Behind the "Largest Healthcare Fraud Settlement in US History"

 

In July, it was reported in newspapers and TV news that GlaxoSmithKline LLC (GSK) agreed to plead guilty and to pay $3 billion to resolve its criminal and civil liability arising from the company’s unlawful promotion of certain prescription drugs including Paxil and Welbutrin, its failure to report certain safety data about Avandia, and its civil liability for alleged false price reporting practices.  The resolution is the largest health care fraud settlement in U.S. history and the largest payment ever by a drug company.  Among the unlawful promotion activities were providing hunting trips and Madonna concert tickets for doctors.

In fact the GSK guilty plead was only one of such settlement cases.  What was special was the escalating amount paid setting a new record of $3 billion.  In January 2009, Eli Lilly and Company paid 1.4 billion for the criminal charges and civil liabilities of the off-label marketing of the drug Zyprexa.  In September 2009, Pfizer pleaded guilty to a felony violation of the Food, Drug and Cosmetic Act for misbranding Bextra with the intent to defraud or mislead.  Then $2.3 billion was paid to for the criminal offences and the civil settlement.  In April 2012, Johnson & Johnson agreed to paid $1.2 billion for minimizing or concealing the dangers associated with Risperdal.  In May 2012, Abbott Laboratories Inc. pleaded guilty and agreed to pay $1.5 billion to resolve its criminal and civil liability arising from the company’s unlawful promotion of the prescription drug Depakote for uses not approved as safe and effective by the Food and Drug Administration (FDA).

What had happened to these drug giants?  What were the unique features of these cases?  Would these cases affect our practices?  The following are my observations:

1. There were criminal charges.  It was the government against drug firms and there were vast investigatory power and resources.  In May 2009, the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative was announced.  The GSK case, for example, was investigated by agents from the Office of Inspector General of the U.S. Department of Health & Human Services (HHS-OIG), the FDA’s Office of Criminal Investigations, the Defense Criminal Investigative Service of the Department of Defense, the Office of the Inspector General for the Office of Personnel Management, the Department of Veterans Affairs, the Department of Labor, TRICARE Program Integrity, the Office of Inspector General for the U.S. Postal Service and the FBI.
2. For the criminal charges, apart from fines, the drug firms had to enter into Corporate Integrity Agreements to “behave themselves” and the directors would be held responsible for further offences.
3. Of course there were civil claims.  Because of the contingency fee arrangement and the availability of class actions, product liability and personal injury cases were big money in the US.  Fascinating stories had been written by John Grisham on those lawyers with private jets launching advertisements to recruit clients.  For the current cases, there had been a new frontier of attack.  Under the qui tam provisions of the False Claims Act, private citizens are allowed to bring civil actions on behalf of the United States and share in any recovery.  The purpose is to encourage individuals to come forward and identify companies and individuals that defraud the government.  For example, in the Eli Lilly case, the whistle blowers were its former sales representatives and they shared in 18%, or $78,870,877, of the federal share of the (civil) settlement.
4. For your information, The Law Reform Commission published a report on 28 May 2012, proposing that a mechanism for class actions should be adopted in Hong Kong.  The proposal was put forward after the Commission’s consultation paper in 2009.
5. Although in these cases, it was admitted that free lunches and all kinds of benefits were provided to doctors to “encourage” them to prescribe those drugs in an off-label manner, the blame did not fall on the medical profession too much.  The main reason was that drug firms with money, assets and insurance coverage were targeted.  Doctors did not have deep enough pockets.  Moreover, doctors were also cheated as the drug firms admitted withholding important research results and information, and at the same time falsifying data of researches.
6. However, the images of doctors were affected.  At least they were not independent professionals putting patients’ safety and well being as the first priority.  Also, their abilities in critically appraising studies and evidence were doubted.  For a lay citizen, it was easy to figure out a doctor prescribing just according to a casual chat from a drug representative who provided free lunches and Madonna concert tickets.
7. All the cases were more or less on the off-label use of medicines.  By definition, any use outside those approved by the FDA is off-label use.  It can be about the indications, the dosages, the duration of use, and the use in specific groups of patients such as children and pregnant women.
8. With these cases and judgments, doctors might need to be more careful on the off-label use of medicines.  It does not mean that all off-label use of medicine should be prohibited or avoided.  In fact off-label use of medicine is very common.  However, certain points need to be remembered.  First, the doctor needs to know that he is using the medicine in an off-label manner.  Second, he has to be able to justify the use.  He can either support it with data or studies.  Exhaustion of available treatments may be another justification.  Third, he should try to communicate with patients about the off-label use and to keep records of such communication.  Of course, all these are easily said than done.  At least, we should have the word “justification” in mind.  

