SEPT 8, 2001
Getting to the bottom of rising health-care cost
The public is right - health-care costs in Singapore are going up year by year, be it for hospitalisation, medical treatment or drugs. Whatever happened to the notion of affordable health care? How can patients keep their bills down? Are they making the right choices? Our Health Correspondent finds out
By      Salma  Khalik
HEALTH CORRESPONDENT
THE last decade has been one long struggle to pay off medical bills for Mr Richard Cheong and his family.
First, his father was diagnosed with nose cancer. After fighting it for eight years, he died in 1997.
Then his mother came down with cancer of the lymph nodes and is still undergoing treatment.
For the 24-year old unmarried air-force mechanic and his two older brothers, the bills keep piling up.
His father's bills came to almost $60,000, despite receiving the maximum subsidy at the Singapore General Hospital (SGH).
His mother's bills are fast approaching that amount.
Mr Cheong's medical expenses capture vividly the rise in  health-care costs in Singapore. Nowhere is it more striking than in  the size of hospital bills, which have increased by 6 to 8 per cent  a year.
The cost of medicine has also gone up. A decade or two ago, there  were few medicines that would set you back a few dollars a pill.  Today, this is no longer unusual.
The average amount spent on health care went up by 3.6 per cent a  year for the past five years. Last year, it came to $1,439 per  person.
This increase has eaten heavily into people's incomes. As a percentage of household expenditure, health-care costs have risen  from 2.6 per cent in 1993 to 3.3 per cent in 1998 - or a whopping 27  per cent.
So when Mr Cheong and the public complain that health care is getting more expensive, they are fully justified.
The Government provides a 20- to 80-per-cent subsidy at restructured hospitals. Patients can choose the level of subsidy   they want (see chart).
But as the overall cost of hospital care goes up, the portion the patient pays, even for the most highly-subsidised C class wards,   also goes up.
So what accounts for the rising costs? Point the finger at higher wages and improvements in medical treatments.
Last year, doctors' salaries went up by an average of 22 per cent, while those of nurses rose by 10 to 21 per cent.
Wages account for 60 per cent of operating costs, with medical supplies such as drugs taking up 15 per cent.
The quality of health care here has also improved tremendously  over the past few decades, which translates into higher costs. For example, treatments that did not exist 30 years ago have become commonplace today.
One example is knee replacements. Previously, old people with painful and worn out knees could resort only to pain killers. Often' the pain can be so severe that they can no longer stand up.
Today, about 100 people get new knees every month. It is a simple operation that takes less than two hours and not only gives relief from pain, but also enables the person to continue leading an active life.
An A-class patient at SGH pays about $12,000. A C-class patient pays between $2,670 and $3,920, depending on the implant used.Poor patients have also been hit by the reduced government subsidy - from 85 per cent a decade ago to 80 per cent today. This means that the portion they pay has gone up by a third.
To make matters worse, the cap on the portion they have to pay for major surgery has also been raised - from $150 to $330.
The Government's position on health-care costs has been well spelt-out: Except for the truly indigent, it does not want to provide free medical care.
It will continue to provide subsidies but it wants co-payment by the user to regulate demand.
The Government has promised that nobody in Singapore will be denied treatment because he cannot afford to pay his medical bills.
As Mr Moses Lee, Permanent Secretary at the Health Ministry, tells Insight: ''It'll be tragic if people do not get treatment because they can't afford it. The downside is going to be far more costly and painful, both for the individual and the nation.''
Health Minister Lim Hng Kiang has warned repeatedly that costs will continue to rise over the years because if people demand better-quality health care, they cannot expect the price to remain stagnant.
But the ministry maintains that with the extensive subsidy system in restructured hospitals and polyclinics, it is absorbing much of the cost increases, and that basic health care remains affordable for the majority of people.
But will these assurances by the Government be sufficient to allay the growing concerns of the people?
When people voice their unhappiness over rising health-care costs, it is often not because they cannot afford to pay their medical bills.
What members of the middle class are saying is: We expect the money needed for health care to eat increasingly into our disposable income. We're not happy about that.
