How Do You Solve A Problem Like Health Reform: Has Singapore Got It Right?
November 12th, 2010
by Parmeeth M.S. Atwal
Parmeeth M.S. Atwal
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Editor’s Note: This week, senior health policy experts and emerging health care leaders from around the world have gathered in Salzburg, Austria, where the Salzburg Global Seminar, in association with the Nuffield Trust, has convened a health care series titled, “Reforming Health Care: Maintaining Social Solidarity and Quality in the Face of Economic, Health and Social Challenges.” Health Affairs Deputy Editor Parmeeth Atwal is attending the conference as a Knight Fellow and is provide periodic blog posts on the proceedings. Below is his second post. His first post can be found here.
A portion of the program at the Salzburg Seminar has been devoted to case studies. Participants from several countries have presented their respective national approaches to health system reform. Such information exchanges have yielded some unexpected insights that have had the assemblage talking.
One interesting tidbit, for example, was brought to us by Naoki Ikegami, chair of the department of health policy and management at the Keio University School of Medicine. In describing Japan’s experience with squeezing out health care cost savings in tight fiscal times through greater efficiencies, he noted that the relatively lower salaries Japan pays its physicians have not resulted in physician outmigration to greener pastures for the rather prosaic reason that the vast majority of Japanese physicians only speak Japanese, and the medical text books through which they were taught are also generally only in Japanese. This language barrier keeping Japanese docs at home, Dr. Ikegmai told me, is borne out by relatively low Japanese physician scores on ECFMG (Educational Commission for Foreign Medical Graduates) and TOEFL (Test of English as a Foreign Language) — the tests screening which foreign doctors get to practice in the U.S.
It was the health system reform model presented by Singapore, in the person of that country’s Deputy Chief Medical Officer Dr. Lee Chien Earn, however, that created the most buzz among attendees. He told us that when Singapore first articulated the philosophy that would guide its reform efforts in a 1993 government white paper, they were faced with population health and fiscal challenges familiar to most western, developed nations: rising health care costs coupled with rising demand and patient expectations for increasingly expensive new treatments, and a projected tsunami of chronic disease.
Dr. Lee said Singapore began its reform efforts from the premise that “there is no free health care” — insurance premiums have to be paid by the insured, and employee medical benefits are paid for through wages and taxes. The trick, of course, was how best to structure and finance a health system in which high quality care was affordable and universally accessible.
The Process
Singapore set out to build a system that (1) promoted health and wellness through personal responsibility for one’s own health while avoiding “overreliance on state welfare;” and (2) provided “good and affordable basic health services” to all citizens, relying on competition and market forces to improve service delivery and efficiency, while retaining the prerogative of the state to intervene directly when the market failed to keep health care costs down. To determine the precise care mechanisms to achieve these goals, Singapore’s health decision makers took a pragmatic ‘adopt’ and ‘adapt’ approach. They traveled abroad and saw what models worked. They then picked elements a la carte (including from Kaiser and Geisinger in the U.S.), modifying them to suit local conditions.
The Model
The end result was that Singapore started with the British National Health Service model they inherited, and then grafted on elements of the U.S. private insurance market and the “European risk-pooling insurance system.” Their health care financing system combines a compulsory health savings account (Medisave), a high-deductible health insurance (MediShield), with a tax-funded safety net (Medifund plus “heavy government subsidy”). In short, Singaporean workers start accumulating funds in their health savings accounts early, theoretically saving enough to pay whatever health costs come along later while having catastrophic protection. The health care costs of low-income people, presumably without the means to save enough, are defrayed by taxpayer-funded subsidies. In Dr. Lee’s words, Singapore has achieved universal coverage “by offering multiple layers of protection.”
Singapore has also implemented a coordinated national initiative to build a high quality health care workforce through the Healthcare Manpower Development Programme (which pays for its specialists to be trained at centers of excellence abroad), and by investing in medical education at home. Equally important, Singapore’s health infrastructure operates within a regulatory regime relying heavily on self-regulation (of hospitals and providers), coupled with a heavy emphasis on ensuring transparency in health care costs and clinical outcomes. Health care entities are required to publish the volume of cases, average length of stay and the size of medical bills by percentile, and the government periodically measures and publishes clinical outcomes data.
Challenges
A number of ongoing challenges confront Singapore’s health policy makers. Among them: improving integration and coordination between and among primary, acute, step-down and long-term care providers — as Dr Lee puts it, ensuring patients “the right care at the right setting at the right time.” Another challenge: instilling in providers greater willingness to be measured, as well as an ethos of “doing the right thing even when no one is measuring or when the patient doesn’t know better.”
A third challenge for Singapore is achieving better engagement of health workers in efforts to improve health care delivery processes. A final challenge on the consumer side is giving patients the tools to be more informed, active participants in managing their own health.
Whether Singapore has ultimately struck the right balance between market forces and regulation in its health care redesign certainly bears watching. In the short term, the nation’s experience seems to illustrate what many participants at the Salzburg Seminar have been discussing over the course of this week: the seemingly greater willingness and tendency of smaller nations (of varying income levels) to pragmatically look beyond their borders for solutions to the endemic and increasingly universal health system challenges confronting us all.
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