(Source: HKMA News July 2012)

Fifty Shades of Grey

I am not talking about the best-seller “Fifty Shades of Grey” in which Mr. Grey indulges in sadistic-masochistic behaviours, though I am looking forward to its appearing as movies, either in its original, or in its “modified” versions by Hong Kong film-makers.  It just appears to me that June 2012 is a month of different shades of grey.  Patient A worries about her daughter’s primary two examinations.  Patient B is desperate to get rid of his renal stone.  Patient C wonders whether Netherlands can enter the final of UEFA European Championship.  Patient D is counting his final days from terminal liver cancer.  Patient E has a relapse of depression from the European sovereign debt crisis.  Patient F is saving every penny for his 300 square feet dream flat and defaults follow-up for hypertension…  Last but not the least, Patient Z is worrying about global warming.

I am sure that June 2012 is no different from any June, or in fact any other months in 2012 or other years.  What is different is only my perception.  Somehow I had picked up more negative messages and feelings from my patients.  The Buddha teaches us that life is suffering.  Although he also points out the ways to the cessation of sufferings, they are more easily said than done.  However, I got a little bit enlightened after I paid a visit to Siu Chi.

Since 2007, I have been sponsoring a little girl, whom I named Siu Chi from her original name, in one of the charitable organizations.  I first met Siu Chi when she was a four-year-old in kindergarten.  She was adorably cute with pretty round face and short haircut fringe bang.  When the little one first met me in the playroom, she was terribly nervous and withdrawn.  For thereafter visits, I tried to “bribe” her by bringing her little gifts like toys, books, soft drinks, candies, and fries.  As most of the children did, she loved junk food from McDonald’s very much.  It took several months’ time and we became friends. 

Even as young as four, she was already a clever and practical child.  Whenever I appeared outside her classroom, she smiled and ran to me.  After having a quick glance towards my hands, she would ask me sweetly, “What are you bringing for me today?”, “Is it a box of colour pencils?”, “Is it a book this time?”…  And if she saw the paper bag of McDonald’s, she would scream happily, “McDonald’s!”

I became busier at work and studies, thus I stopped visiting her for a period of time.  It was months ago that I decided to re-visit her again.  Time flied.  I no longer picked her from the prep school building; instead, it was the big kids’ schoolroom in the main building.  When she was called by the staff, she put down a book she was reading.  We had not seen each other for one year and a half, and she was then a grown-up kid.  She was still having her short haircut, but no more flat fringe.  And she was wearing glasses!  Unlike when she was little, she threw a glance at my hands without saying a word about the gift.  I handed her the little gift and she happily held it in her hand.  I was curious why she did not do the unwrapping as she used to do.  I suggested her to unwrap the gift and see if she liked it, she answered in a charm look, “it is impolite to unwrap the gift immediately before you.” 

I was watching her playing happily with friends in the playground when a staff approached her.  I heard murmur of their conversations and then Siu Chi quietly sat next to me.  I asked if there was any problem and she replied, “The nurse said you thoughtfully come and visit me, so perhaps I should better chat with you instead of play with friends.”  I felt a bit uneasy while highly praising her for being a very good and polite girl.  I suggested buying her favourite fries for her next time.  She grinned. 

