Commodification of health care

Over the weekend, the Sunday Times reproduced Dr Lee Wei Ling's earlier letter to the Straits Times (15 Oct) about the commodification of medical care. The letter is reproduced below.

I have always had the highest regard for the good doctor. Despite the open road for her to jump into high political office, she has instead opted to align herself with the less 'rewarding' mission of championing the needs of the common man. Here she has been able to put her finger on the nub of the problem. In various ways, each of us has been struggling with issues related to the commodification of medicine, and the commercialization of patient care. In today's world, I guess some degree of commercialization cannot be avoided. But Singapore is already paying the price of being overly pragmatic in wholeheartedly submitting to these crass values of commercialization, and there are clearly worse consequences than what we already see happening to the medical profession. Things will get worse. Medicine is a noble profession, but it will not stay that way if we do not fight to hold on to her noble values. The Singapore Medical Association has been greatly weakened and has but a little voice in this struggle. That is why Dr Lee's voice is so invaluable. There are few individuals with the kind of stature and 'protectedness' (she will hate my saying this, but it's true) who can articulate this to the powers that be. Her diagnosis is correct. I am not sure what she can achieve, but her's is a voice that must be heard.

Interestingly, this route that the medical profession is taking, unless I am mistaken, was actually begun many years ago by her own brother who proposed the development of Health Care as one of the pillars of Singapore's economic growth. The lifting of the GOF is merely a logical step in this process.

Medical care is not a commodity

By Lee Wei Ling

MOST developed countries believe that the free market is the best system for allocating scarce commodities. The right price for such commodities, they believe, is best determined by allowing the forces of supply and demand to operate freely.

But a free market can work efficiently only if sellers and buyers have roughly equal knowledge about the commodities changing hands. Such a condition does not always exist. Medical care, especially, cannot be priced like any other commodity because the seller (the doctor) has much more information than the buyer (the patient).

The patient is therefore at the mercy of the doctor, not only in terms of what he is charged but also in terms of what he needs to 'buy'. For example, procedures that may be unnecessary, such as blood tests and radiological examinations, may be ordered by a doctor, and the patient would be in no position to refuse.

One could argue, of course, that patients can shop around to find doctors who would offer them the cheapest package. But this is impractical: Patients with urgent medical problems do not have time to shop around. Patients from foreign countries would want to get their medical problems attended to quickly so that they can return home. Moreover, patients are usually informed of the medical procedures they require only after consultation with a doctor. They do not know beforehand what they would require in order to shop around effectively. This, together with the time constraint, makes it impossible for most patients to make an informed choice among doctors.

Prior to 2006, the Singapore Medical Association (SMA) had a 'Guidelines on Fees' (GOF) for doctors in private practice. The GOF recommended a range of fees for various medical procedures. It was only a guideline, so doctors could deviate from the quoted fees if they wished. However, if they did so, they were expected to inform patients in advance.

This enabled patients to know what was the 'premium' they were expected to pay for the exceptionally superior treatment their doctors were promising, and they could decide for themselves whether they wished to pay that premium.

Sometimes, patients discovered they were charged much more than what was recommended in the GOF only after they received their bills. Some complained to the SMA as a result.

In such cases, the SMA would request the relevant doctor to justify the extra charge, and if there was no reasonable explanation, it would advise the doctor to refund the difference. This advice was also transmitted to the patient who complained. Most doctors who overcharged without good reason followed the SMA's advice and refunded the money. The guideline worked, functioning both as a moral and practical rubric.

In 2006, the SMA abandoned the GOF because it was encouraged to believe that the guidelines might contravene the Competition Act. Ironically, the purpose of the Competition Act was to protect consumers from being overcharged by allowing free-market forces to determine prices. And the GOF was designed precisely to protect patients from being overcharged by private medical specialists - always a possibility given the asymmetry of information between doctors and patients.

To abandon the GOF on the grounds that it is anti-competitive is so illogical that I wonder whether anyone in the Competition Commission of Singapore understood that medical fees cannot be determined by free-market forces. The abandonment of the GOF has made patients the easy prey of unscrupulous private specialists.

They can now charge as much as they think they can squeeze out of patients. Charges tend to vary, depending on the patients' addresses, whether they have medical insurance policies or are dressed expensively or wear jewellery. Foreign patients are more likely to be overcharged because they have no time to shop around. I know first-hand of an Indonesian patient who was charged $100,000 for a simple laparoscopic removal of a gall bladder, a procedure that usually costs $10,000 in the private sector. There have been enough cases of shameless profiteering to earn some private hospitals here a bad reputation.

Public-sector doctors cannot overcharge because their fees are fixed by the Ministry of Health. Many of us in the public sector have had friends, both local and foreign, ask us for advice about which doctors in the private sector they should consult. They know that without medical information, they are unable to tell which are the good doctors, professionally as well as ethically.

The current situation, with some specialists in the private sector overcharging, is bad for Singapore. The Government hopes to promote medical tourism. But news of overcharging spreads very quickly abroad. Unless action is taken soon, greed will kill the goose of medical tourism before it has had a chance to lay any egg, let alone golden ones.

Overcharging is also bad for Singapore's medical fraternity. Young doctors watch what their seniors do and will overcharge too when they enter private practice. As it is, there is already an erosion of medical ethics here - not only because of overcharging, but also because of superfluous referrals to other specialists who are one's personal friends, unnecessary and expensive investigations and even some unnecessary procedures that carry risk of harm to patients.

Medicine as a profession is a calling, and medical care cannot be treated as a mere commodity. If the medical fraternity does not act soon to cajole or coerce the black sheep among us to stop taking advantage of patients, Singapore's reputation will suffer and all its doctors will be tarred by the same brush. If we delay reforming the system, its faults will become more difficult to reverse.

Reviving the GOF would provide one solution to the problem of overcharging. It is not a perfect solution but, as with many other problems in life, there is no perfect solution. We know that the GOF will work - because it did.

The writer is Director of the National Neuroscience Institute. Think-Tank is a weekly column rotated among eight leading

figures in Singapore's research and tertiary institutions.

This story was first published in The Straits Times on Oct 15, 2008.