Yes, they can afford the costly treatments, but only at the expense of giving up more and more of the finer things and luxuries in life.
For Mr Cheong, paying his mother's medical bills means he cannot buy a car.
Mr Lee sees the issue as a question of choice. As with other things in life, there are cheaper and more expensive alternatives in health care and it is up to the individual to choose wisely within his means.
People may always want the best and latest available treatment' but they have to be realistic.
To use a simple analogy, they may want to drive the latest Mercedes-Benz, but on their income, they can afford only a Toyota Starlet or, perhaps, to take public transport.
The difference in price is tremendous. But all forms of transport will get them to their destination - with some taking longer and providing less comfort.
The same is true for health care.
Those who are in genuine need can apply to Medifund for help' provided they are in a C- or B2-class ward.
Last year, the endowment fund paid for the hospital bills of 11,800 patients and the outpatient expenses of 90,826 people.
The small group who can afford to pay but who find it difficult to do so immediately can apply to pay their bills in  instalments.
At SGH alone last year, 690 patients asked to pay their bills in instalments, up from 434 the previous year. Mr Cheong was one of them. This month, he and his brothers will pay the last instalment on their mother's bill, incurred early last year. Last month, she was admitted for treatment again.
When people talk of health-care costs, they may not be aware that there are actually three distinct components.
One involves acute hospital care. This is short-term and, while expensive, is often a one-off payment.
Another is the cost of the long-term medical treatment of a disease, which could go on for years, or even for the rest of a person's life.
The third is the cost of long-term care as a result of a disability. For example, someone who has suffered from a stroke may need help with normal daily activities.
HOSPITALISATION
FOR short-term hospital care, there is no means test, so patients can opt for any class of ward.
Even the rich can go to a C-class ward, where they pay only 20 per cent of the cost of the stay and treatment. And there is a cap on treatment costs.
At SGH, a C-class patient who undergoes an operation can be charged up to $330 for the surgery, no matter how major it is or how long it takes.
The cap for surgery in a B2 ward is $550. This jumps to $6,435 in a B1 ward.
Much of this out-of-pocket payment can come from MediShield for those covered by this insurance scheme, and Medisave, the compulsory medical component in the Central Provident Fund.
Those who really cannot afford to pay can apply to Medifund.
At least 65 per cent of beds in restructured hospitals are B2+ and below.
The differences in the wards can be quite stark. The lower the class, the more people to a room. Only B1- and A-class wards are air-conditioned and have television sets and phones.
Patients in B2- and C-class wards have to walk quite a distance to the toilets and bathrooms, which are situated outside the wards. The walls in a C-class ward are usually only waist high, so there is even less privacy.
Those in the lower-class wards also do not have the right to choose their doctors, unlike those in B1 and A, so they may be treated by a registrar instead of a consultant.
But the hospitals pledge to provide the level of care necessary. If a patient suffers from a complex problem that requires the care of a highly-experienced senior consultant, then he will get it.
Mr Lee of the Health Ministry says: ''If you don't have the money, it means you have fewer choices.
''If you need a bypass or a routine cataract operation as a subsidised B2 or C class patient, we will assign competent doctors to you. They can do the job.''
His advice: ''Even if I can afford it, I should be cautious about spending too much. This means choosing the right ward class.''
Should the demand for cheaper beds increase because people want to take advantage of the subsidy, then the ministry will have to get more money from the Government to cater to this need, he says.
Mr Cheong's parents were cared for in the cheapest possible ward He says: ''The hospitalisation doesn't cost much. But the drugs are expensive.''
The consultant recommended a new drug which cost $13,000 for four doses. They approached an SGH medical social worker for help and were given a rebate of one dose.
They still had to pay $10,000 in cash as Medisave could not be used for it.
Six months later, his mother had a relapse.
LONG-TERM MEDICATION
AS THE population ages, the pinch from paying for health care will increase. Older people tend to have more health problems which are also often more complex.
The subsidised screening for older people shows that four in five need treatment for at least one serious condition. At that age, they can expect to live another 30 years.