Now and then, to arrange a visiting time slot was a challenging issue for us.  Siu Chi was a primary school child, and she had her busy life.  She had tutorials and prep times after school every Monday, Tuesday, Thursday and Friday.  She attended drawing lessons on Saturday afternoons.  And for Sundays and public holidays, there were always group activities like visits or tours.  It was not until a few weeks later that we found another time to meet.  The staff called to confirm the meeting while I suggested buying fries for Siu Chi.  It was actually a rule for all sponsors to get approval from the staff before bringing any food to the children just in case they had food allergies or other physical problems.  The answer was surprisingly a “NO” this time.  The staff revealed that it was no good to have fries after her proper meal.  That was the only “NO” I got throughout the years since I had sponsored her.  Siu Chi was disappointed.  She whispered, “What if I eat the fries after my stomach digests the dinner food?” 

While we were worrying about the fries, I noticed that kids were brought in constantly by policemen.  Siu Chi seemed not disturbed by such scenes.  She said that she had got used to new friends coming and old friends going.  Was she worrying about her future?  Her mother was in rehabilitation center and her father in prison.  She had grown up and gained unnecessary social skills in two years.  What would be the road ahead of her?

Well, what I knew at that time was that I could paint some colours on the background of grey by smuggling some fries for her.  To Siu Chi, she practiced “the power of now” nicely.  Afterall, it is perception that matters.  

(Source: HKMA News June 2012)

The road to pubic-private partnership becomes more winding

The road to public-private partnership (PPP) between the Hospital Authority and private medical practitioners becomes longer and more winding.  This is my impression after going through the Director of Audit's Report No. 58 (Chapter 3), “Hospital Authority: Public-private partnership (PPP) programmes”, published on March 28, 2012.  While the Audit Commission focuses on performance indicators and cost-effectiveness of the programmes, I look more into the culture, attitude and intention of the Hospital Authority behind these programmes.

In 2008, the PPP was recommended as a means to solve the manpower and resources problem of the Hospital Authority.  Since then, all we have got are several pilot projects.  These pilots were implemented “to meet service gaps” identified.  After four years, these gaps are instead filled by increased services from the Hospital Authority.  So these pilots can be conveniently shelved.  These are mentioned in paras 2.8 and 2.9 of the Audit Report: “Over the years, the HA had made arrangements with the FHB to extend the operation of the Cataract Surgeries Programme and the General Out-patient Clinic PPP Programme beyond their original pilot periods.  As at December 2011, the two programmes were entering the fourth year of operation.  The HA did not have any plan for rolling them out as ongoing services.  Audit noted that the HA commissioned two new cataract centres in December 2009 and May 2011, and that a new clinic was opened in Tin Shui Wai North in February 2012.  It can be seen from paragraph 2.8 that the two pilot PPP programmes have been used as stop-gap measures to address service gaps identified.  According to the HA, such measures have short-term usefulness and objectives that will benefit many patients.  Audit considers that while the measures have contributed to the strategic objective of managing growing service demand, they may not be conducive to the long-term development of PPP in healthcare.”

There is no evidence of any intention of setting up sustainable PPP programmes.  The Audit Report concluded in para 2.23 that “Four years have elapsed since the HA launched its first PPP programme (i.e. Cataract Surgeries Programme) in February 2008.  Audit considers it timely for the HA to devise such a mechanism to take stock of the overall development of PPP, consolidate the experience (including good practices identified and lessons learnt) and map out the future strategy for the further development of PPP in healthcare.”

There is even no evidence of any intention of studying or developing workable modes of PPP.  The amount of subsidy from the government is obviously a key factor in PPP programmes.  However, there seems no interest from the Hospital Authority to investigate into this factor.  One example is the Share-care Programme in which the $1200 subsidy is far below market price.  This is described in para 2.11: “As noted in paragraph 2.6(c), an objective of launching the pilot PPP programmes was to test the market and public acceptance.  This could help the HA design better PPP programmes in the future.  So far, the HA has varied the eligibility criteria for some of its PPP programmes, but it has not changed other key parameters (e.g. levels of government subsidy and patients’ co-payment) of its PPP programmes since they were launched.”

So what happen to these pilots?  They are either extended to be never ending pilots, or they would be ended with pending evaluations, and the participating patients are going back to the Hospital Authority as if nothing has happened in between.  Para 2.13 describes an interesting hidden exit plan: “Audit noted that the HA had not explicitly laid down any exit plans for its pilot PPP programmes.  Upon enquiry, the HA informed Audit in February 2012 that, while not laid down, its exit planning was based on the HA’s fundamental responsibility of providing healthcare for all Hong Kong residents.  According to such exit planning, should a PPP programme be terminated, the HA was ready to take back all affected patients.”

