Kung Hei Fat Choy. Wish everyone a prosperous year of Rabbit.
In previous months I suggested
readers to focus on happy events of lives, and my new year wish was tranquility
in 2011. However, the beginning of the
new year was disturbed by a piece of news appearing in several newspapers on January
17. In short, the news was about the use
of Healthcare Vouchers by Hong Kong citizens over 70 years old. It quoted a government official (who remained anonymous
throughout) saying that healthcare providers (mainly general practitioners and
family doctors as I understood) cheated the aged by charging them more than the
providers’ usual charges. However, there
was no evidence supporting this serious accusation. The magnitude of the problem was also not
assessed. Whether there was one doctor
(or even none, as the accusation was not supported by anything) or hundreds of
doctors cheating the aged remained unclear. The mysterious official also inferred from the
“suspected to be fabricated” story and warned that further public money would
go to doctors’ pockets without benefiting the aged. He then concluded that a new mode of
contracting the public money to organizations for checkups was needed.
What had happened was blatantly unacceptable.
The accusation was very serious. It affected the accused doctors’ fitness to
practice as it could be misconduct in a professional respect. It damaged the image of the profession as a
whole. However, there was no way to try
to discuss or to solve the problem. The
one who spoke and who raised the problem was anonymous. He was not using any official channels to try
to verify or to tackle the problem. He
just aired to some media in an irresponsible manner, adding his own inference
and comments. All these raised readers’ suspicion
of malice intention behind this plot.
In view of the serious nature of
this incident, the HKMA quickly held a press conference in respond to the
ungrounded accusation. As the Editor of
the News, I also shoulder the responsibility of giving an account of this
matter to readers with my analysis.
The ungrounded accusations
The ungrounded accusations were
found in four newspapers on January 17, 2011. Below are the quotes:
Apple Daily:
『為免醫生繼續從中「掠水」，政府檢討後不會直接就醫療券加碼給長者，考慮明碼實價向醫療機構購買預防疾病的服務。』
『政府發現有醫生對使用醫療券的長者加價，甚至有人曾承認政府既然派錢，為何不從中得益。但由於沒有參與醫生以往的收費紀錄，政府難以調查多少醫生「抽水」。』
『政府認為，若未來調高醫療券金額，錢只會流入醫生口袋，長者不能受惠，加上長者只會繼續使用醫療券「睇傷風咳」；故當局不會直接在醫療券加碼，考慮直接向醫療機構購買預防護理或身體檢查等服務，供長者使用。政府擬預先定價，參與的醫療機構不能向長者額外收費，變相直接將錢給予長者。』
Ming Pao:
『政府調查發現，70%長者用醫療券看傷風咳，更發現有私家醫生藉詞「政府派錢，醫生可與病人對分」乘機加診金，因此，政府在醫療券加碼下，正研究為醫療券使用者設下只作健康檢查的條件，藉此提高長者預防疾病效益，同時也可防止私家醫生從醫療券「抽水」。』
『了解醫療券計劃的消息人士指出，當局更觀察到有私家醫生藉詞醫療券是「政府派錢，醫生可與病人對分」，將門診診金由150元提高至200元，並建議長者用2張共值100元的醫療券支付診金，令醫生多賺50元。』
HK Economic Journal:
『為免資助被侵吞，當局擬集體採購服務，讓長者不用額外付費，或要醫生報告額外收費。』
『現時長者如用醫療劵打流感針，因由醫生定價，用者需付餘額。政府消息直言，不傾向採用這模式，以免醫生「侵吞」資助，曾有醫生說：「政府派錢，我們分一點也很應該！」他舉例，流感針每劑 120 元，但疫苗計劃推出後，推高至 160 元，政府資助的 80 元，一半到了醫生口袋。』
SCMP:
“Health officials are alarmed by the abuse,
which saw some doctors increasing medical charges for elderly patients enrolled
in the scheme. The Food and Health
Bureau is working on new measures to curb the abuse. One idea is to pay for primary care services
directly from private doctors.”
“’Some doctors have raised their fees on patients
who use the vouchers,’ a person
familiar with the scheme said. ‘As a result, the elderly cannot fully benefit from the government
subsidy ... the vouchers are effectively shared between the patients and
doctors.’”
It is common to have government
officials to comment on reports or policies before their formal announcement. However, there were some special features in
this incident. First, serious
accusations were made on doctors and defamatory wordings were used. Similar wordings were used by all the
newspapers reflected that those wordings were likely to be said by the
official. Second, there was no proof at
all and there was not the slightest intention to substantiate the claims. It is obvious that the intention of making
such accusations was not problem solving as there had not been any discussion
with the profession or any action against the doctors accused. Third, an important governmental policy
involving public money in the magnitude of tens of millions was suggested to be
made and be modified according to some hearsay or fabricated stories.
From the setting and context of
the newspaper reports, it is natural for readers to come to an impression that
the government official smeared the profession on purpose. He was so desperate to sell his plan of channeling
future public money to some organizations that he did not mind betraying his
own profession. However, this was done
in an unskillful, or maybe arrogant, manner. No one bothered to find proof for the
accusations. The ungrounded accusations
were generalized to the whole profession. The generalization was used to support some
changes in the policy. Come on!
Healthcare Vouchers
Healthcare Vouchers were
introduced by the government in 2009 as subsidies for HK citizens over the age
of 70. Each year each elderly can have 5
electronic vouchers each having the value of $50. It was said to be a pilot project when law
makers criticized that the total value of $250 per year was grossly inadequate.
