Letters to the Editor
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THE COSTS OF MEDICAL CARE TOMORROW
Professor Arthur Lim, in his Medical Alumnus Lecture on NUS Alumni Day on 5 September, discussed the issues facing the medical profession and the government in the next millennium. One of the chief concerns was escalating healthcare costs.
Relentless blind pursuit of medical high technology can indeed bankrupt governments. Entrepreneurs, both in and outside of the profession, who argue for the commercialisation of medicine, can hasten the demise of governments. The campaign to introduce advertising and free market medicine in which investors insist on maximising their returns has a similar effect.
The needs and wants of the public may be confused in the world of advertising and free market forces. Advertising necessarily emphasises the positive while relegating the negative to fine print. Caveat emptor may become the only protection for patients. The only thing to pray for may then be not to fall sick at all amidst this confusion. It is for the protection of patients that medicine has until now forbidden advertising. People in business scoff at this so-called old-fashioned idea. However there may come a day when the medical entrepreneurs shout loud enough to overwhelm the voice of those with less avande garde medical thinking. Will they, by succeeding in doing so, bring governments closer to ruin? If one considers the cost-benefit ratio of healthcare expenditure in the past and compare it with the costly advances of medicine today, the worry becomes real.
High technology is appealing to its practitioners, politicians and the public. However the return on such investments to the nation is often not substantial. Does this matter? The same sum of money invested in effective primary care for the management of many acute and chronic medical problems may bring health to many more people. Also, the overall economic productivity thus salvaged may be greater than what high technology is able to do. Very often high technology results in the prolongation of poor quality life. There is of course, a need not to be nihilistic. There is a need to strike a middle path between innovation and the tinkling with expensive gadgets with the medical nihilism of Ivan Ilich. In other words, there is a place for technology but its limitations must be acknowledged.
Prof Lim suggested that the doctors of tomorrow might become the "digits" of non-medical administrators. However, there is another possibility. Instead of doctors becoming so, the medical profession in and outside of institutional care could work with medical administrators to consolidate the health care delivery system.
The non-medical administrator should be an ally and not a foe. The medical professional and the non-medical administrator can together chart a way through the rocky terrain of healthcare. This hospital administrator (probably non-medical), has been cynically described as one who is the driver of a car that he has little control of, being advised by the professional backseat drivers on the direction to take and all that he can do is to jam the brakes now and then. The solution lies in non-medical administrators imbibing the cultural values of the medical profession. Medicine is an inexact science. The challenge is not having a hard-nosed cost accounting mindset but to think in terms of maximising resources for human recovery and repair. This begs the question of the raison detre of medical institutions: are they non-profit social organisations or commercial enterprises?
Many things can be done to help reduce health expenditure. The first is to educate the public on what they can realistically expect their doctors to do. The media has a new task the de-marketing of health care. With each marginal and untried innovation highlighted by enthusiastic reporting, false hopes are raised. This gives way to anger and disappointment when they fail to deliver or when their true costs are known. People have forgotten that in reality, there is such a thing as the inevitable.
Next, there is a variation in standards of care that can be reduced by better communication and the sharing of knowledge. Evidence-based medicine tells us to some extent, but not entirely, the limits of the medical professions armamentarium. Yet, such information is not often disseminated widely enough for all practitioners to be aware of. Clinical practice guidelines and clinical care paths can help to guide practice towards cost-effectiveness. What is also needed is the wisdom to understand the limits of such guidelines. What must be recognised is that there is no such entity as the "average patient". Hence, guidelines and care plan must factor such uncertainty in its statements. Also, the guidelines are meant as clinical signposts and not as legal benchmarks of standards of care. Legal benchmarks if desired should be drawn up with a different agenda. It is important to reiterate that clinical guidelines are not legal benchmarks of care.
The third thing to consider in the reduction of health expenditure is the implementation of seamless care. This is a challenge to health care organisations around the world. With it in place, there can be less duplication of resources and care given for cross-purposes. For it to work, organisational goals must be subsumed under national goals. Otherwise costs will merely be shifted, not saved. The implementers of case-mix funding and DRG need to tackle these issues if the new gadgets of health financing are really going to make any difference to cost containment.
The fourth and most difficult thing to consider is the primary interest of healthcare. It is only when the profit motive is secondary or even absent, that healthcare can truly be said to be for the sole benefit of patients. This is where non-medical administrators need to touch base with the doctors under them. In business, the goal is to maximise the return on investment in dollar value. In medicine, the return of investment lies in maximising the use of resources for a better outcome if that is possible, and the best repair which can be made given the existing resources. Therein lies the dilemma that doctors and medical administrators need to overcome.The world of medicine tomorrow hinges on how affordable it can be made. With concerted efforts of the medical professional, the politician, the medical administrator and the public, together with a good understanding of the role of medicine, healthcare need not bankrupt governments or the people. It should not.
A/PROF GOH LEE GAN