With such attitude and intention, the Hospital Authority is likely to implement all other recommendations from the Audit Commission, leaving the above mentioned “minor” parts.  Thus it is supposed to “step up efforts in promoting the charitable arrangements offered by participating ophthalmologists of the Cataract Surgeries Programme; and in launching other PPP programmes, examine the desirability of implementing similar charitable arrangements.”  The responsibility of the government and the Hospital Authority will be shifted to private doctors.  Apart from that, private doctors are expected to “include the HA as a co-insured party in their insurance policies for the PPP programmes.”  The private “partners” should be monitored more closely and be paid according to their performance.  The Hospital Authority is recommended to “review the effectiveness of performance-based payments; and consider adopting performance-based payments for PPP programmes in future.”  Also, it should “step up the monitoring of healthcare providers’ service delivery; and remind healthcare providers to give due consideration to the service protocols.”

The conclusion is that the title of this article is wrong.  There has not been any road to public-private partnership.  There might or might not be a road to public-private partnership.  If there is going to be one, it will be long and winding.

(Source: HKMA News May 2012)

New Medical Council Chairman, please drop your bias!

It was heart-sinking to read about the comments and accusations from the Chairman of the Medical Council on the elected members.  The following was found in the Apple Daily on April 1, 2012. 

【本報訊】醫委會改革擾攘多年，有委員曾建議改由全港醫生普選全部醫委會委員。醫委會主席劉允怡表明反對，認為由業界普選的醫生在某情況下，只會維護業界利益，醫管局引入海外醫生事件最為明顯。 

醫委會現有 28名委員， 7人由醫生直選， 7人由醫學會選出， 14人由政府委任，當中包括 4名非業界人士。劉允怡表示，由業界普選所有委員最能維護大眾利益，只是「偷換概念」的說法，令人誤以為普選一定好。以醫院管理局引入海外醫生為例，雖然市民一般贊成，但直選醫生全數反對，未有保障公眾利益。 

My first reaction was that such comments were outrageous and absurd.  The reasons were multi-folded, and would be explained in a convergence version.  First, while it was acceptable for the Chairman to give his personal opinions on how the Medical Council should be composed of, it was unacceptable for him to attack a designated group of members while they were fulfilling their duties as members of the Council by deliberating and deciding on matters during policy meetings.  The Chairman was supposed to be impartial, and to listen to members’ opinions so as to come to a decision reflecting the majority view of the Council.  In this case, the Chairman openly accused elected members of not protecting the public.  It was just like a judge, after the jury returned the verdict of guilty of murder for a defendant, openly called the odd member of the jury who voted for not guilty the bad apple of the jury.

Second, let’s forget about whether the Chairman’s statements were factual for the mean time.  The above judge-jury analogy did illustrate an important point.  In the decisions on applications for limited registration submitted by the Hospital Authority, the Council was bounded by provisions in the Medical Registration Ordinance (MRO).  We were not talking about legislation or ethical dilemma.  We were judging according to the details prescribed in the MRO, among which were whether the applications were necessary and appropriate in those given time periods and situations.  Each case was decided separately.  There was no room for consideration of public opinions, not to say that there was no means of getting public opinions on a particular case as the details were never revealed to the public.  In the judge-jury analogy, we did not expect the judge to scold the odd member of the jury and preached to him that public opinions favour finding the defendant guilty.

In fact this was exactly what I discussed and condemned in my previous Editorial.  Limited registration application was not public consultation for a new policy.  It was wrong, if not illegal, for the application side to exert pressure on members of the Council who were required by law to adjudicate on the applications according to the MRO.  It was not desirable for members to be influenced unduly, either consciously or subconsciously, by such pressure.  I have derived a three-stage test for such purpose: (1) Are there actions that can exert undue influences on members as regarded by an ordinary person?  (2) Do members realize that there exist such undue influences?  (3) Are members influenced by such undue influences?  I had gone through the three stages in the decision making process of the previous applications and I reassured myself that I was not influenced by undue influences that did exist.  I am afraid I have to gone through that once again as there are now the Chairman’s accusations.

