11 Oct 2024
Disclaimer
Views published are my own and do not represent the views of my employers
and the academic institutions which I am affliated to.
Background
MediShield Life premiums to increase as government expands national health insurance scheme. Premiums may increase by as much as 35 per cent from April 2025 over a three-year period but for most Singaporeans, this will be fully offset by government support measures.
On 10th October, Associate Professor Jeremy Lim and Associate Profossor Wee Hwee Lin published articles in The Straits Times on the topic of Medishield Life and public healthcare insurance.
Realities
Universal healthcare is a pipe dream
There must be no doubt that universal healthcare (UHC) system is a pipe dream.
UHC is for idealists or for politicians to win elections. It has no place
in the lexicon of realists or healthcare reformers. Something has to give. Either you do not
have the best quality of care (poor health outcomes, low standard of service delivery)
or the access is poor (gatekeeping for specialist care, long wait times).
Ensuring everyone gets the best possible standard of care, especially at no cost,
is impossible.
Value based care sounds good but …
Prima facie, value based care sounds good. In layman terms, it is getting the most out of your buck.
For instance, in the US, both private and public insurance have shifted to reimbursing healthcare
providers and hospitals based on diagnosis codes and service delivery outcomes with success in controlling
cost. However, while the concept is great, the question is how do you define value? While healthcare
providers quibble over how much value a procedure or a consult is and should cost, healthcare services
debate over what healthcare outcomes they should be measured by. The inherent problem with value
based care is that it neither provides more supply or control the demand for healthcare. It
is therefore unsurprising that it is not the panacea for healthcare cost controls.
The mirage of technology to lower costs
It is probably funny to hear this coming from a healthcare AI researcher and practitioner
but it is important to do a reality check. The promise that technology
like Telehealth and AI can lower healthcare costs is likely an empty one,
at least in the short term. The most obvious way to explain this is through
the example of the Electronic Health Record (EHR). It was touted as a gamechanger in
improving quality of care, service delivery and healthcare outcomes through
comprehensive clinical documentation, seamless healthcare communications,
clinician decision support and other features. However, high upfront investment
costs, lacklustre clinical workflow culture and change management issues
continue to plague the effective use of EHRs for its cost. I hypothesize
these issues would remain true for telehealth and AI.
Take the example of healthcare AI, it is well known that AI is data and
compute intensive. Bearing in mind that EHRs without AI costed the
Singapore government an estimated $450 million over 3 years, it is unlikely
that EHRs with AI would cost less, after accounting for additional compute
and storage resources required. Furthermore, people must have understood by now
that technology (AI by extension) fundamentally isn’t a solution for human
process issues and productivity isn’t like to be transformed overnight.
We should make full use of technology but I would say lower your expectations.
Going back to Singapore’s first principles
No aircon in hospitals
I will argue that Singapore’s principles to financing the healthcare system
have always been rooted in rigourous demand and supply controls. We should
continue to do this. One famous, or rather infamous example, is our founding
prime minister Mr Lee Kuan Yew’s objections to having air conditioning in
hospitals. An uncomfortable stay at the hospital serve as both a demand control
(people would avoid staying in hospital too long) and a supply control
(hositals would be less costly to run).
Problem with using financial incentives to control cost
One has to look no further than the US to see that, if you put all
your healthcare reform attention on healthcare financing (Medicare, Medicaid,
private insurance), you neglect other levers to control healthcare costs.
While it is not wrong to use financial incentives to control pricing, it puts
policymakers in a bind of trying to look for different ways to use taxpayers
monies to plug the gap. This has been the source of much debate in the
US, where there have been partisanship over how the Affordable Care Act should
be reformed. On one hand, the republicans are probably correct that Americans
are paying too much for healthcare through the various national UHC subventions.
The Democrats are also correct that a lot of Americans would be left with
no healthcare if the national support is rescinded.
Singapore’s healthcare system has been relatively affordable. In recent years,
the fee for service model had stopped working for insurers as more insurees start
to accrue increasingly unreasonable expenditures e.g. staying overnight in hospitals
with extravagant meal options for simple day surgery procedures. While both
private hospitals and doctors cannot escape the blame of these unreasonable
expenditures completely, this phenomenon is well studied in healthcare financing
academica, also known as “moral hazard”. Unsurprisingly, coupled with global inflation,
insurance are seeing escalating operating costs. Insurers have since implemented
empanelment of heatlthcare professionals in an attempt to control their
“losses”, which caused quite a bit of stir amongst healthcare professionals.
