor there tell me 150/100 is acceptable for my age. You must be new lah."
"knowledge based population"
I think you mix up economy with population lah.
Singaporeans knowledgable meh?
Maybe you dun know how it is in the heartlands.
Coffeeshop talk nawled veri different from knowledge.
I resent yr comments about the minister of health being fired.
U have to look at the whole picture. Unless doctors can unite and purchase medicine as a group, drug companies will always charge more for small practice and less if u buy in bulk.
Walmart succeeded by squeezing the small inefficient MOM and POP shop and solo GP will one day find themselves price out of the market as they have to purchase drug at prices higher than the polyclinic and hospitals and thus appear as though they are overchraging when they are not.
Regards
Well Gary,
All I can say is that what are you studying medicine for when you have already decided not to be seeing patients?
You're a businessman. Economics, bottom lines, profits, losses, budgets. Yes they are important. But so is medicine.
As doctors which should we be more concerned with?
Yes WalMart did it and their business is bigger than the GDP of most countries.
Yes NHG and SINGHEALTH are doing bulk purchases to save costs. This is a big advantage which GPs do not have.
Now here's the catch. MOH has rules which prohibit groups of doctor coming together to bulk purchase drugs unless they are officially affiliated via a company of some sort.
The plan is simple. I call all the private GPs in Singapore and suggest that instead of them individually ordering the drugs from the pharmas, why not we pool all the order together, put them through one name/doctor (get bigger discounts ie bulk billing) and then we privately re-distrubute the drugs. Apparently this idea was shot down by MOH.
The other option is to get SMA to be the central buying body for SMA members. SMA was not interested.
Frankly you administrators can talk as much as you want about costs in your NHG and Singhealth. But please don't make the GPs out to be greedy and foolish. Certain problems like that of bulk purchasing are not open to us because of the rules you guys come up with.
In my opinion, MOH doesn't give two hoots about private GPs. Whether private GPs sink or swim is not their concern. It appears that private GPs are not an important part of Singpore's health care system as far as the MOH is concerned.
If the govt really wants to help lower costs for private GPs why not change laws to allow private GPs to buy drugs via the "bulk-orders" of the health groups? Why? Pressure from the pharmas?
Or simply just allow the private GPs to pool their orders without having to merge to become one big conglomerate.
I guess that's the idea for all business, corporate types. They prefer the big organizations. Why? Leverage. You have more leverage working for bigger organizations and thus your pay can be bigger. So the more consolidation the better.
Anyway enough about economics and money. Personally I find it disappointing when young medical students decide even before housemanship they never want to be seeing patients on a regular basis. We don't need such doctors.
WHen u have a 80 k debt even b4 u start working and 5 years bond in future.
Monet start to come into the picture.
The pot calling the kettle black??
Anyway if health costs come down or even maintain, who benefits? Us or or patients?
Practising medicine without considering costs is one quick way to either bankrupt yrself or yr patients.
One works in the real world not the ideal world where everybody can afford treatment and where everybody want treatment.
Many healthcare problem can be solved simply by knowing what the patient want and not what is good for them?
I realise that in today's world, doctors are moving up the "professions we love to hate" charts.
People probably hate doctors as much or more than lawyers now.
The great thing about hating doctors is that unlike lawyers, they usually don't ever fight back. You don't get countersued or anything.
With all the information about health and drugs etc on the internet, who the hell needs doctors these days? People can read emedicine.com and diagnose themselves and buy the drugs from online pharmacies and have them delivered via Fedex the next day!
I would never advise my children to take up medicine. It's a waste of time. I wish I had never become a doctor. Should have done business and become a banker.
It's too late for me now. My fate is sealed.
SPEECH BY MR KHAW BOON WAN, ACTING MINISTER FOR HEALTH
NHG ANNUAL SCIENTIFIC CONGRESS 2003 CONGRESS DINNER, 4 OCTOBER, RAFFLES CITY CONVENTION CENTRE
"IS HEALTHCARE COMPETITION HEALTHY?"
Key Issues in Health Care
1. There are many problems which all Health Ministers worry about. But we can generally boil them down to one common problem: "money no enough".
2. Patients worry about not having enough money to pay for hospital bills. Doctors complain about not having enough money to raise clinical standard. Hospital CEOs fight for more money so as to balance hospital budgets without having to raise fees.
3. I heard these pleas 25 years ago when I first joined MOH. I continue to hear them now that I am back to the Ministry.
Significant Progress
4. Nevertheless, against this backdrop of limited resources, we have made significant progress during the last 25 years.
5. First, we have more money now than before. We have collectively built up significant reserves to help us pay for medical services in the event we fall gravely ill. Singaporeans now have a total of $ 28 bil saved in their Medisave Accounts for their old age. Medifund has $ 900 mil in endowment, generating interest income which helps the poor pay for their hospital bills if their Medisave Accounts run out.
