This is the full version of the article.
There have been many articles published by authors from insurance companies arguing that over-servicing by doctors causes insurance losses and rising premiums. While there is truth to the rising utilisation of both diagnostic and therapeutic procedures, it must be kept in mind that by the ethical code of conduct and professional practice repute, doctors do exercise restraint. We do not create extra work for ourselves. Let us try to understand what professional medical practice is and what patients seek, regardless of insurance or third-party payers.
Let us take the example of a “simple” hypertension for the purpose of this article’s discussion. So how do we make the diagnosis? Professional and scientific medical societies arrived at some consensus on what constitutes the diagnosis of hypertension and what blood pressure cut-offs determine this. Blood pressure rises with age and life insurance companies have known for a long time that people who have lower blood pressures throughout their lives survive the longest. However, patients with rising blood pressures who are diagnosed to have hypertension and get treated live longer than those who do nothing. That is the evidence from the multitude of clinical trials on hypertension and treatment. Yet, every now and then, we still have patients and their families who ask, “Doctor, he was taking medications, why did he suffer a stroke (or heart attack, or kidney failure, or die)?”
This is because it is not possible to identify all the risk factors and completely control them. The choice of technology, method and cost will thus determine the fidelity of medical assessment and management. Let us discuss diagnosis, assessment and treatment in this article.
Diagnosis
How do we measure blood pressure? The usual diagnosis is made based on office blood pressure (clinic) measurements in a seated position after five to ten minutes of rest, usually discarding the highest reading and averaging several assessments. Having blood pressures higher than 140/90 mmHg on two or more visits support the diagnosis of hypertension. This is the usual way that patients who undergo age-appropriate health screenings are diagnosed. Most of the epidemiologic studies and clinical trials are based on office measurements. Yet, by doing only office measurements, we may under-diagnose hypertension and therefore, its residual risk. Some patients have seemingly normal blood pressures in the clinic but have higher blood pressures at home (masked hypertension). Others have high blood pressure at night while they are sleeping. Normally, our blood pressures dip while we sleep (dippers). However, some patients with treated hypertension and people “without” hypertension, do not dip (non-dippers); some even have rising blood pressures (risers). All of these patients actually have some form of hypertension which can only be diagnosed by undergoing a 24-hour ambulatory blood pressure monitoring test.
The greatest impact to health from a public health perspective is to make medical care for common conditions accessible, simple and affordable. Thus, in most primary care clinics, the office blood pressure measurement is the main method for diagnosing hypertension. The majority of the patient-public will have a reasonably good chance of identifying hypertension and monitoring while on treatment, and the cost-benefit is very good. However, is the doctor who misses a case of hypertension because he did not use 24-hour monitors guilty of under-servicing? Or is the third-party funder that only covers assessments to this level guilty of causing bodily harm?
Assessment
By professional consensus on the minimum standards of care, several physical assessments and laboratory tests are obtained to determine the cause of hypertension and the degree of hypertension-mediated organ injury. These include an eye examination (blood vessels), ECG (assess hypertensive heart damage or identify clues that the heart is the cause of hypertension), and blood and urine tests. Because current methods do not allow us to pick up all causes, most patients are diagnosed with primary hypertension (you see it but cannot explain it). For affordability at the primary care clinic, the number of tests will be limited (and in the case of publicly funded services, the budget determines the tests). Unless the patient exhibits obvious signs implying more severe hypertension, it is often hard to pick up a secondary cause without more tests.
For example, most doctor’s clinics will routinely obtain serum (blood) potassium concentrations as part of the diagnosis and monitoring of hypertension treatment. Low blood potassium concentrations may be associated with an endocrine disease called hyperaldosteronism (excess secretion of the hormone aldosterone), which causes sodium and fluid retention leading to hypertension, and increases urine excretion of potassium at the same time. At least 5% of unselected hypertensive patients in primary care clinics may have this condition, but only 20% of these patients would have a low blood potassium. However, the screening test (aldosterone-renin ratio) is rarely done in primary care clinics and is more commonly ordered by specialists in the initial assessment of hypertension.
What this implies is that the patient-public must be counselled to understand that the moment they elect to use a third-party funder, some care decisions are made on their behalf and often, these decisions are likely based on a combination of actuarial, cost-benefit and cost-effectiveness analyses. However, when a commercial insurance company is involved, a further third-party (shareholder) is involved, and this party will only be interested in the lowest benefits payouts and highest dividend returns. Moreover, a government funder will also have to raise taxes to pay for benefits, with elected officials subjected to intense lobbying by electors who are owners or workers of these companies. Ultimately, the patient-public has to ask, if medical care is to benefit individuals, why is a third-party asked to pay for them? Therefore, the theoretical construct of patient-centred care should be completely privatised doctor-patient relationships, sustained on professional codes of conduct.
