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NO FREE LUNCH

Introduction 
It was Milton Friedman that coined the famous phrase. “There is no such thing as a free lunch”. Implicit to this statement is that there is a cost to everything. Health is no exception although some may beg to differ.

Defining and Differentiating “Need” and “Demand” 
A surplus or shortage exists because there is an imbalance between demand and supply. Demand must be differentiated from need. Need necessitates, demand desires. The most fundamental question here is that are we here to meet needs or are we here to satisfy desires? Secondary to this question is, what and who defines what is a need, and what is a desire? Is subsidised health care available to all (I stress, ALL) a need or a desire? Is being a hub a need? Is yet another high-technology gadget or another a new department or polyclinic a need or a desire?

Having decided that perhaps all the above and many other issues and objects as needs or desires, do we, the medical profession as part of the health care community, decide whether it is our business to arbitrate between these needs, desires and the available, albeit insufficient resources?

I believe that needs should be met. Real needs. By whom? That is the question. Is it by the private sector, the public sector or both? Or maybe, the health sector should not get involved at all! But some needs will have to be met by the health sector regardless. Needs of not just the public, but our internal customers, the health care workers as well.

A Very Demanding Problem 
The problem remains at the focal point of demand. Or more precisely, managing a situation of shortage or surplus that arises out of an imbalance of demand and supply. The health sector has traditionally managed this imbalance by usually managing only one side of the supply-demand equation: the supply side. Let us go through a few examples:
1. Not enough medical officers: increase medical students intake (i.e. increase supply)
2. Not enough polyclinics: open more  
3. Too many people overcrowding A & E departments: open clinics adjacent to A & E     
    (provide substitute services)
4. Too many medical officers in civil service (in the past): early release.
 
All these are measures designed to regulate the supply of resources. There is nothing wrong with managing supply. Managing supply is crucial to addressing shortages and surpluses. But equally important is that of managing demand. The recent initiative to raise A & E charges is a step in this direction. Let us hope that a petit allegro will lead to a grand jete in time to come.

Tackling Demand 
Whatever the case may be, it is perhaps time to think more about managing demand in health care. Especially, the tougher and often unpopular options of managing demand: denying demand, making demand punitively expensive and shifting demand elsewhere. This is because the demand for health care resources is insatiable. We simply cannot just think about relentlessly increasing supply to meet escalating demand. We will have to modulate demand itself. Both sides of the demand-supply equation have to be managed just as intensely. If not, we may then be immured in an insoluble and insolvent mathematical and economic quagmire.

We Need A Grand Plan 
Where so we go from here? First, in addition to tackling demand itself, there could perhaps be a more integrated approach to managing demand and supply. First, the question of ”who does what” has to be tackled. If the money is in performing procedures, then more people will gravitate towards intervention work. Common sense dictates this is so, as the economically shrewd will not want to get enmeshed in a monetarily low-yield non-interventional service. (Please don’t laugh, if defense companies can make roast duck, nothing is impossible). The management of demand and supply has been somewhat parochial in outlook so far, with each institution and organisation managing their own microclimate through gradual attenuation, these efforts being usually directed at meeting demand. A grand plan is needed. A plan that provides for the equitable distribution of rewards, not a promenade of half-hearted efforts.

Money Talks (and Does Much, Much More!)
Next, the question of “how” arises. There are essentially 3 ways to balance the demand and supply act:
1.  Administrative measures 
2.  Professional measures 
3.  Financial (funding) measures.

There are now more and more moves to improve professionalism and regulate the way doctors work. Efforts to increase the supply of doctors and nurses also fall into this same vein. Administrative measures such as increasing opening hours of some clinics or opening new clinics next to A & E departments have also been tried. These are effective measures. But there really is a limit to what these 2 can achieve. More is needed. We have to perhaps start relying on the third arm of measures: financial. Let us go through 2 examples that underlines the power inherent in financial measures:

Pay more to pay less.... 
If a civil servant can get cheap and non-standard medication from a SOC with minimal fuss, then he would loath to get it from a polyclinic, though cheap, comes with a mountain of paperwork, or worse, pay more to the GP. Perhaps if we raised the claimable amount by a civil servant for seeing a GP from $10 to $18, we may reduce significantly the workload in the polyclinics and cut expenditure, bearing in mind that the average cost of consultation in the polyclinic is more than $19. Nett result: civil servants go to their GPs for simple ailments like flu and even chronic conditions such as hypertension if there are not many medications. They do not wait so long at their GPs, polyclinic workloads and waiting times also improve. Best of all, it now costs the government $18 instead of $19++ to do the same job. Civil servants probably pay $1 to $2 more for flu, but nobody should complain....Not when waiting times shorten and consultation can take place in GP clinics at night, away from productive and precious office hours.

Pay more and keep paying more.... 
If a health care institution receives subvention proportional to the amount of work done, it would hate to discharge patients. Not only is demand not curbed, there is little incentive to remove inappropriate work. The commercially enterprising may even look for more work. And when work in not easy to find, one can always go on a conquest of other territories and fiefdoms. Revenue caps are effective, but frankly, I never had problems spending money, I only have had problems earning it. The end-result is an all enveloping miasma of more and more work, and a growing morass of more and more subvention. Will DRGs(Diagnosis Related Groups) work? Will Balance Billing do the job? Nobody can be sure now, but at least we should agree that financial measures should be considered and tried.

Conclusion
The "how", "who", "what" and even "where" of arbitrating demand and supply in health care. There should be no scared cows. We either slaughter a few obstreperous ones now, and watch them bleed, or all of us shall bleed later on. There is no such thing as a free lunch.