Singapore - Fine balance needed between ethical, cost-effective healthcare

The $11 billion Singapore will spend on healthcare this year is, per capita, far more than what many of our neighbours spend, and yet, this will still grow disturbingly higher ("Focus on cost-effective healthcare"; last Saturday).

There is little corruption on our island, but there is an immense amount of wastage. Even if clinicians do not bankrupt a country, they can make premiums for MediShield Life rise to stratospheric levels.

The sick naturally want the best medical care that money can buy, and everyone wants universal healthcare to be available.

Yet, almost every patient who consults me feels that healthcare comes at too high a price.

Such is the conundrum and self-contradiction health ministries face.

It seems cruel and unethical, but healthcare, especially high-cost procedures such as MRIs and CT scans, or drugs that cost upwards of $1,000 a pill, should be rationed.

Treatments in all settings, but particularly in tertiary health institutions, should ideally be conducted after weighing their cost-effectiveness ratios and the amount of quality life that they provide.

Otherwise, clinicians would simply be treating for treatment's sake, with increasingly negative relationships between spending and meaningful outcomes.

Worse still, especially in the private sector, investigative or surgical procedures may benefit doctors more than patients.

A few good examples of cost-effective healthcare policies are measures to decrease smoking; counselling for caregivers of dementia victims; vaccinations to prevent flu, pneumonia and some cancers; sustained home nursing following by short hospitalisation; and even conservative treatment for heart disease and appendicitis.

Conversely, there is little quality added to patients' lives in doing repeated MRIs for the terminally ill, keeping fatally ill patients alive in intensive care through respirators, or proceeding with vessel stents and non-essential surgery where parameters are not met.

We have to avoid going down the slippery slope. A fine balance between what is ethical and what is cost-effective will take some great and well-thought-through formulations.

Yik Keng Yeong (Dr)

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