What people do not realise is that empanelment is not a new concept. For the longest
time, US healthcare insurers have implemented network providers, facilities and
vendors. This incentivises insurees to seek healthcare within a specific set
of trusted parties that will not charge a price that is not affordable from
the insurer’s perspective.
While it is not a great idea to learn the US approach to address high healthcare costs,
it is worthwhile to think about how to adapt the innovative healthcare financing
regulations and models that have emerged as a result of free market competition
within the US. For instance, the Affordable Care Act (ACA) created a marketplace
for users to select the most price competitive insurance policy, forcing companies
to provide market competititve prices for the masses or risk losing business.
Another example from the ACA is the gauranteed issuance which would help to
take some steam off the national insurance like Medishield Life.
Conclusion
At the end the day, I would like to remind readers that there is very little difference
between government healthcare subsidies / subvention in comparison to private
insurance. The taxes you pay that goes to healthcare is like insurance premium and
the subsidies / subvention provided by government is like insurance payouts
when you are ill. Finessing how to pay for healthcare is important but I will
argue that the best is to NOT pay if you stay healthy and far far away from doctors
and healthcare institutions. Instead of optimising for financing, we should put
200% more effort in comparison on supply and demand controls.
19 Aug 2022
Preamble
I bought a book at Durham International Airport on my way back from US to Singapore. The title of the book is HBR at 100. One of the first essays within is Peter Drucker’s “Managing Oneself”. Here is a summary of the main points.
TLDR
Managing oneself is about understanding your strengths, ways you perform, your values, where you belong, your relationships and managing secondary interests. A seminal piece of work in self awareness IMO.
What are my strengths?
- Feedback analysis: This is a method where you write down what you expect will happen, whenever you make a key decision or take a key action. Nine or twelve months down the road, compare the results with your expected outcome. The author said that he was always surprised by what he discovered from this exercise.
- Concentrate on your strengths: From the analysis, put yourself where your strengths can produce results.
- Improving your strengths: From the analysis, plug your gaps in knowledge. Acquire new skills or improve current skills.
- Discover where your intelligence arrogance is: Far too many people are contemptous of knowledge in other areas outside of their expertise or they believe that being bright is a substitute for knowledge. First rate engineers take pride in not knowing anything about humans because humans in their mind are too disorderly. Human resource managers take pride in not knowing any quantitative methods. But taking pride in such self ignorance is self defeating. Go to work on acquiring skills and knowledge you need to fully realise your strengths.
- Achieve results by working in ways that you best perform because how one performs is unique, like personality. It is formed way before a person starts working.
- For instance, most people are either listeners or readers. Readers (e.g. Dwight Eissenhower) are poor performers if they have to listen to people’s discussions or questions as part of their work. Listeners (e.g. Lyndon Johnson) behave reversely. They tend be poor performers if they have to read detailed memos and material as part of their work.
- To perform, one has to figure out how they learn. Again, do you learn better by reading or listening?
- To perform, one has to lean on his strengths. Have you done your feedback analysis? Are you a loner or do you work better in teams? Can you lead or are you better off as a subordinate?
What are my values?
- To understand your values, you can perform the “mirror test”. Ethics requires that you ask yourself what kind of person do I want to see in the mirror in the morning?
- Incomptabile value system between organization and individuals condemns one to non performance.
Where do I belong?
- After answering “What are my strengths?”, “How do I perform?”, “What are my values?”, one can then decide where one belongs. Minimally, one should be able to tell where they don’t belong.
- Successful careers are not planned. They develop when people are prepared for opportunities because they know their strengths, their method of work and their values.
Responsibility for relationships
- Accept that other individuals, who are in a relationship with you, are just like you.
- Take time to understand them: What are their strengths? How do they perform? What are their values?
- This is the essence of managing your boss: Communication to achieve that understanding.
Second half of your life
- As equally important as your primary job is to have a secondary job, a side hustle.
- Not everyone can succeed in their primary job.
