Are doctors in Singapore really guilty of over-servicing their patients?

Insurance firm Aviva recently made the news with a U-turn on its move to stop coverage of diagnostic endoscopies under its Integrated Shield Plans, after doctors raised concerns.

In announcing its initial decision to stop coverage of diagnostic endoscopies, Aviva had sent a letter to doctors in March, stating that there had been instances of doctors “over-servicing” patients.

This could drive up costs for policyholders, Aviva said, citing an example of a policyholder’s claims for 12 nose scopes in a single year “without clear medical need”.

While there is increased utilisation of diagnostic and therapeutic procedures, it must be kept in mind that by the ethical code of conduct and professional repute, doctors generally exercise restraint.

Here, I would like to explain what professional medical practice entails, what patients seek regardless of third-party payers such as insurance firms and what are the questions these pose for the way we approach healthcare and health insurance.

Let me explain using the example of “simple” hypertension (high blood pressure).

Professional and scientific societies have a consensus on what cut-offs of blood pressure determine the diagnosis of hypertension.

Blood pressure rises with age and life insurance companies know that people who have lower blood pressures throughout their lives than others, survive the longest.

Patients who have rising blood pressures, but are diagnosed to have hypertension and are treated, live longer than those who do nothing.

That is the evidence from the many clinical trials on treating hypertension.

Yet we have patients and families who ask: “Doctor, he was taking medications, why did he get a stroke (or heart attack or kidney failure or died)?”

It is because it is not possible to identify all risk factors and completely control them.

The choice of technology, method, and cost will determine the fidelity of medical assessment and management.

Let us discuss diagnosis, assessment, and treatment.

DIAGNOSIS

The diagnosis is usually made based on what is termed office blood pressure (clinic) measurements higher than 140/90 mmHg on two or more clinical visits.

Some patients have seemingly normal blood pressures in the clinic but have higher blood pressures at home (masked hypertension).

Normally, blood pressures dip while we sleep. However, some patients with treated hypertension and people “without” hypertension, are non-dippers; or have rising blood pressures. These patients actually have hypertension which can only be diagnosed by undergoing a 24-hour ambulatory blood pressure monitoring test.

The greatest impact to health from a public perspective is to make medical care for common conditions accessible, simple, and affordable.

The office measurement is the main method for diagnosis in primary care clinics. The typical patient will have a good chance of identifying hypertension and monitoring while on treatment. The cost-benefit is very good.

However, is the doctor who misses a case of hypertension because he did not use 24-hour monitoring guilty of under-servicing?

Or if the third-party funder that declines coverage of 24-hour monitoring guilty of causing bodily harm?

ASSESSMENT

To properly treat hypertension, doctors have to determine its underlying cause and severity in a patient.

By professional consensus on the minimum standards of care, an eye examination (blood vessels), electrocardiogram (assess heart damage or give clues that the heart caused hypertension), and blood and urine tests are obtained.

Current methods cannot identify all causes, and for most patients diagnosed with primary hypertension, you see the high blood pressure readings but cannot explain the cause.

For affordability, the testing is limited for third-party funded services. Unless one exhibits obvious signs implying severe hypertension, it is hard to diagnose a secondary cause without more tests.

For example, doctors will obtain serum potassium concentrations for the diagnosis and monitoring of hypertension. Low blood potassium concentrations may be associated with hyperaldosteronism.

Excess secretion of the hormone, aldosterone, causes sodium and fluid retention, leading to hypertension, and increases excretion of potassium in the urine.

At least 5 per cent of unselected hypertensive patients in primary care clinics may have this condition but only 20 per cent of these patients would have a low blood potassium.

But the test (aldosterone-renin ratio) is rarely done in primary care clinics but is more commonly ordered by specialists.

What this implies is that the public must understand that the moment they elect to use a third-party funder, some decisions are made on their behalf, and often these decisions are (or should be) based on a combination of actuarial, cost-benefit, and cost-effectiveness analyses.

When a commercial insurance company is paymaster, a further third party is involved.

This is the shareholder of the insurance firm, who is interested in the lowest benefits payouts and highest profits.

A government funder, on the other hand, will have to raise taxes to pay for benefits.

Ultimately, the public has to ask, if medical care is to benefit individuals, why is a third party asked to pay?

This is particularly true for lifestyle-related non-communicable disease such as hypertension. The individual who made poor health decisions leading to complications should not begrudge the higher costs of treatment.  

Insurance cannot pay for everything, and personal accountability is needed to restore moral equipoise.

TREATMENT

Hypertension is “easily” treated at younger ages by 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.

It is easy 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.

Most patients must take several medications to control hypertension.

When patients develop complications of hypertension, such as stroke, heart failure, or chronic kidney disease, the costs escalate exponentially.

Yet in most cases, the root cause of this is due to patients’ indiscipline in maintaining their health, rather than doctors overserving them.

PRIMARY CARE VERSUS SPECIALIST CARE

If the specialist does the same thing as the primary care doctor, why should he exist?

Patients presenting with hypertension to a specialist get a battery of tests that prove or disprove some of the causes of hypertension.

The specialist aims for definitive diagnoses and specific treatment. The specialist also manages more difficult to diagnose hypertension, or hard to control hypertension, or hypertension with organ complications.

Naturally, the public develops the impression that specialist doctors are “better”.

In the example of hyperaldosteronism, a doctor will typically find five patients with the condition if they screen 100 patients.

Screening allows the doctor to say to the 95 “negative” patients that they do not have hyperaldosteronism, and directs the five positive patients to specific treatment.

Is the doctor overservicing?

From a third-party payer perspective, the cost-benefit calculation may not be favourable. However, like most things in life, the perception of value lies with the recipient.

OFFERING ALL OPTIONS

Insurance companies cannot influence professional medical care because it can only stipulate what is a covered benefit or not.

A patient is provided the same professional service whether he is on a lower tier insurance plan, on government subsidies, or on an “as charged” medical insurance plan.

The recommendations are the same, but priority of access is determined by the covered benefits.

Actual access is a patient choice, as they have to assent to the test or treatment and co-pay deductibles or non-reimbursable items.

Competing medical insurance 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 insurance companies curtail coverage.

To be sure, I am not saying that all doctors are perfect and there could well be isolated cases of doctors ordering one test too many.

But most doctors understand and already work with constraints at all levels, such as poor patient health literacy, financial concerns, social support, amongst others.

Working within a formulary and standard tests are routine 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.

Insurance companies and government funders bemoan “over-servicing”, but this does not fully reflect professional medical practice.

The reality is that what you pay is 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.

The patient public sees the benefits of specialist care but cannot appreciate its economic model.

Yet they wish for the same level of service, resulting in the politicisation of healthcare 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 with ageing.

To guide the typical patient 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 define costs, and help with complex decision-making for patients with advance complications beyond the average age of life expectancy.

ABOUT THE AUTHOR:

Dr Jimmy Teo Boon Wee, a nephrologist, is an associate professor at the Yong Loo Lin School of Medicine, National University of Singapore. These are his own views.