Third, the accusations were not based on facts.  According to the discussions above, it was obviously that even if the accusations were based on facts, they were not appropriate.  However, the fact that such accusations were groundless made the whole thing even more heart-sinking.  The decisions for the applications for limited registration were made case by case.  Council Members voted by secret ballot for each application.  There was by no means for the Chairman, or in fact anyone, to know who had voted for or against a motion of approving each application.  When looking back at the cases, the voting results were dissimilar for different cases.  For example, for a senior and experienced doctor specialized in a field where such doctors were obviously lacking, most of the members voted for the motion to approve the application.  As the result reflected, there must have been many elected members who had voted for it.  It was only in some controversial cases, such as placing an inexperience doctor to a post where no local doctor was willing to take up because of unfavourable working environment, that many members voted against the motion for application.  Even in such cases, the number of members voting against were not equal to the number of elected members taking part in the decision making.  

As a member of the Medical Council elected by the profession, it hurts to hear that I have failed to protect the public.  I believe members who have voted for me would not expected me, or in fact any elected member, to behave in the described manner of looking after the privileges of the profession and scarifying the well being of the general public.  I can reassure you with certainty that the accusations are groundless.

(Source: HKMA News April 2012)

Science begets knowledge; opinion begets ignorance.

Working as a family doctor for more than twenty years, I feel sorry to say that quite a significant portion of patients are so ignorant.  It is not that they are ignorant about medical knowledge or advance in medicine (as I consider this natural, just like I am totally ignorant about car repair), but they are so ignorant about simple logic and scientific methods, not to say evidence-based medicine.  It is only through an open mind equipped with logic and ability to appraise scientific evidence that the patient can learn new knowledge and take part in the management of his medical problem.  Walter Isaacson (the author of Steve Jobs) even writes in his book Einstein that “an appreciation for the methods of science is a useful asset for a responsible citizenry.”  Over 2000 years ago, Hippocrates stated that: “There are, in fact, two things, science and opinion; the former begets knowledge, the latter ignorance.”  He insightfully explained why patients became and remained ignorant.

It is not uncommon to encounter patients arguing with you about treatments they learn from their friends, who in turn learn about such treatments out of nowhere traceable.  When you try to explain to them, their query is usually a reverse burden of proof.  Yes, they ask you to prove why such treatments will not work!  Some knowledgeable patients rely on opinions from authorities.  However, how they look upon authorities may depend on how frequent the subjects appear on commercials and how confident they are when communicating the treatments they advocate.

Have we doctors done enough to help our patients?  Evidence-based medicine was elected by BMJ in 2007 to be one of the 15 greatest medical advances since 1840.  However, we still encounter too many advertisements, books, seminars, products and “expert opinions” on miracles and alternative treatments.  Too frequently, patients come to us (or more sadly, leave us) because there are better but never proven methods in treating their diabetes, alopecia, erectile dysfunction and even cancers.  Advocates of such alternative treatments not only make unsupported claims on the miraculous effects (and at the same time, with no side-effects at all) of their products, but too often, they launch attacks on traditional medicine.  Have we discharged our responsibilities to our patients and the public in taking time and effort to address these scams?   

Recently, I have read a book about alternative medicine: Trick or Treatment by Simon Singh and Edzard Ernst.  In this book, the writers dissect various alternative treatments by adopting the evidence-based method and the appraisal of existing evidence.  They skillfully introduce the importance of clinical trials to laymen by telling the story of bloodletting and the first American President.  Bloodletting had been a recognized method of treatment for various diseases since ancient Greece.  At that time diseases were thought to be caused by an imbalance of four bodily fluids known as the four humours.  They were: blood, yellow bile, black bile and phlegm.  By removing some stagnant blood from different parts of the body, different diseases could be treated. (This reminds me of the “lymph plumbing” (通淋巴), which I hear from patients and watch in the media everyday.)  The former US president, George Washington, at the age of 67, caught a cold on a Black Friday (13 December 1799).  It turned out to be epiglottitis.  Within 24 hours, several bloodlettings were performed as treatment and about 3 liters of blood were drained from him.  Obviously, he died the following day.