6. Second, we are no longer working in outdated pre-war hospitals. We have completely rebuilt all the hospitals which we inherited from the colonial masters, with the exception of the Alexandra Hospital. Even the AH has got a face-lift and is no longer the British military hospital that it used to be.
7. Third, we have many more doctors and nurses. There are now over 6,000 doctors and 18,000 nurses. These numbers are more than double or triple the numbers 25 years ago.
8. These are not trivial achievements. Many countries look at our healthcare system with envy and admiration. My job is to help you build on this strong foundation so that young Singaporeans will inherit an even stronger healthcare system when it is their turn to take over responsibility.
Fighting SARS
9. Our healthcare system was put to severe test during the SARS crisis. We passed the test with distinction. Let me take this opportunity to thank all of you for your dedication and courage.
10. I have personally derived inspiration from the way we overcame SARS together. I see useful application of the approach to the other non-SARS problems that we face, whether it is the fight against obesity, the campaign to adopt a healthy lifestyle or the drive to keep healthcare costs low.
11. The key strategy is to take an inclusive approach, involving all partners and stakeholders, mobilizing all public, private and people sectors to work for a common cause.
Unlimited Demand Chasing Limited Supply
12. This is absolutely necessary because demand for healthcare services, like all other goods and services, tends to exceed limited supply. But unlike normal goods and services which are allocated through pricing and the ability to pay, healthcare is a public good and in economic jargon is “non-excludable”. Put simply, this means that we cannot deprive the sick and dying of medical care, even if they are unable to pay for it. Governments all over the world, including Singapore, therefore step in to subsidise, at varying degrees, the provision of healthcare. This complicates matters because, in doing so, price signals and demand get distorted.
13. Let me give you an illustration. During the SARS crisis, demand for hospital services shrank by a third, as many patients stayed away from hospitals. I was very worried about our ability to meet the pent-up demand that would come, once the patients dropped their fear of hospitals. So when the SARS crisis was over, I was mentally prepared for the long queues of patients who had earlier postponed their visits to the hospitals and their doctors.
14. But surprise! The huge pent-up demand that I feared never materialised. The deferred demand during the SARS crisis simply evaporated. I can’t help wondering how much of this unmet demand is medically unnecessary.
15. We can never get an answer to this question. But even if only a fraction of that is medically unnecessary, it means a lot of money and resources can be saved if we are able to cut out such unnecessary demand.
16. Each year Singaporeans spend over $4 bil on medical services. A 10% reduction in demand means a saving of $400 mil a year, with no negative impact on our health. This is not a trivial sum. The question is how to cut out such unnecessary demand in order to contain healthcare cost. At the core of this question is how to effectively and equitably ration supply and moderate demand for healthcare as a public good. To rely solely on pricing to do this would be politically and socially untenable. We therefore need to harness the cooperation and understanding of everybody, hospitals, doctors and patients alike.
Cutting Out Over-consumption
17. As providers of healthcare services, we have a role to play in this. After all, patients look to us for advice and recommendations. Do I need an X-ray? Do I need a surgery? Do I need a CT scan?
18. With Internet and a better educated population, we are already seeing better informed patients who sometimes come to our clinics asking about a particular service, or a particular test. Many are just curious. Some are confused, while others are misled. We must resist temptation to accommodate all such requests, unless there are sound medical grounds, on the mistaken notion that “customer is king”, and that “satisfying customer demand is our mission”. In healthcare, the relationship between a doctor and a patient is different from that between a car salesman and a car buyer. The crucial difference is that we are professionals. We know more than our patients and we are entrusted to make the judgement call on what services they should receive.
19. We should therefore counsel our patients and ensure that they understand the course of treatment best suited for their conditions. We should not promote over-consumption, whether deliberately or inadvertently. That is the reason why professional bodies, whether lawyers or doctors, generally take a conservative approach to advertising. The line between providing legitimate public information and encouraging over-consumption is not always clear cut. Above all, we must not over-service. We must certainly not hype up unnecessary demand.
20. Patients, too, must play their part. Medicine is not something that can be mastered through the internet or books alone, but comes with practical experience. I suppose that is why we refer to medicine as a “practice”. Patients must therefore learn to trust their doctors. By all means, question and seek clarification. But at the end of the day, recognise that your doctor is professionally competent and has your interests at heart. Trust him.
