24 January 1999

Health Care Reform should set off on the Right Track
("Letter to Hong Kong", Radio Television Hong Kong)

(Keywords: health care reform, financing, Harvard consultancy, service quality, user-pay, HMO)

          Of late, the purported "leaked" report of the Government consultant on health care financing has adorned the prominent pages of our newspapers leading to extensive speculations. How genuine are the "leaked" informations? Who initiated the "leakage"? Time will tell. The Health and Welfare Bureau has repeatedly indicated that it is not the "culprit", yet there is no smoke without a fire.

          In any case, such piecemeal informations with possible exaggeration and other inputs by the media have produced unnecessary concern, worry, frustration and much uncalled-for smear.

Release report to dispel speculations and worries

          The public become concerned of when and how much the current heavy subsidised public health care will be taken away. Both employers and employees are worried how much contributions they have to put in for their health on top of the already determined Mandatory Provident Fund. the health care profession are concerned that their professional autonomy, the way they practise medicine, could be controlled by a "central funding body" that holds the purse and acts as an agent, with doubtful professional support, to buy health care services for the public.

          The Hospital Authority is worried not only that it might be disbanded but that the suggested 10 to 12 regional bodies, which in essence are multiple "mini hospital authorities", will duplicate effort. Worse there will be no "one standard control". Even the insurance industry is concerned in relation to their future role, or lack of it, in financing health care.

          The only way to dispel all these misconceptions and frustrations is to put a stop to speculations through release of the full report and for the Government to come out with its own document expressing its approaches.

Unfair accusations against medical profession

          A quick scan through the media reports indicated the Harvard consultant's document has sizable sections devoted to criticising the medical profession. Criticisms, constructive or destructive, should always be welcome as they could bring on improvements. Yet most of such accusations, as reported, were uncalled-for, not basing on facts and belied common sense.

          To condemn a doctor for having a high income is against the principles of free economy as his/her emolument could well be related to hard work through protracted long hours of work.

          Yes, some doctors may ask for a high fee. Yet this is a free market where patients have a choice to seek another provider and where Government provides an equally high standard safety net at going away price. The crux of the matter is that patients must be informed beforehand the expected fees for them to make their decisions and choices.

          Since the Academy of Medicine was established by statute to set up specialty standards and vet qualifications, and a specialist registry instigated by the Medical Council, doctors practising as specialists are requested to have compulsory career long education, lest their names would be struck off from the roll. This scheme is now being introduced to all practising doctors.

          No doctors can work in a close shop nor has the Government handed over all their monitoring and controlling mechanism to the profession through a system of "benign neglect". The Medical Council, which discipline the profession, is at least 50% controlled by Government through its appointed members including representatives of the general public.

Means to ensure service quality

          The Hospital Authority is in charge of all the standards of public hospitals and staff, and it is accountable to the Government.

          Private medical institutes are within the monitoring remit of the Department of Health through issuing of licences. For years, some medical professionals have called for the Department to issue guidelines for standards of private medical institutes and to police their implementation. Regrettably, since 1990, nothing active has been done. Instead, Government still relies on a yearly hospital social visit and a copy of the hospital's annual report as their vetting yardstick.

          On the other hand, the medical profession should be open-minded to the issue that proper clinical audit is essential if we are to provide the best for the patients we serve. The profession must take a lead to exhibit our accountability to our patients. We need to put our heads together to study the need for a central body to set standards and initiate any necessary controlling actions.

Current health care financing system unsustainable

          If the purpose of the Government's consultant or the Government's brief to the consultant is to smear the medical profession and apportion the doctors all the blame to the projected ailing health care system, then the move is downright amoral. Let us do not forget it is the medical profession who has pointed out that the system of using a finite budget to provide infinite needs will soon face a fiasco. It is the medical profession who has consistently and persistently call onto Government to do a total health care revamp -- something 25 years too late!

          Talking about the unsustainability of the current public health care financing system brings on the other area of the purported leakage of the Harvard's consultancy report -- options suggested for health care financing.

          In my mind, any options of reform should meet the principles of: sustainable over time; ensuring good safety net for the poor; maintaining and improving service quality; increasing cooperation between private and public sectors.

Proposed options based on user-pay concept

          On that basis presumably, as reported, two options were put forward by the Harvard consultant for a short term and a long term goal. The options call for compulsory contributory savings and insurances. A fixed percentage of salary or income is used on a monthly basis by each individual during his/her working life to contribute to a saving fund. This amount will accumulate until the person retires when the sum so accrued will be used to purchase an insurance policy for future days. Meanwhile, his/her medical expenses in relation to hospitalisation and some chronic diseases will be covered by a similar compulsory contributory catastrophic insurance. Those with no work or inadequate contribution will fall into Government's safety net.

          The contribution money will be managed, as proposed, by a Central Funding Body.

          On a long term basis, as reported, the consultant proposed to organise Hong Kong into 10-12 regions. The health care service providers, be they public or private, will group themselves together to provide a total spectrum of health care. There will be both intra-regional and inter-regional competition to get patients.

Worrying role of the future Funding Body

          As a start, the proposed options are nothing more than a user pay concept. except that instead of having to fork out the money every time you are sick, the money is slowly accumulated and saved for a raining day. Secondly, the scheme so proposed are but a health tax in disguise. Further, until a significant sum has been accumulated, the scheme is not going to be effective. The estimation for materialisation is 10 to 15 years.

          What is the role of the Central Funding Body? If it is just a safety deposit box, the question is: why do I have to deposit my money in a central safe deposit and not in my own deposit box?

          One suggestion, as reported, is that this body will act as a health care buying agent for the population. This immediately begs the question of : on what basis does the body purchase service? The downside is obvious. If the benchmark is cost orientated, the scheme will lead to unhealthy competition of service providers. Overnight, health care becomes a price war with service providers cutting one another's' throat. Overnight, the concept of capitation will materialise, inviting the infiltration of the satanic Health Maintenance Organisations.

          The yardstick could be standards orientated, one might suggest. So be it, yet it needs a body the size of the Hospital Authority at least to be able to set standards, vet standards and continually monitor the standards of service providers. Anything less tantamount to pulling wool over the public's eyes. The administrative cost will thus be colossal, and if this sum is to be come out of the public contribution, then only a small percentage so contributed will actually be used to maintain health care.

Alternative simpler option warrant consideration

          Government should well consider a simpler option. If the concept of "those who can pay pays" is taken on board, then health care must be considered as both a welfare and a service.

          Anything catastrophic, or essential and an emergency, is a welfare for which Government has a total responsibility to provide through heavy subsidy.

          Anything else in health care is a service and must be purchased, be it from a public or private provider. For the super-rich, they can pay out of their wallet. For the poor and indigent, Government pick up the tab. Meanwhile, worried that they will have to pay their medical bill, many will be spurred to take up an insurance policy. The reported proposal of a compulsory contributory saving scheme need not be excluded. Instead, it should be welcome as another means to boost up our health care budget.

          The beauty of such an option is that it can start function from the word go. Overnight, the option can materialise. Overnight, some of the workload of the public sector will be alleviated; patients being siphon back into the private sector.

          The question is: how do we draw the line to separate what types of medical service is for welfare and which conditions are for service. It is not an easy task. It is a political decision that has to be decided by the Government, the service providers and the consumers.

          It needs a political will and determination by the Government to carry this out!

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