Medical care during Covid-19 and circuit breaker — 3 issues to address

In line with the circuit breaker measures that require schools and non-essential businesses to close, the Ministry of Health (MOH) had issued a directive on April 6 asking all medical practitioners to defer non-essential medical care from April 7 until after May 4.

MOH defines essential medical services and procedures as “those, if not provided or performed, would result in significant or rapid deterioration of the patient’s medical condition, and potentially threaten his or her health and well-being”.

Examples of essential services include wound dressing, cancer treatment as well as obstetric and child delivery.

Those deemed non-essential include aesthetic services, surgeries for stable cataract or stable joint arthropathies and health screening.

Since issuing the directive, MOH has sent auditing teams to clinics and hospitals to check their appointment and operating lists, and to ensure that doctors comply with the regulations.

As a gastroenterologist and hepatologist in private practice, I would like to share how some of my patients have been affected by the rules and discuss some issues about liability and insurance that should be addressed.

Let us start with three patients of mine.

Mr A, 90, was admitted for intestinal obstruction, pneumonia and acute kidney injury. He is fighting for his life in the intensive care unit (ICU).

Mr B, 60, has advanced colon cancer and was hospitalised for chemotherapy. He had chemo-related toxicity, with symptoms such as abdominal cramps, diarrhoea, numbness of the feet and poor appetite.

Mr C is a 40-year-old colon cancer survivor. He needs a colonoscopy every few years to survey for recurrence of colon polyps, a pre-cancerous condition. His next colonoscopy was scheduled for early April.

When he called to confirm the timing of his scope, I told him to reschedule it after May 4 as I deemed it non-essential.

These patients do not have Covid-19. But they have been affected by the circuit breaker regulations.

In hospitals, no visitor is allowed to visit or stay in with inpatients. There are exceptions for special circumstances, such as paediatric patients or those who are dangerously ill, where one relative can stay in.

Mr A is one such patient. He is married with five children and has many grandchildren. Though they want to visit and encourage him, only one visitor is allowed at any time.

Mr B’s condition is not critical or life threatening, so he does not get an exemption for visits by his family members and has had to endure the treatment side-effects alone in his hospital room for several weeks now. But he has a kind disposition and reads to pass the time.

Fortunately, advances in telecommunication and free Wi-Fi in the hospital mean patients such as Mr A can communicate with their family members via video calls.

I also speak to Mr A’s son daily to update him on his father’s condition, instead of my normal practice of doing so in person.

As for Mr C, he is a working professional who understands the importance of the circuit breaker measures and why his surveillance colonoscopy has been postponed.

Do not get me wrong. I support the circuit breaker measures and MOH’s decision to limit medical care to only essential cases.

In doing so, we avoid having too many patients and relatives crowding at hospitals and clinics. There would be fewer people on public transport, and hence, the chance of spreading Covid-19 in the community is reduced.

Generally, medical professionals and patients understand the rationale of the circuit breaker measures, too, and are not complaining about the inconveniences caused.

There are, however, issues that need to be addressed. I have identified three below.

1.       What is non-essential care?

MOH has a list of essential and non-essential care. But in real life, the cut-off is not so straightforward.

For example, cataract and joint replacement surgeries are labelled as non-essential surgeries that ought to be postponed till the circuit breaker is over. But some patients with dense cataracts are almost blind without surgery. And some patients with worn-out knees are totally immobile without knee replacement surgery.

While their lives are not in imminent danger, delays in treatment mean they have to endure more pain and suffering, especially in the more serious cases.

Yet doctors run the risk of being penalised by MOH if they proceed with surgeries. MOH’s directive did not state the penalties, but doctors are understandably wary of running foul of the authorities.

I know of some surgeons being called up by MOH auditors to explain why they performed certain surgeries like cataract operations and endoscopies during the circuit breaker.

There will be some grey areas on what constitutes essential versus non-essential care.

MOH’s directive adds that the final approval for patients to get treatment during the circuit breaker lies with the doctor in charge, and “approval given to access care must be balanced against the safe distancing consideration and risk of community transmission of Covid-19”.

Perhaps MOH can set up a hotline where doctors can seek urgent clarifications and apply for waivers of such treatment.

2.       Waiver of liabilities during Covid-19 crisis

The Covid-19 (Temporary Measures) Bill provides temporary protection for businesses and individuals who cannot fulfil a contractual obligation due to the outbreak.

The decision to delay a patient’s appointment lies with the doctor, based on his assessment on whether treatment is essential.

But non-essential care does not equate to unimportant care.

For instance, I have postponed Mr C’s surveillance colonoscopy till after the circuit breaker. There is no certainty that it will end on May 4, and even if it does, whether all the restrictions will be lifted. The Government has said as much.

What if Mr C’s colonoscopy is delayed by several months, and invasive cancer is discovered in the delayed scope?

Can Mr C file a complaint with the Singapore Medical Council against me? Or can he take up a civil suit against me seeking compensation?

It is important to give doctors the same peace of mind that the Government is giving to struggling businesses affected by the pandemic.

With a waiver of liability during the Covid-19 crisis, doctors will be more willing to delay care that they deem non-essential.

Otherwise, doctors may err on the side of caution and continue to provide care to seemingly non-essential medical conditions.

3.       Post-discharge insurance coverage

This is a topic that has not been explored.

Most integrated shield plans cover their insurance clients’ hospitalisation and post-discharge outpatient care for three to 12 months, depending on the insurer and its policies.

Post-discharge medical care beyond the coverage will not be reimbursable.

This condition compels patients to want to see their doctors for routine follow-ups even during the circuit breaker.

If a patient is admitted for a medical condition on Feb 10, for instance, his post-discharge outpatient care may be reimbursable only till May 10.

This patient is unlikely to be willing to have his follow-up appointment delayed till May, as he will have to pay for the follow-up consultations and medication without insurance cover.

The Life Insurance Association of Singapore should consider extending post-discharge outpatient medical coverage by, say, another three to six months.

This will help doctors convince patients to have their non-essential medical care delayed.

I hope MOH will consider the suggestions above.

While doctors join the rest of the society in fighting Covid-19, MOH and the multi-ministry task force also ought to fine-tune their policies and correct any unintended consequences from the various policies.

Eventually, all aspects of society, including healthcare, will adjust the way business is conducted to help contain and control the spread of Covid-19.

ABOUT THE AUTHOR:

Dr Desmond Wai is a gastroenterologist and hepatologist in private practice.