Treatment
Hypertension is “easily” treated at younger ages by an aggressive modification of lifestyle including taking a no-added-salt diet high in fresh fruits and vegetables, cessation of smoking and alcohol intake, and weight loss. Now, it is easy for doctors to advise this but in truth, the vast majority of Singaporeans are addicted to salt and sugar, and I can literally count with the digits of my hands the number of patients who are successful in managing hypertension with these measures alone. Therefore, most patients require several medications to control their hypertension. Some might argue that doctors drive costs up as a result of over-servicing. Then again, the patient who is on multiple hypertensive medications and refuses to exercise or engage in a healthier lifestyle may eventually wind up with complications of hypertension, such as stroke, heart failure, or chronic kidney disease. And these costs escalate exponentially. Perhaps some doctors may over-service. Perhaps some patients, through their personal choices, over-consume. Patients are facing death in many ways and would want to do all they can to avoid suffering, and thus seek all possible medical solutions.
Primary versus specialist care
If the specialist does the exact same thing as the primary care doctor, why should they exist? Patients presenting with hypertension for assessment and management are often subjected to a battery of tests that prove or disprove some of the causes of hypertension. This is because the specialist approach for hypertension aims for definitive diagnoses and specific treatment, where possible. The specialist also manages cases of hypertension that are more difficult to diagnose, hard to control, or involve organ complications. Such patients are further evaluated to identify residual risks, and this results in the public having the impression that specialist doctors are “better”, or in them wanting more complete work-ups and management options. And the public may not be wrong, because if you spend more on definitive diagnosis and management, you may avert more expensive complications. In the example of the screening test for hyperaldosteronism, the doctor will need to screen 100 patients to find five patients with the condition. What it allows is for the doctor to say to the 95 “negative” patients that they are less likely to have hyperaldosteronism, and direct the five positive patients to receive specific treatment. Is the specialist over-servicing? From a third-party payer perspective, the cost-benefit calculation may not be favourable. However, like most things in life, the perception of benefit and value lies with the patient.
Unprofessional not to offer all options
Insurance companies as third-party funders are unable to influence professional medical care because they can only stipulate what makes up a covered benefit or not. Regardless of whether a patient is on government subsidies, a lower tiered insurance plan, or an “as charged” medical insurance plan, they are provided the same professional courtesy and service. Thus, the recommendations are the same, although the priority of access may be determined by the covered benefits. Whether or not patients can get true access to those options will be their choice, as they have to assent to the test, treatment, co-pays, deductibles or non-reimbursable items.
There lies some of the problems with competing medical insurance plans. Plans set out to attract participants by offering seemingly unlimited benefits, including “as charged” plans. In the absence of negotiations with doctors on standard formulary, stipulated benefits and pre-approvals, beneficiaries will be indignant if you curtail coverage. The reality is that most doctors understand and already work with constraints at many levels, like patient health literacy, financial concerns and social support, among others. In fact, working within a formulary and certain standard tests are part and parcel of routine work in most hospitals. Ultimately, the most important pre-approval comes from the patient. However, that should not detract from the fact that in professional medical practice, all reasonable options have to be discussed, including expensive ones. Healthcare insurance is a misnomer as it pays to manage disease, not if you are in good health. Doctors are responsible for medical care and disease management. Healthcare, however, is an individual’s responsibility.
Insurance companies and government funders of medical care that bemoan “over-servicing” fundamentally misunderstand what professional medical practice is. The reality is that you pay for what you get, but the law of net marginal benefit applies. Most benefits for the majority of patients are already obtained through primary care management. Specialty care can reduce residual risk and also define other diagnoses beyond the observed hypertension diagnosis. The higher costs are often a result of dealing with the complications of hypertension. The patient-public sees the benefits of specialist care but cannot see economic value (or have a distorted sense of value), and yet wish for the same level of service resulting in the politicisation of medicine not only here in Singapore but all over the world.
To contain public expenditure on medical costs would be to limit access to specialty treatment of late complications and focus the majority proportion of public and private health expenditure on primary care. Late complications are inevitable for lifestyle-related non-communicable diseases in association with ageing. To guide the patient-public on cost-effective care by not over-consuming, the Government and insurance companies should work with the professional specialty societies to establish standard access at different tiers of service for patients at different age groups for the most common conditions, particularly chronic diseases. This will help define costs and also help with complex decision-making for patients with advanced complications beyond the average age of life expectancy.