Appropriate healthcare in Singapore: A reflection

There are many factors that contribute to high healthcare costs. ¹ In Singapore, the recent public outcry over rising healthcare costs for everyone ² calls for reflection on what clinicians and other health professionals can do to help contain the problem.

Like the rest of the world, healthcare costs in Singapore are also rising. The annual healthcare budget has increased from S$4bn in 2004 to S$10bn in 2017, with a projection to be at least S$13bn from 2020 onwards. ³ This is in anticipation of the weighty increase in healthcare costs to meet the needs of an aging population. Locally, in Gross Domestic Product (GDP) terms, this translates to 2.2% of GDP. More importantly, there is still the need to carefully guard against expenditure growth, especially as healthcare costs are expected to be one of the largest expenses during retirement. ⁴ In the USA, healthcare costs represent an unsustainable 17.6% GDP. ⁵

Given that there are multi-factorial reasons attributed to the rising healthcare costs, any help that could contribute to lowering costs is worth considering. The Canadian Medical Association adopts the following components for appropriateness in healthcare. ⁶ There must be evidence for effectiveness and efficacy in the clinical literature. The provider’s scope of practice is adequate to deliver the care. The other components are that care must match the individual characteristic and preferences (patient centred), delivered in the appropriate setting and in a timely manner. All this should result in the right care at the right cost and with good outcome. Locally, clinicians and other healthcare professionals could emulate this by way of practising appropriate use of medical interventions and investigations. The aim is to help create a sustainable and high value healthcare for our nation. It is noteworthy that the Ministry of Health (MOH) has announced that, effective from 1 April 2021, all policyholders will have new riders with a co-payment feature of at least 5%. ⁷ Having policyholders pay part of the bill should help address over-consumption and over-servicing concerns. It will also draw attention to the need for appropriateness of care.

Appropriateness of care is important as it eliminates waste and prevents harm. Inappropriateness can contribute to overuse, when clinicians carry out more clinical preventive work than is needed with the intention of commanding a higher fee. Overuse, as defined by Chassin and Galvin, is the provision of medical services for which the conceivable harm exceeds the conceivable benefit. ⁸ Overuse of unnecessary services has many implications – potentially harming patients physically and psychologically, wasting resources and diverting investments in both public health and social spending; a trend that is likely on the increase worldwide. ⁹

Overuse can represent many forms; examples are: screening tests for cancers, diagnostic tests, therapeutic procedures and medications. An example of overuse would be repeat magnetic resonance imaging (MRI). The Health Science Authority of Singapore recently issued a letter on the increasing scientific evidence of gadolinium deposition in the brain following the use of gadolinium-based contrast agents during MRI scans. ¹⁰

Another contributor is the ‘buffet syndrome’ among healthcare insurance policyholders who are not required to pay out-of-pocket hospital bills.

In the face of these challenges, what could improve the situation?

Education is very important. Doctors and health professionals need to have knowledge of the national and current clinical practice guidelines. Many of these are readily available on the MOH website. ¹¹ These guidelines provide a quality care framework that guide how doctors prescribe and manage their respective patients’ treatment. The respective professional societies’ peer review meetings and feedbacks could keep these guidelines current. By establishing recommendations prepared by the respective Specialty Societies as standards of care, the Societies reduce the risk that doing less might spur malpractice. These guidelines should help bring about changed behaviour. Institutions could also report good clinical practices for other institutes to emulate. Education for trainees and physicians on appropriateness and overuse should be part of the medical training curriculum. There are also opportunities during case presentations for supervisors and/or mentors to discuss and take the lead to comment on the appropriateness of investigations and drugs prescribed, as part of the total case discussion. Clinicians should best avoid, if possible, marginally useful low value tests or prescribed unnecessary care.

To minimize medical resources’ overuse and to reduce the risk of harm, the American Board of Internal Medicine Foundation and others launched the Choose Wisely Campaign in 2012. ¹² In Australia, The Royal Australasian College of Physicians has EVOLVE, ¹³ a clinician-led initiative between the College and Specialty Societies. It aims for higher quality care through identifying and reducing low value medical care, for example, tests, treatment or procedures that are overused, inappropriate or with no clear or robust evidence of effectiveness and/or potentially harmful. Specialty Societies in these countries have identified the top five lists of low value clinical practices. For example, the rheumatology association is not undertaking imaging for low back pain in patients without indications of a serious underlying condition. As most episodes of low back pain do not require imaging, ¹³ imaging may identify irrelevant incidental findings and increase the exposure to unnecessary treatment. Opinions may and do vary due to some subjectivity in deciding what is appropriate versus inappropriate in an individual patient. When practices vary, clinical judgement then becomes necessary. This also explains the need for evidence-based medicine research, especially in areas where knowledge is lacking or controversial.

We need to create similar recommendations for local clinical practices and to disseminate recommendations widely to clinicians through publications, conferences, presentations, various social media and news sites.

It is hoped that with recommendations on the appropriate use of tests and investigations, the appropriate usage could lead to a reduction in health insurance claims. More significantly, reducing such practices is essential to the operation of a sustainable healthcare system.

Doctors have a duty to provide competent, compassionate and appropriate care to patients grounded on a balance of evidence and accepted good clinical practice. This duty also necessitates not over-charging or over-servicing patients for financial benefit. As members of the medical profession, doctors are highly regarded by the public, with much trust placed in them. This trust is contingent on the profession’s maintaining the highest standards of professional practice and conduct. ¹⁴

Taking into account the complex and interconnected dynamics of healthcare costs, equally important is the need to engage the other healthcare stakeholders. Of importance is that the pharmaceutical industry must uphold its obligations and social responsibilities to population health. ¹⁵ The MOH has already made the announcement that mandates new rider changes as a way to control over-consumption of services; likewise, the public must also understand that undergoing more tests may not necessarily be in their best interest; and doctors must effectively communicate and share appropriate information with patients to help them make the right decisions and re-examine choices.