- Should you fail or find your work boring in your primary job, not all is doom and gloom.
- Furthermore, the secondary job might develop into the second career.
15 Aug 2022
Preamble
I watched the movie “Everything, everwhere all at once” on my plane ride back from San Franciso, US to Singapore. I thought it was a good movie with lots of meaning. Here are my thoughts in point form.
Always busy
- Evelyn was shown to be always busy all the time managing the laundromat business.
- She was unable to focus on relationships around her.
- The multiverse was a metaphor to how we are always overwhelmed by information in the new information age.
- Concurrently, not all of this information is actual information. They are mixed with misinformation.
- Furthermore, experts are not always able to help us decipher information anymore. We do not have ready access to them. Even when we have access, they might not be correct.
- Individuals are forced to evaluate information on their own.
Fear of not living the life that you were supposed to live
- Evelyn was shown the possibility of living an alternate life.
- These alternate lives made Evelyn want to escape from her own reality.
Fear of having difficult conversations around queerness
- Daughter of Evelyn is a lesbian
- Evelyn has difficulty telling father that daughter is a lesbian
Women and their struggles
- As an independent woman, Evelyn has to run the laundromat.
- As a mother, Evelyn has to take care of her daughter, Joy.
- As a daughter, Evelyn has to take care of her father, Gong Gong.
- As a wife, Evelyn has to take care of her husband, Waymond.
Thinking about the impossible to make connections with alternate universes
- Absurd requirements to make a verse jump isn’t too far fetch with respect to innovation and creativity.
- Often, lateral thinking allows one to think orthogonally and explore uncharted grounds.
Concluding thoughts
- This movie captured the contemporaneous state of the world, which is deep in confusion under the bombardment of tremendous amount of information.
- It was also a time when liberalism was on the rise. Feminism, LGBTQIA+ and cultures wars were hot words of strong contention.
- The movie did not give definite solutions to the confusion but offers a potential way to ground ourselves in its ending.
05 Jul 2022
I am really excited to attend Prof Steven’s SFETP workshop this coming Saturday 9/7/22. This is a long awaited course for me, since I have read Prof Steven’s book 1 year ago to help supplement knowledge required for my clinical epidemiology work. Here I would like to review 2 papers given to us as readings for the first lesson of the workshop:
First paper: How better pandemic and epidemic intelligence will prepare the world for future threats by Oliver W. Morgan, et al.
TLDR: Pandemic and epidemic intelligence requires (1) Modern approach to surveillance and risk assessment. (2) Improved trust and cooperation between stakeholders and society.
Key points:
- Traditional surveillance approaches: People visiting healthcare facilities, clinical assessment and diagnosis from notes, laboratory confirmation of pathogen, genome sequencing, mortality estimation, active and passive case finding
- Modern surveillance approaches: Detection of public health signals from social media, alternate sources of data from police records, occupational health, environmental reports, animal deaths, etc., geospatial and remote sensing from mobility data, crowdsourcing of open sourced case based data, wearables and internet of things.
- Challenges in pandemic and epidemic intelligence: data fragmentation, multiple data sources, licenceship, ownership, cybersecurity risks, analysis challenges, increased computing requirements, organizational challenges and highly diverse multi disciplinary team
- The establishment of the World Health Organization (WHO) pandemic hub to build modern disease surveillance capabilities and global trust architecture to better deal with future global health threats.
Thoughts:
- This is an opinion paper by authors from the WHO. Hence, paper is directed at WHO’s response to modern pandemic and epidemic intelligence challenges: The pandemic hub.
- Nevertheless, the paper offers a succinct summary of: (1) The traditional and modern surveillance approaches. (2) The challenges these approaches face in gathering pandemic and epidemic intelligence.
Second paper: Singapore Statement on Global Health Strategy by Adam Kamradt Scott, Yik Ying Teo, Rebecca Katz
TLDR: Freedom from the consequences of infectious disease requires dedicated, sustained and cooperative efforts across all levels of society and government, both locally and internationally.
Key points:
- 7 statements on Sydney’s global health security: 1. Inclusive, equitable and data drive interventions. 2. Linking prevention, detection and response capabilities to health system strengthening and universal health coverage. 3. Compliance with International Health Regulations and other associated agreements. 4. Action and engagement with all sectors. 5. Embrace the One Health approach. 6. Partnering between low and high resourced countries. 7. Sustainable efforts.
