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.
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.
6) For patients with very poor compliance or very badly managed conditions, tell them to go to the hospital, OPS because treatment is very expensive and going there would be cheaper. Waive the fees for these patients. They will appreciate it.
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.