Health Care in Singapore

I've had the good fortune to be invited by the Singapore Centre for Biomedical Ethics to do a week of teaching about health system ethics. Right now I'm at Heathrow airport in London, in between the Boston to|London and  London to Singapore legs of my trip.

Although there's been a lot of interest in Singapore among health policy cognoscenti, I'd been in the dark about the Singapore system until I started preparing for my visit. My impression thus far is that the People's Action Party, which has governed since independence in 1965, sees health care as (a) a crucial contributor to well-being but (b) largely an individual responsibility to provide for oneself and one's family, and (c) not a right the state is responsible for fulfilling.

When Singapore became independent in 1965 it was impoverished, with a life expectancy of not much more than 60. The government's initial emphasis was on the determinants of population health - housing, clean water, jobs, and education. On the basis of their vigorous action, health and mortality improved markedly. In 1984 they introduced a mandatory medical savings account program - "Medisave" - in which all working people, including the self employed, contributed 6-8% of income to their "Central Provident Fund" account, to be used for their own medical care and for family members (spouse, children, parents and grandparents). In the 1990s the government introduced an insurance scheme ("Medishield") and a means tested fund for low income folks ("Medifund"). But there's still a very strong emphasis on individual responsibility and paying a fair share of the cost, even for the poor. (For information about the Central Provident Fund and the system of "3 Ms", see here .)

I've been told the Singaporean government sees "insurance" in a negative light. "Insurance" connotes dependency on the state and abdication of personal responsibility. In the U.S. the frequent comment that our health system is so out of control because the population lacks "skin in the game" comes from the same moral and economic perspective. As a dyed in the wool liberal I'm a staunch believer in a universal system - either something like Medicare for all or guaranteed access to strictly regulated health plans. The framework of values in Singapore is jarring for me, but their outcomes appear to be terrific, in terms of health indices and a much less costly system than we have in the U.S.

Since I recurrently criticize conservatives for what I describe as their "theological" commitment to market solutions, to be consistent I have to challenge my own liberal theology on this visit to Singapore. Stay tuned

Victor Fuchs on health reform

I've never met Victor Fuchs, but I've admired and learned from his writings for years. His article in this week's JAMA on "How and Why US Health Care Differs From That in Other OECD Countries" is a gem. Here's a summary:

US expenditures differ from the average OECD country in three ways:

1. As a percentage of GDP, US expenditures are twice as high.
2. The share of expenditures funded by government in the US is 46%, compared to a 75% average for other OECD countries.
3. The mix of services differs substantially - intense focus on technology vs more basic care.

Here's how Fuchs explains the difference, again in a series of three:

1. The US population has a much more distrustful attitude towards government - a trend with deep historical roots.
2. The US population is much less committed to equal outcomes through redistributive policies.
3. The US political system provides many "choke points" that allow special interests to block or reshape reform efforts.

Finally, Fuchs draws three practical conclusions for future reform efforts:

1.  "[G]overnment's role should be limited to what is necessary, not just desirable."
2. "[P]rovision of basic coverage for all should not require equality for obtaining additional coverage...individuals should be free to purchase more than basic care."
3. "[R]eform should have features that would appeal to some special interests, or to some elements within each special interest group."

Fuchs, who is presumably in his mid 80s (he graduated from NYU in 1947), is giving us the gift of his wisdom. His two page JAMA piece ends this way:

Comprehensive health care reform in the United States is necessary to avoid a financial disaster, but enactment of such reform will require attention to US history, values, and politics."

Fuchs' analysis is relevant for liberal critics of the Affordable Care Act. In the eyes of single payer advocates and other progressives, the ACA is a disappointing flop. But by Fuchs' three practical conclusions, the ACA was the best that could be achieved in 2010. The right approach for progressives is to do all we can to make it work.

Plastic Surgeon-Patient Sex

I recently received these questions about doctor-patient sex with a plastic surgeon:

My married sister's plastic surgeon called to give his condolences after the passing of our father. The doctor continued to call and fostered a personal friendship with her. He started to confide in her about his marital problems. They arranged to meet for dinner and entered into a 18 month affair. When my brother in-law discovered the affair, the doctor quickly abandoned her and started to make her look like the person who wanted the affair. My brother in-law filed an ethics complaint which is under investigation for over a year. I am the only person my sister will discuss the affair with, but not the only person that can see how the affair has affected her mentally. She is extremely depressed, filled with guilt and shame and has talked to me about ending her life. She refuses therapy, so I do the best I can to help her. Lately because of our conversations, I truly feel he took advantage of a vulnerable patient who was depressed over the loss of her father. She told me she had become dependent on him. Can you explain this dependence? She says she now knows how people follow a cult leader. Her pain is real and the result of a consensual affair with her doctor. He is not a mental health doctor; will he be held to the same standard? (emphasis added)

 In my response I emphasized that how important it was to help the patient accept counseling. Here I want to discuss the question of whether the plastic surgeon would be held to the same ethical standard as a psychiatrist.

