To push primary healthcare, make visits to GPs, polyclinics ‘free’

In an ideal world, our general practitioners (GPs) and family physicians would be the first and only stop for most Singaporeans.

It is in the primary care clinic that doctors should be assessing and advising patients on their risk factors and how to not get sick in future. In other words, making prevention as important as cure. But as most doctors are paid per consultation, there is no incentive for them to take a holistic, preventive health approach that looks beyond the immediate ailment.

Think about it, when was the last time a harassed doctor told you to stop smoking or get a cholesterol test? Patients who are ill with, say, diarrhoea or flu, also have little interest in whether they are due for a mammogram or Pap smear, not least because of concerns of additional charges.

Singapore is proud of its efficient health system. We spend less on healthcare as a percentage of gross domestic product than other developed countries. This is despite doctors and clinics here seeing many more patients per day, compared with their American or European counterparts. But just because we are efficient, does that mean we are effective?

Not quite.

Singapore does poorly in many diseases that can be avoided with stronger primary and preventive healthcare. For instance, more than 25,000 Singaporeans suffer visual impairment because of poorly controlled diabetes, with more than 8,000 blind in at least one eye.

The city-state also suffers the dubious distinction of having the fourth-highest incidence of kidney failure in the world. Every five to six hours, a Singaporean is diagnosed with kidney failure, with more than 1,700 new cases of kidney failure a year. The underlying causes are, again, poorly-controlled diabetes or high blood pressure.

Government healthcare spending has ballooned and is expected to increase from more than S$9 billion this year to more than S$13 billion in 2020. Policymakers exhort preventive healthcare and the primacy of primary healthcare, but our healthcare financing system currently does not really match rhetoric to reality.

‘FREE’ PRIMARY HEALTHCARE

As long as we impose copayments and pay GPs on an episodic basis, we are unlikely to ever enjoy fully the benefits of primary healthcare. Patients have no incentive to seek preventive care, and doctors have no incentive to offer it. Perhaps it is time to explore making primary healthcare “free”, with three points to note.

First, it is not really “free” to patients. Healthcare needs to be paid for regardless, and we are still paying; it is just that it is “free” at the point of care and we pay instead through taxes and insurance premiums.

In our model where hospital services are heavily subsidised for all Singaporeans, we may, in the current model, be perversely encouraging patients through skewed incentives to forgo early primary care — which is cheaper for the system as a whole — and opt for late expensive hospital care because of greater subsidies there.

Second, “free” primary healthcare would restore GPs and polyclinics as the first port-of-call for most patients, which is what it should be.

Finally, and this addresses fiscal concerns, a primary healthcare-centred system is, according to the World Health Organization (WHO), “the most efficient, fair and cost-effective way to organise a health system”. Dr Margaret Chan, WHO’s director-general, said: “Decades of experience tell us that primary healthcare produces better outcomes, at lower costs, and with higher user satisfaction.”

What could such a system be like?

For one, chronic-disease patients would be proactive in seeking medical advice, and healthy Singaporeans would adopt preventive health measures such as vaccinations and screenings. The increase in such consultations, coupled with GPs focusing on preventive health and good disease control, should improve our national statistics for stroke, heart attack, blindness, kidney failure and so on. And better care upstream should reduce hospitalisations and bring down their extremely high costs, as Dr Chan pointed out.

Some may worry about the deluge of Singaporeans rushing to GP clinics and the system collapsing under the increased volumes. A look at other countries with free primary care consultation will be instructive. In Denmark, residents consulted the physician an average of 4.6 times a year. Other Nordic countries such as Sweden and Norway have even lower rates of 2.9 and 4.2, respectively.

There might be some abuse for sure, but we should bear in mind that the financial impact of abuse here would be much less compared with unnecessary specialist services in hospitals for which Singapore subsidises as much as 80 per cent of the total charges. And we guard specialist care much less zealously.

One inappropriately-ordered S$1000 magnetic resonance imaging (MRI) scan could fund 10 to 15 GP consultations. Furthermore, underlying mental health issues such as depression can increase the cost of care for a condition such as diabetes four-fold, if not appropriately managed. Good primary care with easy access to doctors would encourage such patients to consult and enable the system to detect such patients early.

In the United States — which has the highest costs in the world — health insurance planners have recognised this. Chicago’s Harken Health has started a plan offering “unlimited, no charge health visits” to its primary care centres and free access to a “local, dedicated care team by phone, email, text or video chat”. Monthly premiums are not different from competitors, which have 20 per cent co-payments for services. Harken’s chief executive officer Thomas Vanderheyden told Modern Healthcare: “It’s reasonably proven that if you overinvest in primary care, you have lower downstream cost in the system. We’ll have to tweak this or that, but we have high confidence.”

Another American insurance giant Aetna is rolling out diabetes “leap plans”, which feature US$10 (S$14) copayments for consultations and offer free blood sugar test strips, glucose monitors and other diabetic supplies. Aetna also offers a care management programme with online tools and coaching. Patients also have financial incentives to adhere to treatments. They receive a US$50 gift card for getting a blood test twice a year, or a US$25 card for hooking up a glucometer or biometric tracker to the Aetna site.

Singapore will of course continue the transformation of primary healthcare the Ministry of Health has already undertaken to ensure the ecosystem is ready for a future of more chronic diseases and an increasingly ageing population. The delivery side measures are on the right trajectory, but we should explore ways to strengthen financing to drive the right behaviour.

As long as Singapore society refuses to let its citizens die because of their inability to afford healthcare, we are already paying for everyone’s healthcare. “Free” primary healthcare might simply be a smarter way to do it.

ABOUT THE AUTHOR:

Dr Jeremy Lim is head of the health and life sciences practice for the Asia-Pacific for Oliver Wyman, the global consultancy. He is the author of Myth Or Magic: The Singapore Healthcare System.