- Singapore’s declaration: 1. Sustainable only when global health security is embedded in universal health systems. 2. Health emergency, preparedness and response workforce must be strengthened by multisectoral, multidisciplinary expertise. 3. Enhanced surveillance of animal and environmental conditions. 4. Governments must sustainably finance, build, strengthen, practice preparedness and response capabilities in adherence to International Health Regulations. 5. Technical, social, economic and political measures are to be taken to reduce the impact of disease. Particularly in improving health literacy and reducing misinformation.
Thoughts
- Singapore’s declaration seeks to map out how the Sydney’s Global Health Security’s statements can be executed.
- One of the key thrusts in this paper is on the emphasis of concerted and cooperative action across all levels of society at the country level and all countries’ governments at the international level.
04 Jul 2022
Preamble
I read with interest about Prof Jordan Peterson’s recent “ban” on Twitter. Apparently, he tweeted “Remember when pride was a sin? And Ellen Page just has her breasts removed by a criminal physician.”
Respecting people’s names (not gender)
Putting the LGBTQ issues aside, hypothetically speaking, if a man called John decides to legally change his name to Peter, shouldn’t we just call him Peter? Of course. He has gone through due legal process and the man deserves to be respected for wanting to be called Peter. Hence, it is quite inexplicable for wanting to call Elliot Page by his original non-legal name, Ellen Page.
Respecting people’s right for elective aesthetic procedures
Still not delving into the LGBTQ issues yet, hypothetically speaking, if a woman undergoes elective breast implant to augment her looks to be more attractive, would the physician still be called criminal? Of course not. Plenty of physicians carry out such procedures. Bear in mind that the word criminal actually implies contravention of some criminal law that specifically prosecutes crimes such as battery or murder. Also, elective mastectomies have happened before for cis-women for the purposes of reducing breast cancer risk. Most prominent example being Kayleigh McEnany.
Should Prof Jordan Peterson be “banned”?
Non radical idea here. I don’t think Twitter should have done anything to Prof Jordan Peterson. It gives him attention. It amplifies his voice. It supplies firepower for followup YouTube video and a chest thumping exercise.
My main issue with Prof Jordan Peterson’s ideas
There are many logical things that he say which are hard to disagree with. Clean your own room. Realize your potential. Socialize your kids. Have better self awareness. Read and write well to give yourself an advantage over other people. Believe in God. I can go on and on because I have read his books and watched his lectures in detail. That doesn’t mean that I believe his ideas are without flaws. It is just that it weaves logic with potentially fatal wrong ideas seamlessly. Let me illustrate with a detailed example here. In his book “Maps of Meaning”, he expressed the idea of reducing complexity and anxiety by accepting certain fundamental concepts as true: e.g. the role of the hypothalamus, the neurological reflexes, the teachings within the gospel, etc. He asks that you ask less of these truths, to reduce your anxiety. It is definitely true that your life would significantly more blissful and less complex by asking less questions about these fundamental “truths”. However, one should ponder whether there is anything moral about accepting (without questioning) that the playbook for lobster survival is supposedly the way to live as humans, the neurological reflexes within us that are capable of hunting our fellow humans to relieve our hunger pangs, or even whether every word in the gospel is God’s word when there are so many versions of the Gospel? I think, as humans, we have evolved to control these urges from the hypothalamus and neurological reflexes for good reason! Why should we devolved back to an animal? Is that the only way to realize one’s potential? I really don’t think so.
A lesson in empathy
Even when I had an issue with Prof Jordan Peterson’s ideas, I don’t want to talk about his beef/salt diet or his psych problems or his Russian medical escapade. Instead, I want to empathize with why he is doing what he is doing. This is a man who is deeply religious and philosophical. Roughly speaking, his entire life’s cornerstone is built on “immovable truths” such as religion, narratives, masculinity vs femininity, dragon vs chaos, etc. The would order is “strange” to him because his theories have become so true that they are “facts”. I don’t think there is a need to chip away at his believes because they are really “immovable”. There is no point in engaging this man anymore. Instead, the engagement should turn its focus towards people who listened to him and are open to changing their “immovable” ideas.