To my eye, although the code of ethics for the plastic surgery specialty prohibits "sexual misconduct," it defines the term in a way that leaves patients and the profession vulnerable:

Sexual or romantic relationships with current or former patients are unethical if the physician uses or exploits trust, knowledge, emotions, or influence derived from the current or previous professional relationship.

The relationship between plastic surgeon and patient is intensely personal as well as technically demanding. Especially for surgery with aesthetic aims, patients entrust the surgeon with potential for making them look more the way they dream of appearing. For female patients, interventions may involve face, breasts, genitals, and their overall sense of "desirability." In terms of the question the patient's sister posed to me - the doctor-patient relationship in plastic surgery would seem to have all of the key characteristics that occur in mental health practice: exposure of deeply personal concerns, potential idealization of the clinician as a "saviour," and "transference" of feelings from the past. And, unlike psychiatry, ordinary practice involves disrobing and touching.

It's hard to see how a "sexual or romantic relationship" between plastic surgeon and patient would not draw in "trust, knowledge, emotions, or influence" derived from the professional relationship, whether or not the physician is consciously "using" or "exploiting" those factors. Even if passions are not involved, it would be very difficult to ascertain whether the factors the code of ethics prohibits were present. Sexual attraction and feelings of love are not known for inducing heightened intellectual and analytic lucidity!

I was unable to find any data on the frequency of complaints about sexual/romantic relationships between patients and their plastic surgeons. Unfortunately, a review of five years of complaints made to the ethics committee of the professional association did not report on the specific content of the complaints. But in light of the nature of the patient-doctor relationship in plastic surgery, I believe that the position of the American Psychiatric Association - that sexual relationships with current or former patients are unethical - would apply with equal relevance to plastic surgery.

In answer to the question posed by the patient's sister, I could not respond that the physician would be held to the same standard as a psychiatrist, but did say that I thought that should be the case.

Sex isn't the only lust that physicians succumb to

Money and power can also lead to ethical collapse.

A sad story today's New York Times tells how Dr. Sidney Gilman, a respected teacher and researcher on drugs for Alzheimer's disease, has been nailed for warning a hedge fund manager he'd been dealing with to dump a pharmaceutical stock before news of a failed drug trial became public. Gilman had access to the information from his role on an FDA panel.

From responses to a number of the posts I've written about doctor-patient sex, it's clear that physicians who violate basic ethical standards can be superb caretakers for their other patients. Dr. Gilman, now 80, apparently had an exemplary career in teaching and research. A neurology lecture series at University of Michigan Medical School is named for him. And a colleague reported that he frequently turned to Dr. Gilman for advice about ethical issues:

He always gave me rock-solid advice and counseled me to maintain transparency so as to avoid even the appearance of a conflict of interest.

Re Dr. Gilman's teaching about transparency, the Times reports that to avoid arousing suspicion about his consultation to the hedge fund about the Alzheimer's drug, Gilman asked his co-conspirator to label the consultations as about other, unrelated topics.

Dr. Gilman could do a service to medicine and medical ethics by sharing the inside story about how a physician who apparently conducted himself in an admirable manner for most of his career descended into obvious unethicality (and criminality) as he did. What steps led from honorable conduct to dishonor? Did he delude himself as to what he was doing, or did he make a Faustian bargain to proceed? Better understanding of the "mechanisms" that facilitate serious ethical lapses can help educators work more effectively towards prevention.

(For an interesting post from a hedge fund insider, see here.)

Accountable Care Sprints Ahead

A recent report from the Oliver Wyman consulting firm - "The ACO Surprise" - argues that ACOs are on the verge of triggering a major transformation of the US health system. I hope their prediction comes true!

For all the complexity of federal ACO regulations, I see ACOs as making four core basic commitments:

1. Take responsibility for helping a population be as healthy as possible
2. Connect specialties, disciplines, and sites (hospitals, rehabilitation, nursing homes) in a coordinated manner
3. Engage patients as active partners - ideally leaders - in promoting their own health and guiding their treatment
4. Accept payment for producing valuable results for the population, not for the individual units of service rendered

Here's the Oliver Wyman view of the near term ACO landscape:

• 2.4 million current Medicare ACO patients
• 15 million non-Medicare patients of the Medicare ACOs. The report predicts that the Medicare ACOs will move towards caring for all of their patients in the "ACO manner"
• 8 - 14 million patients to be cared for in non-Medicare ACOs

If Oliver Wyman is correct, it won't be many years before 10 percent of the US population receives its care in accord with the ACO philosophy. Insofar as ACOs are successful in creating more value for patients per dollar of investment, they'll come to dominate the marketplace.

In my physician hat I see the ACO vision as embodying the fundamental values that motivate most clinicians. The reason I joined the not-for-profit Harvard Community Health Plan practice in 1975 was because it was organized around those values.

In my patient hat, I've chosen to have my own medical care from one of the "Pioneer ACOs". I want my doctors, nurses and hospitalists (if I come under their wing in the future) to collaborate in what they do with, for and to me.