These vouchers can be looked upon as cash
coupons in electronic form as they can be used equivalent to cash when visiting
registered healthcare providers.
It is the cash equivalent nature
of the Vouchers and the free choice of healthcare providers that rebut the
accusation about doctors’ over-charging. It is likely that each owner of the vouchers
will value his own assets and will guard against abuse. It doesn’t mean that there do not exist cases
of doctors overcharging patients. But
the use of Healthcare Vouchers is unlikely to encourage overcharging. Since the vouchers are to a certain extent
equivalent to cash, a doctor can only cheat his patient once. If he charges differently from his usual
charge, his patient will know it and will be gone for good. My own experience as a provider is that
coherent elder patients are very alert of charges including how many vouchers
are used and how many are remaining.
Another point to illustrate that
the official was not telling the truth was about influenza vaccines. Evidence shows that there are significantly
increasing numbers of doctors charging less. Many doctors now do not require the kids or
the elderly to co-pay apart from the government subsidy. What the profession facing is a race for fee
cutting instead of the imaginary fee raising to raid the government or the
elderly.
Extra work for healthcare providers without extra gain
Concerning the use of Healthcare
Vouchers, in fact much extra work has to be done by the provider doctor. He or his staff has to register on-line for
the patient, and to explain to the patient the number of vouchers used and the
number remaining. There have to be
print-outs for the consent forms. There
are regular on site checking and audits by the government. The consent forms have to be stored. Any mistakes in the process will cause the
doctor inability to have reimbursement. In
fact family doctors have helped the government to build up a data base of
registered elderly and have smoothed out many handling and data input problems.
However, we are not acknowledged or
paid.
The accepting of Healthcare
Vouchers is in fact a contract between the healthcare provider and the
government. However, the terms of the
contract have never been negotiated. Many
doctors do have grievance in taking the extra works. Some of us accepted the unfair terms mainly
because the scheme was promoted as a pilot project. So it was worth to give it a trial without
caring too much about the details. Moreover,
it is always easily got blamed when elderly are involved. How can doctors chase for a few bugs and
hinder the long-awaited subsidy scheme for the elderly?
The arrogant official may argue
that doctors do benefit from the scheme as extra money is injected into the
market. My own experience (still case
reporting, but at least you can trace me for verification) is that I have been
seeing my own patients who now use the vouchers to pay. There are minimal extra consultations just
because of the vouchers. One of the
reasons is the amount of the subsidy can only pay for one consultation per
year. It is likely that an average
elderly patient needs more than one medical consultation with his family doctor
in a year. So it is natural for him to
use the voucher to pay for one of the inevitable consultations.
Design of data collection is problematic
I believe that there are actual
statistics for the scheme because doctors are required to input extra data
including the reason for each consultation before he can finish the cumbersome
registration and reimbursement procedures. However, the statistics may not be meaningful
as there are faults in the design. One
of the faults is about the reason for consultation. This was the main argument by the official to
divert public money to some organizations. Only one reason can be chosen for each consultation.
This ignores the fact that each
consultation by the family doctor is multi-purpose. Especially for the elderly, in order to save
money, they usually go for a consultation when there are acute problems such as
URTI. During that consultation, they will
raise all their problems for the doctor to solve. For example, they might ask about their fear
of lung cancer because of their recent cough. The doctor can then educate them for cessation
of smoking. Then related topics of
metabolic syndrome as related to smoking will be discussed and the patient’s
body weight, BMI, blood pressure, and may be sugar and cholesterol levels
measured. Opportunistic screening and
health education is the norm rather than the exception. It is sad that while hidden agenda and family
medicine are undergraduate stuff, these need to be taught to officials
again.
Preventive medicine and family doctors
Something has to be said about
the ultimate intention of the hidden official. Let us first suppress the inevitable suspicion
of conflict of interest and hidden gains by him and concentrate on the
discussions of rationales. Is it good
practice and is it beneficial to the health of the elderly when channeling them
to health check centers instead of their family doctors? Is it more cost effective and more beneficial
to the elderly if he goes to an unfamiliar center to do blood tests for liver
function and tumor markers than to see his own family doctor for opportunistic
screening for early symptoms of cancers, cardiovascular diseases, renal
diseases, eye problems and mood disorders? Should consultations by doctors be replaced by
routine profile tests? Should the
interpretation of test results be detached from the patient’s history and
delivered by a staff unknown to him? I
guess it does not need a profession to answer the above questions. It is another sad fact that while doctors have
the duty to educate the public, the government is seemingly doing the opposite.
Important messages
- This kind of smearing action is harmful to the profession and is unacceptable. It must be stopped.
- Based on this smearing, there was an intention of channeling public money to health check organizations.
- In response to the accusation and smearing, the HKMA has quickly held a press conference and sent a complaint letter to the Chief Executive and Food and Health Bureau. There will be further actions if necessary.
- Your support and united actions are needed.
- Many family doctors have been penalized for the generosity, both in doing extra works for the government in the use of Healthcare Vouchers free of charge, and in providing free preventive medicine and counseling services to the aged.
- Ask yourselves: if you have practiced preventive medicine and provided advices and counseling in your consultations with the elder patients using Healthcare Vouchers, would you choose the options of “Preventive” and “Health Advice/Counseling” as the “Reason for visit” when handling Healthcare Vouchers?
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(Source: HKMA News February 2011)
