Consultations in Singapore; how much should doctors earn?

“A sick often has neither the time or inclination to shop around to determine what a reasonable price should be.” “Time now for a guideline”, Straits Times Editorial, 20 Jan 1982

That was 25 years ago. Now, this decision by the Singapore Medical Association (SMA) will allow doctors to adjust their consultation fees as they please.

Singapore Medical Association withdraws guidelines on fees

SINGAPORE : Doctors now have more flexibility to adjust their fees, following a decision by the Singapore Medical Association (SMA) to withdraw its guidelines on fees, as of 1 April.

In a letter to its members on Monday, the SMA said it had been advised by its legal advisors that its fee guidelines contravened the competition act (Sect 34(2) (a) of the Competition Act).

But the SMA has also urged its members not to vary pricing drastically.

This is so that there will not be unnecessary increases in healthcare costs.

The SMA added that charges levied by doctors should be “appropriate and within reasonable limits”.

The Association also highlighted that under the “Private Hospitals and Medical Clinics Act and Regulations”, doctors would have to advise their patients, before consultation, on charges that were likely to be incurred for consultation, investigation and treatment.

SMA will be conducting a survey later this year to find out the prices of the various charges in primary care clinics.

In a reply to the public outcry, Competition Commission responds to media queries on SMA’s withdrawal of Guideline on Fees (GOF).

1. SMA has decided to withdraw the GOF based on advice that it has received from several of its legal advisors. The CCS welcomes this decision.
2. Competition authorities agree that fee guidelines are generally harmful to competition. The CCS believes that fee guidelines are inappropriate in today’s circumstances. Giving flexibility to medical practitioners to set their own fees in line with their business costs will ultimately benefit consumers.
3. The CCS would encourage medical practitioners to display their consultation fees so that consumers can make informed decisions. MOH’s website currently provides consumers with information on hospital bill sizes. This has enhanced competition between hospitals, which has in turn benefited consumers by bringing about more competitive prices.
4. The CCS would welcome other associations to take SMA’s lead and replace their fee guidelines with a system of published prices. This will also allow other consumers to benefit from greater transparency and competition of prices.

SMA President Dr Wong Chiang Yin posts a reply to the whole issue “Could SMA have not withdrawn the Guidelines of Fees (GOF)?“

 

 

 

 

 

Implications for patients with withdrawal of GOF

 

 

From now on, when questioned about charges, doctors can tell their patients that there is no guideline whatsoever. This is the fee i am charging you. Perhaps the patient will only discover that when he/she pays at the reception. Perhaps he/she will feel disgruntled when leaving, however, can he/she do anything? Lodge a complain to Cosumers Association of Singapore (Case)? Decide never again to see that doctor who he/she feels is overcharging? Decide to seek a 2nd opinion? Compare various doctors’ standard of care vs cost ratio? Complain to SMC? (oh too bad, SMC is in no position whatsoever to decide if the charge is reasonable or not! You removed the guidelines remember?)

 

 

 

Comments on Singaporean doctors’ blogs have been rampant since this happened. Angry Doctor has a series on “How much is that doctor in the window?” (comments here)

For fear of doctors’ overcharging, Health Ministry is to monitor fees charged by private doctors.

SINGAPORE: Health Minister Khaw Boon Wan says his Ministry will monitor the charges levied by doctors on patients.

And it will gather information from private clinics and publish the data, like what it has done for hospital bill sizes and some clinical procedures.

This is possible as the Ministry is already gathering data from the Chronic Management Programme, where half of all GPs here are on board.

Mr Khaw says doctors should also display their fees as required under the Private Hospitals and Medical Clinics Act and Regulations, so patients know how much they have to pay before they decide to seek treatment.

He was responding to questions on what the Health Ministry will do to ensure doctors do not overcharge their patients, following the withdrawal of the Guideline on Fees by the Singapore Medical Association (SMA).

