In Singapore, can someone explain and evaluate the effectiveness of means testing for healthcare?

Question

I hope u can explain and evaluate in detail the effectiveness of means testing as a criterion for determining the provision of basic health-care by the government compared to other possible solutions, here in Singapore. U can add in some details on health care policies and give me the sources so i can read up more in this issue. Thank you!

Answer 1

DEFINITIONS

From Barron's:

  Principle that holds that Social Insurance programs should be for the benefit of lower socioeconomic segments of society and not for that segment of society that does not require financial assistance.

From The American Heritage Dictionary:

  An investigation into the financial well-being of a person to determine the person's eligibility for financial assistance.This article from geraldtan.com

From Wikipedia (25 Dec 2006):

  The term means test refers to an investigative process undertaken to determine whether or not an individual or family is eligible to receive certain types of benefits from the government.

  The "test" can consist of quantifying the party's income, or assets, or a combination of both.

From Singapore Ministry of Health:

  "Means Test" is a method to calculate the subsidies that an elderly will get if he/she needs step-down care services.

  It takes into consideration:

gross income of the patient, his/her spouse and the immediate family members

number of family members and

ownership of major assets such as private property

EXAMPLES OF OTHER COUNTRIES WITH MEDICAL MEANS TESTING United States : Department of Veterans Affairs

United States : Medicaid

Ireland : Medical Cards (Health Service Executive)

TWO FUNDAMENTAL PROBLEMS WITH NOT HAVING A MEANS TEST

  The two fundamental problems of NOT having a means test are

Inability to control demand leading to ‘free-loading’ and a ‘buffet mentality’; and

Consequent need to try and control demand by class-differentiating: accentuating differences between unsubsidised and subsidised services to discourage ‘free-loaders’ from using subsidised services.

PROBLEMS ASSOCIATED WITH INABILITY TO CONTROL DEMAND LEADING TO ‘FREE-LOADING’ AND A ‘BUFFET MENTALITY’

Abuse of Polyclinic and A&E

  Because we have no means test, many patients want to get access to the subsidised specialist outpatient services by going to the polyclinics and A&E to get referrals to the subsidised specialist clinics in hospitals. This creates unnecessary work at the polyclinic and A&E level, as if the folks there do not already have enough to do. It is not uncommon for the polyclinic and A&E doctor to realise that the patient before him is there ONLY because he wants a referral to a subsidised clinic for a chronic disease.

Inability to control workload or shift workload to private sector which has excess capacity

  Because subsidised services are so freely available and cheap, the swarmed hospitals and polyclinics are unable to shift patients to an environment where excess capacity exists – the private sector. They are also unable to control workload as patients in search (but not in need) of subsidies come in waves to them.

Overload and overworked public doctors leading to talent drain, less time for teaching and research

  The previous reason leads to overwork, which results in doctors and other healthcare professionals leaving the public healthcare system, often not in search of better pay but just a comparable figure and a more manageable volume of work. Folks who we have trained at great expense do not stay and we end up in a vicious circle – continually training (and thereby incurring cost) people to address the brain drain.

  For those who stay, they also have no time for teaching and research. And because we have no means test and yet have to address the crowds, we pay doctors by work volume – and we wonder how come our doctors do not produce as much research as our Hong Kong counterparts even when we are similarly enmeshed in earth-shattering events like the 2003 SARS outbreak.

  With our desire to be a medical hub and a knowledge-based economy, what are the costs of keeping our public doctors running like hamsters on a wheel, with no time for research or teaching?

Needless subsidising of free-loaders with truly needy not getting adequate care

  This is the simplest issue: the cost of needlessly subsidising free-loaders who can actually pay. The opportunity cost is of course that of the resultant denial of adequate services and subsidies to those truly in need due to the crowding-out effects of free-loaders.

Stifling of private GP services and skills and wrong ‘site-ting’ of care

  The biggest cost to the country as a whole is the wrong ‘site-ting’ of care. Patients who can easily be treated at the GP or polyclinic, community hospitals and private nursing homes refuse to be treated at these places because hefty subsidies are freely available to all at the public hospitals. It is cheaper to stay in a C class ward than to go to a community hospital or nursing home where the means test already exists.

  Similarly at the primary care level, people would rather remain at the subsidised specialist clinic level than go to the GP or polyclinic because the former is the cheapest option even for those who can afford it (yes, again because there is no means test).

Supplier-induced demand in areas where there is excess capacity

  Because there is no means test, we are unable to shift workload out of the public system; excess capacity exists in the private sector, both for the private GPs and private specialists. More and more GPs now turn to aesthetic medicine. This is good if their patients are mainly foreigners and such work helps to bring in foreign exchange. But we know most are locals, leading to unnecessary spending on healthcare. Private specialists who are not doing too well also are tempted to go down the path of supplier-induced demand.