They are tested for high blood pressure, high cholesterol and blood sugar. These often point to more serious problems, but there is medicine that can help keep them under control.
Some will need treatment to control these conditions for the rest of their lives. And this hits them at a time when many have retired from active working life and no longer draw a regular salary.
There have been suggestions that the Government should reconsider the use of Medisave for people in their twilight years, and allow them to draw on their savings for life-saving drugs.
Previously, people with such problems would succumb later to more serious illnesses like a stroke, heart attack or diabetes. And they would suffer for the last few years of their lives.
Today, they can do something about these conditions so they can live better-quality and longer lives.
But this means they also have to shoulder the burden of paying for longevity.
The stark reality is that if people are content with the standards of treatment and medication available a decade ago, they would not be faced with rising costs.
Drugs that were prescribed 10 years ago to lower cholesterol levels are very much cheaper today. Gemfibrozil cost 55 cents and Zoccor $3.15 a pill in 1992. Today, their generics cost eight cents and $1.55.
Now there are newer drugs and because these are still under patent, their price is high. One such drug is Lipitor (atorvastatin), often considered superior to other statins. A 20-mg pill costs over $4.
Crestor (rosuvastatin), hailed as the super statin in the United States, is expected to hit the market soon - and is unlikely to be cheap.
But newer and more expensive drugs may not always be better. It depends on an individual's needs.
According to Dr Tay Ee Guan of Hougang Polyclinic, for some' almost any statin will control their cholesterol level effectively' while others may need a particular drug.
Some of the newer drugs have fewer side effects, but again, he says, not everyone gets those side effects.
In their choice of medicine, most patients have to take their doctor's word for it.
Madam Low Soi Heang, 51, was diagnosed with high cholesterol during a subsidised health screening.
Her doctor at Redhill prescribed Lipitor at $200 a month. But she says this is too expensive on her line supervisor's pay, especially as she has two teenage children in school. Her husband does not earn              much either.
She plans to take the medicine for two months, then stop.
Some doctors consider their patient's financial concerns, others prescribe the drug they think is best, and yet others may be swayed by the sales pitches of drug companies.
Those who need a cheaper alternative can turn to the polyclinics' which charge $1.40 for a week's supply of each medication.
Those above the age of 65 pay half the price. Polyclinics today treat 50 per cent of people suffering from chronic illnesses.
LONG-TERM CARE
EIGHT to 9 per cent of people who are 65 and older need help in day-to-day life. The cost of such care can be very high.
Those who can afford to may hire a maid. Others may need nursing-home care or help from a home-help service.
The Government is launching an insurance scheme called ElderShield, which can be bought with Medisave money.
People who are insured and cannot do any three of these things without help - bathe, move from their bed to a chair, go to the toilet, eat, walk or dress - get $300 a month for up to five years.
This pay-out is based on what poorer people may need. The Government provides 25-per-cent to 75-per-cent subsidies for nursing-home care.
The cheaper nursing homes charge $1,000 to $1,200 a month. Those whose per capita family income is $300 or less are given a 75-per-cent subsidy. So they need to pay only $250 to $300.
This is where ElderShield comes in.
Again, it comes back to a question of choice - how much people want to pay for differences in the quality of care.
If people are willing to accept slightly lower standards and choose value-for-money treatments and care, then health care will remain affordable for the majority.
What clouds the issue is that health is a very emotional subject People do not always make rational calculations when the health of their loved ones is at stake.
The head may tell them to go for the cheapest treatment but their heart will say spare no expense in providing the best possible medical care.
Many people are like Mr Cheong. They are prepared to cut back on expenses in other areas to provide their family members with the medical treatment they need.
He is willing to forget about buying a car and continue riding his motorbike, and give up part of his take-home pay of $1,900, to pay for his mother's medical treatment.
His mother, seeing the financial strain on her children, wants to stop all treatment. But Mr Cheong tells her: ''I want you to recover so you can bring up my son.''
Copyright @ 2001 Singapore Press Holdings. All rights    
Hosted by www.Geocities.ws

1