"There are few things wholly evil or wholly good. Almost everything, especially of government policy, is an inseparable compound of the two, so that our best judgment of the preponderance between them is continually demanded."
-Abraham Lincoln1
Healthcare leadership
February's heavyweight issue carries articles by various leaders from different sectors of healthcare, sharing both current developments and future plans. Having a vision is important, followed by a good team and real-life implementation with regular feedback for refining and adjustments.
This month marks the completion of my first year serving as a Nominated Member of Parliament (NMP). The personal growth has been tremendous, in learning about how a country is run, and even a bit about Singapore's participation on the global stage. At my core, I remain a simple heartlander (referring to one who lives in the heartland), comparing prices between Sheng Siong, Giant and NTUC FairPrice. Some days during Parliament sittings, I feel overwhelmed, much like how I used to feel as a houseman in a Morbidity and Mortality meeting with complex discussions flying over my head! Perhaps the one area I am most confident in is the clinical practice of medicine, especially my own subspecialty. Another area in which I can hold intelligent discussions would be on the local healthcare system – in-depth conversations to ruminate, debate and (hopefully) reach consensus on difficult issues.
In my 16 years of volunteer service on the SMA Council, I have heard so much about the problems that plague those in private practice, such as difficulties with private healthcare insurers (in Integrated Shield Plans [IPs] and Employees' Benefits plans), third-party administrators (TPAs) and medical concierge services. These last two arose out of an apparent need to bridge gaps in services, and as like any other businesses, they charge a fee. But how do they charge, who do they charge and who regulates them?
In my capacity as an NMP, I have raised questions about these,2,3 and have received some answers. But the devil is in the details. An article written in 2016 made mention of some changes to how TPA fee arrangements should be disclosed.4 But what has truly changed since then? I know that the Singapore Medical Council Ethical Code and Ethical Guidelines5 has clearly stated that fee-splitting is wrong, but that applies only for doctors. The onus is on us to be aware of the fees, and to not fall afoul of our ethical code. But are the contracts transparent? Do we understand market forces?
I have heard that one simple solution is for doctors to refuse to sign any TPA agreement. But is it really that easy for a doctor to refuse to sign with any TPA?
Healthcare makeover
The time may be right for Singapore healthcare to have a makeover. COVID-19 is a worldwide threat, and now more than ever before, precious healthcare resources need to be allocated wisely. More people, even among the public, are sensitive to the need for appropriate usage of precious resources such as ICU beds, and the practical limitations of laboratories, trained personnel and even something basic like sheer human endurance. Working endlessly for 24 months, under stressful conditions, without a break takes its toll. Even if the budget is infinite, the time needed to train a healthcare worker is years in the making.
More than ever before, right-siting of care is essential. Education is also key, such as educating the public in basic first aid, basic health knowledge and knowing how to access the healthcare system. Some important questions to address include: What is the role of primary care? What is the difference between a GP and a polyclinic doctor? When should one head to a hospital's emergency department? How should subsidised healthcare be utilised? When should one go to a private doctor? How much does one's medical insurance cover? I had started a blog to address some of these issues, but alas, I do not have the time to maintain it!
At the risk of sounding self-serving (now that I am also in private practice), a robust private sector will help reduce the stresses on the restructured hospitals. In 2012, the then-Minister for Health Mr Gan Kim Yong6 presented the roadmap for Singapore's "Healthcare System 2020". I draw attention to his emphasis on the development of primary care, the introduction of models of care to tap on the capacity of private GPs to provide accessible, affordable and high-quality care, and the acknowledgement that the private sector has the capacity to help ease the burden of national healthcare needs.
In these past nine years, indeed much has been done. The unity of the various healthcare sectors in rising up to the unprecedented challenge of COVID-19 is a matter of public record. I believe the SMA, together with our sister professional bodies, will continue to help in integration and support through even stronger representation for doctors, in particular the private sector, and doctors in training. With medical doctors as office holders within our Government, perhaps we can help to tackle the problems plaguing primary care, as Minister for Manpower Dr Tan See Leng mentioned in his reply to my Supplementary Question in Parliament;7 much as how the Multilateral Healthcare Insurance Committee was set up to address the problems faced with the IPs.
Healthcare representation
In having multiple roles and portfolios,8 my challenge on the personal front is having work-life balance. My poor kids see less of me, and some of you would have seen them barging in on Zoom meetings! Professionally, I stay aware of the different hats I wear, and take care to differentiate them. When I make a comment, I need to know if I am making it in my personal capacity, or in the role of a public figure.
Being mindful of the intent of what I say and the audience I am speaking to is essential, or I run the risk of being taken out of context! I follow one simple rule of thumb: when all is in alignment, I am confident it is the right way. And when they are at odds, I need to ponder more on why I cannot commit to a single view.
In treading through the complexity of the healthcare system, there is no one simple answer, and it will take a group of like-minded people to achieve a fair ecosystem.
As I end, allow me to share three visions:
- My vision for the future of private healthcare: good quality care, timely access, seamless processes and fair payments for all parties. After two years in the private sector, I have an inkling of what it means to run a business. Businesses should be profitable. But healthcare should NEVER be profiteering off people's suffering. That is my personal ethos. If one wanted to be ultra-rich, one should not have entered healthcare.9
- My vision for the SMA: to be the bridge between doctors and patients, doctors and insurers, and doctors and Government; to achieve an equitable healthcare ecosystem for doctors, and for patients. Hence, SMA decided to support Health Connective, an initiative by the lead technology providers, namely Smarter Health, Assurance Technology and Health Catalyst, which aims to be one of the ways for increased transparency, accountability and affordability in private healthcare (read more at https://bit.ly/3Hjr6v1).
- My vision for Singapore (and even the world): to be kinder, sensible and tolerant of differences. Even as the world becomes divided over race, nationalities, vaccination status, etc – as individuals, let us be kind. Learn more about the Singapore Kindness Movement,10 and practise it in our daily lives. Everyone is going through their personal hardships, which we may never fully understand.
In this year of the tiger, I wish all readers "虎虎生威"– to brave the year ahead with the strength and vitality of the tiger!