At that time, bloodletting was the norm.  There was a lawsuit in 1797 between a renowned English journalist William Cobbett and the “Pennsylvania Hippocrates” Dr. Benjamin Rush.  Dr. Rush was the only doctor who had a statue erected in his honour in Washington DC.  He was an advocate of bloodletting.  Cobbett examined the local bills of mortality and concluded that Ruth’s bloodletting had “contributed to the depopulation of the Earth”.  Rush sued him for defamation.  The verdict returned on the day Washington died of blood loss (and/or epiglottitis). Cobbett was ordered to pay Rush a fine of $5000, which was then the largest compensation paid in Pennsylvania.  Apparently, scientists and doctors were not scared by the fine.  In 1809, a Scottish military surgeon called Alexander Hamilton designed a clinical trial to study bloodletting.  His study was valued because there were elements of randomization and control.  He found out that among 366 soldiers of various diseases, the death rate of those treated with bloodletting was ten times to those treated otherwise.  Various studies were then carried out.  And nowadays our common sense that bloodletting means to kill rather than to cure has been firmly established.

Other interesting stories in the book include evidence-based tea (tea, or milk first?), the story of James Lind on scurvy, the study of Florence Nightingale on the importance of hygiene, Dolls & Hill on smoking, Bill Silverman on refuting his discovery of treating retinopathy of prematurity with ACTH, and many others.  The authors also expose plainly and cruelly the origin of some alternative treatments.  Histories review the absurd theories some alternative treatments are built upon.  Among them is the story of Chiropractor.  Chiropractic therapy was founded by Daniel David Palmer, who was born near Toronto in 1845.  He moved to Iowa at the age of twenty.  In 1895, as he himself wrote, he cured a deaf man by repositioning a displaced vertebra (as interpreted by him).  The man could hear soon after his manipulation.  Another man with heart trouble was also cured immediately after he adjusted, again, a displaced vertebra (of course, as interpreted by him) which “pressed on nerves that innervated the heart”.  He then regarded himself as the founder of a miracle treatment and developed a philosophical (if not religious) theory behind it.  He believed that “ninety-five per cent of all diseases were caused by displaced vertebrae”.  Diseases were caused by subluxation in the spine resulting in blockage of the body’s “innate intelligence”.  So replacement of the different displaced vertebrae could allow the rectification of the flow of “innate intelligence” and nearly all illnesses from measles, to sexual dysfunction, to asthma, etc. could be treated.  In two years time, he opened the Palmer School of Chiropractic in Davenport, Iowa.  And his son, Bartlett Joshua Palmer, was his successor.  In 1924, B.J. Palmer started a lucrative sideline in selling “neurocalometer” invented by him for detecting subluxations.  It helped the practitioners a lot since afterall the so-called subluxations were (with due respect) in the minds of the chiropractors.  It was sold at a price of $2200, which at that time was enough to buy a house in Iowa.  However, the apparatus was then found to contain nothing but a thermocouple (you know what it is!).

Too bad?  Not until you read about homeopathy!

(Source: HKMA News March 2012)

Quirkology

I spent the festive holidays quietly, except for a short trip to Po Lam Monastery for a yearly gathering in Lantau on the coldest day.  I walked uphill in freezing rain without an umbrella, appreciating the advance in technology of clothing to keep me warm and dry.  I was also lucky enough to barely miss the risk of being hung in a 360 cable car, which apparently prepared every passenger ready for frozen section.

I finished two books on similar topics by the same author: Richard WISEMAN.  WISEMAN (what a name!) is a Professor of the Public Understanding of Psychology at the University of Hertfordshire.  He was a magician before he graduated in Psychology and then obtained his Ph.D. in Psychology.  He was fascinated by the quirky side of human behaviour such as lying, decision-making, superstition and fortune telling.  In his two books: “Paranormality” and “Quirkology”, I learn about a quick test to distinguish good and bad liars by drawing a “Q” on your own forehead with your index finger of your dominant hand.  I also learn about a script for fortune telling which most people would find it an accurate description of them.  There are also experiments elucidating mysteries of Ouija boards, out of body experiences, subliminal perception etc.  However, what enlightens me most is that his studies go beyond reviewing how such paranormal phenomena come about.  They further look into why people tend to behave in these ways and cling to such phenomena.