Some years ago a patient of mine was in a severe state of psychiatric crisis. The long term problem was a major psychiatric ailment, but the immediate challenge was getting control of acute alcohol abuse. I made what felt like a zillion telephone calls (this was before all parties used a shared electronic medical record) to alert all those likely to be involved with my patient to the clinical situation and what I was recommending. A week or so later my patient reported - with appreciation - "I spoke with nine different people last week and they all said the same thing..." The crisis subsided.

From the perspective of clinicians and patients, care delivered in accord with the first three ACO commitments listed above feels right. The three commitments meet patient wishes and reflect the underlying ideals of the health professions. The fourth commitment is what matters to us from the economic perspective. I share CMS's belief that doing the right thing in health care will end up saving money. But that will be a happy result of ACOs, not the reason for going down that path.

Politics vs Rational Medicare Reform

I'm a staunch New England liberal/yellow dog Democrat. And I support Howard Dean's organization - Democracy for America. But I shuddered when I received this message in a fund-raising email:

Republicans lost big in the election, but John Boehner is trying to force his right-wing agenda on the American people anyway. Republicans in Congress are taking advantage of the fiscal showdown and trying to jam through massive cuts to Medicare that would be devastating to America's seniors. (emphasis in the original)

Republicans, occasionally joined by renegade Democrats, have plenty of bad ideas about Medicare, like raising the age of eligibility (see here) and turning Medicare into a voucher program (see here).

But experts agree that at least 30% of what we spend on health care is waste. I've talked with lots of practicing physicians about this. No one has ever estimated waste at less than 25%, and many have estimated it at 50%.

The threat to Medicare is dumb ideas like vouchers and raising the age of eligibility, not the idea of reducing the trend line of cost increases. Doing that is an economic necessity for a thriving economy and a moral necessity on behalf of future generations and other social needs.

Dumb cuts "would be devastating to America's seniors." Clinically guided waste reduction would be a positive service, not a devastation. I hope that behind closed doors and away from sloganeering, our leaders - Democrats & Republicans - will move beyond demagoguery to consider how the federal government can promote prudent waste reduction in the Medicare program.

More about the Massachusetts Board of Registration in Medicine and Doctor-Patient Sex

There were two letters to the editor in today's Boston Globe about the Massachusetts Board of Registration in Medicine's decision to take away Dr. Gary Brockington's license. (See here for my original post.)

Nurse Mary Hourihan gives a perspective on Dr. Brockington's overall practice like what we've heard from patients of other physicians who have been disciplined for sexual relationships with patients:

As a nurse who has worked at the Faulkner Hospital for more than 30 years, I was shocked and saddened to read your article concerning the state Board of Registration in Medicine’s revocation of Dr. Gary Brockington’s medical license (“Board revokes Faulkner cardiologist’s license after affair,” Metro, Nov. 24). The doctor has cared for his many patients with the utmost professionalism and expertise. Although I do not work directly with him, nearly every day I hear from our mutual patients the reverence in which he is held.

The board is denying thousands of patients the skilled, sensitive care this extraordinary physician provides. I feel that Brockington and his patients deserve reconsideration of this decision.

Mary Hourihan

West Roxbury  

There's nothing surprising about the fact that a physician who displayed a serious ethical lapse with a patient may have been an excellent physician for most or almost all of his patients. (For example, see here.) In my own experience, a former colleague who I knew to be a superb physician, such that I referred one of my sons to him for allergy care, has been convicted for murdering his wife! In prison, he continues to evince the caretaking characteristics that were so prominent in his care of patients. (See here.)

Donald Ross, a physician colleague of Dr. Brockington, comes to the same conclusion I did - that if Brockington's relationship with the patient was a brief, one-time event that occurred during a period of major stress, the Board's actions were too harsh. But I don't agree with Ross that the Board's decision necessarily reflects "lack of compassion." A Board can impose a severe penalty and still regard to person being penalized with compassion, in accord with the precept that we should hate the sin but love the sinner.

In reading the story about Dr. Gary Brockington’s affair with a woman who was a patient and a co-worker, it strikes me that the reaction of the state Board of Registration in Medicine was over the top and lacked compassion in its response (“State revokes Faulkner cardiologist’s license after affair,” Metro, Nov. 24).

Perhaps there was poor judgment involved, but this does not sound like a case in which a doctor used his position in the doctor-patient relationship in an exploitative way. Brockington was also going through a difficult time in his own personal life at the time, and sometimes we don’t make our best decisions under such circumstances.

Perhaps it would have been more appropriate to require Brockington to enter a counseling program rather than imposing what is essentially a death penalty to his career.

Dr. Donald G. Ross

North Andover

As I said in my original post, if Brockington's relationship with his patient was (1) brief, (2) a single occurrence in his practice and not a pattern, (3) occurred at a time of major stress, and (4) preceded by years of responsible caretaking, than (5) permanent loss of license seems too severe a penalty. This is not a matter of compassion but of realism. Some perpetrators of unethical behavior can be rehabilitated and will be able to serve others in a reliably ethical manner.