Competition and Duplication
21. Another aspect of containing healthcare costs is avoiding unnecessary duplication and overheads. Before re-joining MOH, I heard many critical comments on cluster competition: that competition between the clusters has led to duplication, higher costs and perhaps, even over-consumption.
22. After 7 years in economic management, my instinct is for competition. Central planning has proven to be an utter failure with the collapse of the Berlin Wall and the Soviet Union. Communism has proven that “no competition” does not work. The economic contest has already been settled.
23. Indeed, our economic transformation and our prosperity are built on a competitive model. Competition has driven us to be ever more efficient, working smarter and cutting out wastes. To be sure, competition does give rise to some degree of duplication. But provided competition is correctly directed and operates within a rational framework, the efficiency gains will far outweigh the cost of duplication.
24. Of course, one must never take a pure doctrinaire approach, and be blind to the practical realities of an imperfect world. In some cases, a large central facility is the most optimal outcome; in others, several small duplicating facilities competing with one another may make the most sense. We should not be wedded to a single approach and expect one size to fit all. Rather, we should choose the arrangement that yields the highest marginal returns.
Competition and Cooperation
25. We must view the clusters in this light. Competition as a concept does not preclude cooperation. Indeed, with globalisation, we are living in a more collaborative world in which countries rarely make the entire products from start to finish. Design, production, distribution and servicing are each split into segments and spread all over the world. Every country has to carve a niche for itself by excelling in some areas, while linking up with the other countries in the supply chain.
26. At the micro level, companies are also finding value in cooperation among competitors as the correct way to go. This applies equally to our two hospital clusters. They can certainly cooperate even as they compete actively. The key is to embrace cooperation where it leads to mutual benefit.
27. Indeed the two clusters are doing so. You have a Joint Purchasing Unit to exploit bulk discounts and lower prices. You have a joint programme to promote healthcare careers. You cooperate to facilitate cross-cluster training for our young medical officers. I understand you are thinking of a joint facility to promote clinical trials and joint research.
28. I think you can also cooperate in two other areas. First, enable your patients, if they wish, to move across clusters with ease. This means allowing medical records to flow seamlessly so that patients do not have to be re-investigated for X-ray or lab tests. This will require you to share information readily.
29. Second, and related to my first point, enable your computers to talk to one another so that we can more quickly work towards all Singaporeans having their own electronic medical records. Every child already has a health booklet. We should create an Internet version of it for every individual for life. This will transform medical practice in a dramatic way. It is achievable. The technology is already here. But to realise it, clusters should make sure that their IT efforts can provide access to their patients’ records through the Internet.
30. At the same time, there is scope for healthy competition. Clusters should compete to achieve higher productivity and provide more efficient and effective patient care. In short: to do more with less, and to save money for their patients.
Enlarging Market Share
31. My observation is that where cluster competition has gone a bit astray is when they compete on enlarging market share.
32. If the CEO is measured and rewarded for enlarging market share, he would obviously go for more patient-days, more clinic visits, more surgeries, more prescriptions. I am not saying that this is happening in our clusters. But this is potentially a perverse outcome which may materialise.
33. Hence, on the first day of my duty, my simple message to the clusters was that your mission is not to expand your market share. In fact, it is just the opposite.
34. If your patient load drops because Singaporeans are getting healthier and less sickly, you have done well. If your patient load drops because you are able to cut out unnecessary demand and over-servicing, I will clap hands. If your patient load drops because more Singaporeans can now afford unsubsidised medical services in the private hospitals and clinics, we should be happy with such an outcome.
35. In short, we will be happy if you run out of work.
36. This is in fact, not far fetched. Just last week, the Independent, a London newspaper (Sept 22) carried an article entitled: “Heart surgeons cut queues and run out of work”. It reads: “Heart surgeons are running out of work after scoring spectacular gains against Britain’s biggest killer.”
37. It gave reasons why heart surgery rates in London are plummeting. Two of them are worth highlighting. First, more patients are being kept well on drugs, such as statins, thus avoiding the need for heart surgery. Second, the epidemic of heart disease which peaked in the 1970s is heading downwards. Deaths from heart disease have fallen by a third in the past decade and have halved in the last 30 years. It added that “the reasons for the fall are complex, but include improved diets”.
38. I was cheered by this article. I am reassured that our emphasis on healthy lifestyle and holistic disease management, properly executed, can make a difference to our vision of ensuring better health for all and your own corporate vision of “adding years of healthy life”.
39. I was also encouraged by an email which I received from Tan Tee How after his recent visit to San Francisco for a health care conference. He reported a speech by the US Secretary of Health and Human Services, outlining his Department’s key priorities. Tee How noted lots of similarities with our 8 priorities which I articulated a few weeks ago.