After reading the two books, I come to an idea of my own study.  One day I found that there were so many people crowded in Cafe de Coral (a fast food chain store, in case you don’t know) during lunch hours.  I asked myself: why didn’t they go to other restaurants for lunch?  In fact they could make a reservation at Lobster Bar or Cova (and also had the chance of meeting Eve Lai there).  So my study involves distributing out lunch coupons to working people to see if their meal-seeking behaviour can be modified.  They will be given $250 each in one year.  However, my study cannot be carried out because there is no one willing to sponsor it.

Don’t judge me silly or stupid for being blind to the obvious reason of price differential governing the meal-seeking behaviour of workers.  In fact we have been paying for such study since 2009.  It is the Elderly Health Care Voucher Pilot Scheme.  This scheme is more “mission-impossible” than my study.  This is because the subjects of the scheme are all over 70 years old.  They are thus more difficult to change.  They also take it more seriously on matter concerning their health than food.  Moreover, the price differential is even greater between public and private sectors.

Well, people can do all kinds of studies they like.  It is even acceptable to spend public money in a not-well-planned or not-so-worth manner (because it is very common).  But it is a sin to spend public money on unsound theories, and at the same time drawing biased conclusions, which affect the elderly and the medical profession.  Apart from the two books, I have also gone through (again) the 136 – page Interim Review of the Elderly Health Care Voucher Pilot Scheme.  It is stated clearly that “it is expected that the Scheme could help promote key ingredients of good primary care among the elderly and healthcare service providers…”  And that they “expect that more elderly people would be able to choose private primary healthcare services close to their homes.”

My conclusion is that within the 2-year study period, most of the elderly remain sane.  So as expected, they do not suddenly change their health-seeking behaviour because of the given $250 per year.  And that they retain their choice for the public services.  Of course some of them make good use of this minimal subsidy for one or two consultations for minor ailments.  However, the review shows disappointment about the findings and tries to put the blame on the co-payment charged by doctors on each consultation.  The poor quality of the study itself and the review is exemplified by the following:

1026 elderly were recruited for a survey.  Among them, only 35% of them had actually used the healthcare vouchers.  However, “In the survey, the elderly were asked whether, from a perception point of view, the consultation fees in general had increased subsequent to the launch of the Scheme.  45% did not perceive any increase in consultation fees.  42% reported that they did not know whether the Scheme had led to any increase in consultation fees.  14% perceived that the consultation fees increased as a result of the Scheme.”  One cannot expect a vague question than this.  First of all, this question was answered by most of the elderly who had not used the voucher at all.  There was also never any intention to clarify the so-called perceived increase in fees.  What was done was to conclude that: “The sampling survey suggests no significant degree of perceived increase in service fees, though a small but not insignificant (no significant, but not insignificant!) proportion of elderly people did report perceived increase in service fees due to the use of vouchers.”  Based on such data, follow-up actions were taken seriously.  Officials formally invited the media to report on this.  Starting from 2012, doctors have to put down the co-payment before they can register the vouchers for the elderly.  It is stated that it is the co-payment amount that might hinder the behavioural change of the elderly.

The damage has been done.  What I can think of is to formally call for sponsors for the following studies:

• To invite WISEMAN to design a study to see why the good intention of the Chief Executive to subsidize the elderly would be twisted in such a way.
• There had been a willingness-to-pay study in the pilot scheme.  However, the wrong question had been asked.  A study should be done again with the correct question: “What is the amount you are willing to pay or co-pay when there is perceived (yes, perceived, again) free lunch?”
• A follow-up study on those elderly who did show irrational behavioural changes to see whether there is any underlying pathology such as cerebral insufficiency, dementia or frontal lobe lesions.
• To introduce healthcare vouchers to young adults as they are the group who have real potential for behavioural changes and they will exert greater burden on the healthcare system now and later.

 

(Source: HKMA News February 2012) 
 

新年進步

(Source: HKMA News January 2012)