“Singaporeans are educated consumers, so they should demand all those. If you go to a clinic and find those things are missing, then I think vote with your feet, go to another clinic which does so. Why should you be blindly going to that clinic? So I think providers will react if consumers are demanding and discerning. And I think part of public education is to help them, that they have a right as a consumer to know how much the bill will be and so on.” Mr Khaw said.

So, how much should doctors earn then?

This issue has led to doctors beginning to ask themselves a question i am sure did not preoccupy them when they were at the medical interview. (at least for that 15min duration) - the question of how much doctors should be paid.

angry doc is but one of them.

Kent Bottles shares his views on “How much should doctors make: Salaries, happiness, life and meaning“. He refers to an article named “The wages of healing: ethical issues in the compensation of physicians” by Richard B. Gunderman and Mark Adam Hubbard (Med Sci Monit, 2005; 11(2): SR5-10). Gunderman concluded by observing that factors other than compensation contribute to satisfaction with a job. The presence or absence of intellectual challenges, opportunities for growth, appreciation from co-workers, and meaningful interaction with others may all contribute more than money to a person’s level of job satisfaction. These observations echo Peter Drucker’s description of what make for job satisfaction among knowledge workers: challenges, continuous education and growth, measurable results, believing in the organization’s vision, and believing individual efforts make a real difference.

I like his conclusion to this matter:

“As we in the MPM Community make our practices run more efficiently and cut costs to increase the bottom line, we perhaps should also pay more attention to less easily quantifiable factors that make being a doctor special and meaningful. Perhaps the current malaise affecting many American physicians is less about eroding reimbursement and more about wondering if we lead meaningful professional lives that make a difference for ourselves, our patients, and our communities.”

Atul Gawande speaks on medicine’s money issue in the New Yorker as well. Excellent writeup!

Meanwhile, UK GPs enjoy lucrative salaries and are gloating about it.

Dr Simon Fradd says he was astonished at the offer

Overall the contract, which started in 2004, has seen pay increase by 60 per cent in three years to more than £100,000. Health experts said the comments showed that doctors were being paid too much for too little work, while opposition parties lambasted government “incompetence”. GPs’ negotiator Dr Simon Fradd’s admission comes in the week that the government said it wanted to rewrite the GP contract to offer doctors more money to start working again in the evenings and at weekends. The new GP contract, which began in 2004, allowed GPs to scrap their responsibility for out-of-hours cover, in return for a pay cut of £6,000 a year.

Addendum (17 May 2007):

1. “Why withdraw doctors’ fee guidelines when healthcare sector is clearly competitive?” - A letter from Chua Soo Kiat
2. “Financial pressures and monetary incentives have changed the way this internist practices. Will they change you, too?” By: Richard J. Mansfield, MD

Personal thoughts

As much as doctors would not like to let money cloud their clinical practice and care of patients, it is a practical world and often this issue has to be addressed. I do not think we should be viewed as lawyers, with patients as our “clients”. The doctor-patient relationship is a special one, that involves healing and genuine care. The consultation fee is a compensation or appreciation i would say, for the technical expertise that the doctor has offered. I would say for most doctors the appreciation goes beyond the treatment and management of medical issues, but also the kind of care that has been rendered.

Nonetheless, all these has brought me to remember my late grandfather who practised in the historic town of Malacca, Malaysia. He was a traditional chinese physician, and in the effort not to let profits cloud or put doubt on his philosophy of humble service to the community, he only prescribed medicine, and did not sell them. He could have well prepared and sold the brews and concotions as well, making money out of it. However he did not.

There he sat at his consultation table, always feeling intently for the radial pulse and diagnosing the problem from there. No stethoscopes, no blood test, no CT scans, no CXRs, no MRI, no ultrasound.

And there on his table was a stack of red packets, of which the patients will simply put in the amount they desire - a token of appreciation to the doctor. No guidelines of fees. No compulsion. Medical care for all. We return to the time of no guidelines for fees, only this time round, worries abound on the upper limit and the lack of control of physicians on over-charging.

Idealism. Practicality.

What do you think?

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