40. This gives comfort that we are on the right track.
Conclusion
41. And this track runs in the direction of returning to basics and to re-focussing on practising good medicine, finding the simplest way to produce good patient outcomes.
42. I therefore like your corporate vision: “adding years of healthy life”. It is a worthy and ambitious vision which we all can subscribe to. Let me therefore end with this challenge to the clusters. Compete to add years of healthy life to Singaporeans. Compete to produce programmes that will add the most number of healthy years with the least resources. And may both teams win.
"The great thing about hating doctors is that unlike lawyers, they usually don't ever fight back. You don't get countersued or anything."
"I wish I had never become a doctor. Should have done business and become a banker.
It's too late for me now. My fate is sealed."
Hey Gary, you sound just like me.
I always call us docs chihuahuas tied to a tree. We can bark at the patients who beat us with the stick but we can't bite back!
I totally agree with you. I lost faith in medicine some years ago. A lot of my other classmates too. Some have chosen to walk down roads wisely and never turn back. Me, I've got too strong a conscience.
It's difficult.
80K debt? Haha, guess you didn't think about that when you entered med school.
Anyway take a look at this
https://team.nus.edu.sg/registrar/
info/ug/UGTuition2005-6.pdf
I found that the amount paid by foreign students and local students is about the same in NUS. Very different from universities in UK, USA, Australia where foreigners pay much more than the locals.
Based on the Ministry of Education figures it is 2-3% higher for non-resident students.
That's very good for the foreign students don't you think?
If you look at the table carefully you will see that the government subsidy in the form of tuition grant for both resident and non-resident students is the same.
This is interesting because effectively it means MOE is using tax payers money to subsidize the education of foreigners.
I guess some would say that's necessary to attract foreign students. The question then is whether Singapore makes money from the students at all? I mean more than half the fees are subsidized if you look at the figures in the table. What's the point of attracting all these students only to make a loss?
What is your opinion on that future administrator?
I still don't understand what your 80K student debt even before starting work has got to do with your decision to become a medical administrator instead of a doctor.
If I'm not wrong, you're still bonded (and the bond certainly is worth much more than 80K) and when you work for that 5 years the pay is not much different between a med administrator and a medical officer.
So what gives?
With regards to details of Mr Khaw's speech, I'll tell you this Gary; you don't know what the doctors can do, should be doing and what they are doing, because you aren't a doctor.
It would be wise of you to spend some years doing clinical work, learning and observing what doctors do in the hospitals, in clinics BEFORE switching to admin.
This advice was given to many medical admin wannabes by a very senior Medical Professor who joined the Medical Services in MOH. And I have to agree with him.
If you go straight into MOH after Housemanship, you're not much different from a non-medical doctor medical administrator.
Mr Khaw himself says "Medicine is not something that can be mastered through the internet or books alone, but comes with practical experience. I suppose that is why we refer to medicine as a “practice”."
So trust me when I tell you that should you join the medical services at MOH without having established yourself as a clinical doctor, you will never be viewed as a doctor within MOH nor given respect and notice when you mention medical matters.
Good luck
i totally agree with wad dr oz bloke mentioned abt practising for a period of time before going on to adminstration.
if u dun mind i would take an analogy from the SAF. its always better for a OCS instructor to have gone through their PC tour before they go on to teach cadets how to be a PC. or its standard route of advancement in a SAF officer to have first gone through his PC tour, before being thrown into staff or instructor roles in the other units of SAF.
GPs in Australia earn lots. maybe dr oz bloke shd migrate to australia. GPs are also held in much higer esteem in Australia than in S'pore. They are considered family medicine specialists and are very much part of the healthcare system; they don't have polyclinics or whatever. The patients who come are subsidized by virtue of the fact they are australians/PRs and are "bulk-billed". even students like me with OSHC (overseas student health cover) - an insurance i paid for with 349AUD a year, could get even surgery for free.
its that good. but then, spore will never trot down the path of a welfare state.
so how dr oz bloke? australia?
I think I'm going to Canada since I already got final approval on my PR application there.
Australia's problem for me is that I can work there as a GP but I dun get PR until I pass the FRACGP and get fully registered. The whole aim is to migrate.
And I can still practise medicine in Canada after I pass the MCCEE, MCCEQ etc. It's a case of which is more important. The PR or being a doctor?
I think the PR is more important to me.
There are a lot of ills in the current primary healthcare system. The GP segment is ailing, at least in part due to Singhealth and NHG polyclinics with its heavy subsidies.
Post a Comment
<< Home